Directions: Read the treatment transcript for each of the assigned case studies below. These treatment sessions were dictated randomly into a hand held recorder so the data is in no particular order relative to a S.O.A.P. note. After reading the transcription, place the information in its proper order and write a S.O.A.P. note that includes all the relevant data. Use as many approved abbreviations as you can (see list provided). Remember, for a treatment session to be properly documented, it must include enough information to allow a substitute therapist to treat the patient without significant change.
 

Case Study #1- Right Acute Achilles tendinitis with Right Lateral Epicondylitis

• Patient seen on 8/1/99 in clinic for approx. 45 minutes.
• Denies any real progress in terms of pain relief for the heel but does report some improve of the pain level in his right forearm.
• Admits to not being able to do his home program as often as directed due to lack of time.
• Ice massage followed by transverse friction massage over the right Achilles in the area of the Haglund's deformity he has developed there with patient prone.
• Heel cord stretching X 5 minutes in the Pro Stretch.
• Mild stretching of the tendons of the common extensor origin of the R. upper extremity.
• Iontophoresis with dexamethasone applied at 4mA amplitude for a 55mA dosage. To the lateral epicondyle of the right upper extremity.
• Plan to begin strengthening exercises for the wrist extensors and forearm next time if pain level continues to improve.
• May try iontophoresis with Lidocaine over Haglund's to determine if the painful tissue is superficial or deep.
• Active range of motion of the right ankle was 10 dorsiflexion and 20 plantar flexion.
• Reviewed patient's home exercise program and reiterated the importance of complying with the instructions for its use.
• Patient seemed to have more pain free active dorsiflexion after treatment today.

 

• Had patient workout on the overhead pulleys for approximately 10 minutes before measuring range of motion.
• Finger walking up wall in the flexion and abduction planes X 10 each way.
• Codman's exercises with a 2 pound weight in flexion/extension, abduction/adduction, and clockwise and counterclockwise directions X 15 each way.
• Active range of motion exercises in flexion and abduction to 90 X 10.
• Patient reported he had no ill effects from his last therapy session despite the rigorous passive range of motion/stretching session he had to endure.
• Suspect patient isn't being fully compliant with his home program as evidenced by his lack of carryover of range gained in therapy.
• Passive range of motion of all planes of motion of the R. shoulder with patient supine. Passive range of motion of the right shoulder after stretching was as follows: Flexion = 155 Abduction = 150 Internal Rotation = 62 External Rotation = 84 all with pain at extreme end range.
• Began isokinetic strengthening on BTE today for internal and external rotation. Power head set at #3 angle and at #28 height with patient standing. Resistance was set for concentric and eccentric contractions at 35 and 45 inch/pounds respectively. Patient performed one screen for each exercise.
• Will begin upper body cycle and theraband exercises next visit.
• Ice to anterior and posterior right shoulder for 15 minutes with patient supine.

 

• Patient comes to physical therapy in a slightly bent over posture.
• Patient complains of pain with extension and left side bending.
• Patient denies any radicular symptoms.
• Very tender to palpation over the right posterior superior iliac spine. This area has a fibrotic nodule that is tender to palpation as well. The posterior superior iliac spine on this side is not as prominent as it is on the contra lateral side. Possibly suspect a sacroiliac instability that may have been flared up in car accident.
• Phonophoresis with 5% hydrocortisone cream delivered over right lumbosacral area at 1.5 watts per centimeter squared X 5 minutes at 100% duty cycle.
• Mild flexion stretching exercises - reciprocal single knee to chest then double knee to chest with patient supine X 5 ea.
• Will try iontophoresis over fibrotic nodule next session if no better.
• Patient tolerated this treatment session without complaint.
• Mild effleurage / petrissage over the spasms noted over the right lumbar paraspinals X 5 minutes with the patient prone over pillows.
• Patient was able to tolerate a more upright posture after the treatment.
• Ice X 15 minutes to the bilateral low back with patient supine and draped.

 

• Patient to clinic with a standard walker and an antalgic gait displaying decreased stance time right lower extremity.
• Patient performed right quadriceps setting exercises X 25 with patient long sitting. Patient was unable to actively extend knee to 0 while doing these.
• Moist heat was placed around the patient's hamstrings and her right leg was strapped to the extension board X 10 minutes.
• Patient's tolerance to the passive stretching techniques is only fair and she frequently complains of unbearable pain.
• Following the extension board, patient was passively pushed into extension by therapist. Patient was able to reach -4 of passive extension at this time.
• Patient was placed in prone position with right lower extremity over mat. A 10 pound cuff weight was placed around her ankle and she was left to hang in extension X 7 minutes. This was all the patient could tolerate before complaining of pain and insisting the weight be removed.
• Will continue with passive stretching of right knee extension and concentric/eccentric strengthening as tolerated.
• Patient was placed on the MG2300 knee machine where she performed knee extension exercises 2 X 15 with 5 plates.
• Patient was taken to the parallel bars where she was tested for balance during weight shifting and single leg balancing. Bilateral lateral step ups X 10 were also performed.
• Ice x 10 minutes to anterior/posterior knee with patient recumbent.

 

• Patient presents with bilateral pes planus and obvious tibial internal rotation.
• Patient is wearing Birkenstock sandals which he states he lives in for the entire summer months. He does not have corrective orthotics at this time.
• Patient complains of pain over the right tibial tuberosity and the fat pad directly superior. He says that he has a lot of pain during jumping activities and after prolonged periods of rest.
• Deep fibers of the lateral retinaculum are tight as evidenced by significant patellar tilt to that side. Patella glides readily in the medial direction indicating the superficial fibers are not as tight.
• Ober test and modified Thomas test were positive for tight iliotibial bands bilaterally with right greater than left.
• Ice massage was demonstrated for 5 minutes over the affected tibial tuberosity followed by transverse friction massage for 5 minutes across patellar tendon. This procedure was also assigned to patient's home management program.
• Mild patellar tendon stretches were performed and assigned as well.
• Patient was measured and fitted for a patellar tendon support strap and shown the proper way to apply it. Patient was instructed to wear the strap during any weight bearing activities, taking it off only when sitting or in bed.
• Plan to request an order from physician to perform a biomechanical assessment of patient's lower extremities to ascertain if orthotic management is appropriate.
• Patellar mobilization with patient in sidelying pushing patella into a medial position and then pushing posteriorly on the medial edge.
• Iliotibial band stretches in the Ober position with knee at 90 and a 5 pound weight over femur just proximal to the knee joint.
• Patient was instructed to ice knee 3-4 times a day and to reduce strenuous activity to a minimum.