Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Pain location: Describe the location of the patient’s elbow pain (lateral aspect, tenderness over lateral epicondyle).
Pain characteristics: Characterize the pain (sharp, aching, burning), and ask about any aggravating activities (gripping, lifting, specific movements).
Duration: Inquire about the duration of symptoms and any recent changes in pain intensity.
Functional limitations: Assess how the pain impacts daily activities and work.
Objective:
Physical exam:
Palpation for tenderness over the lateral epicondyle (lateral aspect of the elbow).
Range of motion testing of the elbow joint (flexion, extension, pronation, supination).
Assess for grip strength using a dynamometer (optional).
Look for signs of inflammation (swelling, redness).
Assessment:
Diagnosis: State the diagnosis of lateral elbow tendinopathy (synonyms: tennis elbow, lateral epicondylitis).
Severity: Briefly describe the perceived severity based on pain intensity, functional limitations, and duration.
Plan:
Treatment:
Recommend activity modification and avoiding aggravating activities.
Consider ice therapy for pain relief (duration, frequency).
Discuss potential use of over-the-counter pain relievers (e.g., NSAIDs).
Recommend a physiotherapy program tailored for lateral elbow tendinopathy (specific exercises for strengthening and flexibility).
In severe cases, mention potential consideration of bracing or corticosteroid injection (consult specialist if needed).
Follow-up:
Schedule a follow-up appointment in 1-2 weeks to assess response to treatment.
Instruct the patient to return sooner if pain worsens or symptoms don’t improve.
Notes:
Include any additional relevant information like previous treatments or underlying medical conditions.
Document discussions with the patient regarding prognosis, importance of compliance with treatment recommendations, and potential risks and benefits of different treatment options.