Right Elbow Pain Audit Report
Reason for Visit: Right Elbow Pain s/p Contusion since 11/04/2016
S: TM hit Right elbow on 11/04/2016 can completed ESI X 5 visits and his pain was gone. Today he is clinic complaining of the right elbow pain that is localized. TM rates his pain at 6/10 when is working and with the extension of his elbow. TM describes his pain as aching type pain. TM denies any other complications including, numbness, tingling or loss of movement in his right arm.TM denies locking or snapping of his right elbow.
O: Right elbow: no discoloration, no edema noted. Tender with palpation over right olecranon. Full ROM, increased pain with the extension. No impairment of NVS, brisk capillary refills. No locking or snapping of right elbow.
A: Right Elbow Pain;
S: TM hit Right elbow on 11/04/2016 can completed ESI X 5 visits and his pain was gone. Today he is clinic complaining of the right elbow pain that is localized. TM rates his pain at 6/10 when is working and with the extension of his elbow. TM describes his pain as aching type pain. TM denies any other complications including, numbness, tingling or loss of movement in his right arm.TM denies locking or snapping of his right elbow.
O: Right elbow: no discoloration, no edema noted. Tender with palpation over right olecranon. Full ROM, increased pain with the extension. No impairment of NVS, brisk capillary refills. No locking or snapping of right elbow.
A: Right Elbow Pain;