Patient name:  Ms Clare Rigg

D.O.B.:   4/09/1983

Address:  8 Ferndale Road, Greenville

Occupation:  Florist

Social: Single parent:  2 children, 5yrs & 2yrs

Diagnosis:  L tennis elbow

Referring Doctor:  Dr Frank Sala, Orthopaedic Surgeon

Medical history:

• Nov 1992 – Appendectomy
• Apr 2011 – Caesarian delivery

29/07/2013
Subjective:

• 3 months gradually ↑ pain on outside of L elbow & forearm.
• Pain aggravated by lifting 2-yr-old in & out of car; working as florist – pain after ½ hour.
• Pain ↓ by rest; no pain at night.
• Previous treatment: nil.
• Past history L elbow: nil.

Observations:

• No abnormality detected (NAD)
• Palpation: Tender L lateral epicondyle

Movement:

• Active movements: L elbow flexion ✔✔
                                           L elbow extension = 0°, pain end of range
                                           L elbow supination ✔✔
                                           L elbow pronation ✔✔
  Pain reproduced by: stretch of long finger extensors; contraction of common extensors.
  Grip strength:           L = 15kPa
                                          R = 68kPa

Treatment:

        Aim: ↓ pain

1. relative rest; provided tennis elbow brace; discussed alternative ways of performing work duties
2. continuous ultrasound, 5 minutes, 1.5 watts/cm2
3. taught stretches, 3 x 30 sec/5 x day

5/08/2013
Subjective:

• Improving; still painful, but takes more to bring pain on; only hurts after 2 hrs’ florist work.

Objective:

• Grip strength: L = 40kPa (pain)
                                R = 66kPa (no pain)

Treatment:

Aim: ↓  pain; start to ↑ strength of tendon

1.  continuous ultrasound, 5 minutes, 1.5 watts/cm2
2. continue with stretches, add therapist stretches, hold-relax 2 sets x 6
3. add eccentric exercise, wrist flex/ext over edge of table 3 x 10 with ½kg, once daily

10/08/2013
Subjective:

• Much improved; only mild ache at end of shift at florist; not noticing when transferring child in & out of car.

Objective:

1. Palpation: ↓  tenderness to palpation of L lateral epicondyle
2. Grip strength: L = 52kPa (only slight pain)
                                 R = 65kPa

Treatment:

1. stretching and strengthening exercises supervised; progress weight to 1kg; to continue with daily exercise program at home
2. advice; wean off elbow brace
3. review appointment (10/09/2013) to check exercises, ensure full recovery

Writing task:
Using the information in the case notes, write a letter back to the referring doctor. Address your letter to Dr Frank Sala, Orthopaedic Surgeon, The Clinic, 140 Main Road, Greenville.

In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words.