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Determining Treatment Effectiveness

Determining Treatment Effectiveness

SUBJECTIVE

CC: “I am here because my right elbow hurts”

HPI: C. P. is a 52-year-old male, who comes to the office today complaining of a two months’ history of pain in his right elbow. At the beginning, the pain was mild and slowly it worsens. He describes the pain burning sensation that is located on the outer part of his right elbow accompanied of weak grip strength and is an 8 on a scale of 0 -10. Denies the pain radiating. He stated that the pain is worsened with forearm activity, such as shaking hands or holding a racquet. The patient states that has taken acetaminophen every 4-6 hours to alleviate the pain. Denies any other past medical history.

Medications: Denies any herbal medicine.

Acetaminophen Tab 325 mg 2-tab PO every 4-6 hours for pain

PMH:

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Chronic Illnesses/Major traumas: Patient don’t have a significant medical history. The patient denies traumas

Hospitalizations/Surgeries: Denies hospitalizations

Other:

Immunizations: Immunizations currently up to date. Flu shot in this year (2018) and Tetanus booster vaccine in 2016.

Environmental hazard: Patient denies any environmental hazard.

Safety measure: Patient state “I always use my belt car.”

Exercise and leisure: Patient perform exercises two or three times a week. Walk everyday

Sleep: Patient has no difficulty with sleeping. Usually go to bed at 22 00 pm and wake up at 6 00 am.

Diet: Drink one to three cup of coffee a day. Otherwise, drink 2 liters of water 24 hours recall Breakfast with coffee milk and bread. Snacks. Lunch: Rice with some meat, fish or eggs. Dinner: variable

Family History

Mother: Alive, (78 years old) Hypercholesterolemia. Diabetes type II

Father: Alive, (80 years old) HTN, CHF

Paternal Grandfather deceased (98 years) stroke

No family history of cancer or genetic disorders reported

Social History:

Education level: University

Occupational history: Teller in a bank.

Current living situation/partner/marital status: Lives in a house in Miami, Florida with his wife. Sexually active. Denies STI’s

Substance use/abuse: Alcohol (1 cup of wine only weekends), Denies tobacco and illegal drugs uses.

Nutritional Hx: Well nourished.

ROS

General

Negative for chills and malaise, sweats, chest pain anorexia, fatigue, hair loss, weakness, rash, bleeding, weight loss, weight gain.

Cardiovascular

Negative for chest pain, palpitations murmur, bruits or edemas.

Skin

Negative for cyanosis, ulcers, bruising, rash or abnormalities in nails or hair.

Respiratory

Negative for cough, dyspnea, and other respiratory symptoms. Denies pneumonia, TB

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

Negative for nauseas, emesis, dysphagia, bowel habit changes, melena, and constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine, STDS. Patient denies burning on urination or discomfort.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Positive for burning pain localized on the outer part of his elbows accompanied of weak grip strength, denies radiation. Negative for back pain, joint swelling, stiffness, fall, traumas, fracture, and osteoporosis.

Breast

Deferred

Neurological

Negative for headaches. Negative for Syncope, seizures, No paralysis, paresthesias, no changes in mentation, no ataxia

Heme/Lymph/Endo

Negative for bruising, night sweats, swollen glands, increase hunger, thirst, cold or heat intolerance. Negative for lymphadenopathy

Psychiatric

Negative for anxiety, sleeping disturbed, depression and suicidal ideation.

OBJECTIVE

Weight: 186 lbs.

BMI: 23.9

Temp 98.4 F

BP 122/75 mm/Hg

Pain: 8/10

Height 6’2’’ inch

Pulse 74 bpm

Resp 20 bpm

O2 Saturation: 99 %

General Appearance

Patient is a 52 y/o Hispanic male. Appearing of staged age. Alert and oriented; answers questions appropriately. Patient looks sick. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately.

Skin

Skin is white, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Deferred

Cardiovascular

RRR S1, S2 with regular rate and rhythm with no murmurs. No extra sounds, clicks, thrill or bruits. PMI 5TH ICS, MDL. Capillary refill < 3 seconds. Pulses 2+. No edemas.

Respiratory

Symmetric chest wall with good expansion, normal-shaped chest. Respiration even and unlabored, depth normal. Lung resonant. No fremitus. Bilateral breath sounds clear upon auscultation. No wheezing, rhonchi sound. No adventitious sound noted.

Gastrointestinal

Deferred

Breast

Deferred

Genitourinary

Deferred

Musculoskeletal

Point tenderness at ECRB insertion into lateral epicondyle, few mm distal to tip of lateral epicondyle. Decreased grip strength. Resisted wrist extension with elbow fully extended, resisted extension of the longs fingers, maximal flexion of the wrist and passive wrist flexion in pronation causes pain at the elbow.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.

Reflexes 2+ bilaterally throughout.

CN II-XII intact.

Psychiatric

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab test: None

Imaging: No imaging is required for initial evaluation and treatment. (Domino, Baldor, Golding, and Stephens, 2017).

Special Tests

Electromyography in patient with neurologic deficits. US and MRI are useful to evaluate the ulnar collateral ligament and to diagnose traumatic tears to flexor pronator origin of the epicondyle; consider these imaging tests if there is no improvement in the patient’s condition after conservative therapy (Not necessary at this time) (Domino et al., 2017).

Diagnosis

Differential diagnostic:

1. Elbow Osteoarthritis: Osteoarthritis can affect the joints anywhere in the body, including the elbow. Symptoms include: Feeling of crunching movement of the knee due to damage to the cartilage, blockage of the elbow joint, due to lose fragments of cartilage or bone, swelling in the elbow as the disease progresses and tingling, caused by pressure exerted on the ulnar nerve as a result of the swelling (AAOS, 2017).

2. Epicondylar fractures: Symptoms of a fractured elbow include: Severe and acute pain. The patient may complain of numbness in the hand if he has a nerve injury. When examining the patient there is pain on palpation, inflammation, bruising, limited movement (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2017).

3. Ulnar neuropathy: The Ulnar Neuropathy known as Cubital Compression Syndrome in the epitrochlear-olecranon conduit, the majority of the cases is of unknown or idiopathic origin. There are predisposing factors, such as working with the elbow flexed and supported (computer), elbow fractures, tumors or metabolic diseases (diabetes, alcoholism, among others). Symptoms include: Pain in part antero-medial elbow and forearm, can there are paresthesia in the last two fingers. Hypoesthesia in the cubital distribution area is related to repeated movements of the elbow. Symptoms usually improve when the elbow is extended ( Dy & Mackinnon, 2016).

Presumptive Diagnosis: Lateral epicondylitis, right elbow (M77.11): It is a tendinopathy of the elbow characterized by pain and tenderness at the origins of the wrist flexors/ extensors at the humeral epicondyles. May be acute or chronic. Usually involved dominant arm. Risk factors included repetitive wrist motions. smoking. Obesity. Upper extremity forceful activities (Domino et al., 2017).

Plan/Therapeutics & Education:

Further testing: None

Medication: Diclofenac Sodium Tab/75 mg take 1-tab PO TID x 7 days. Diclofenac sodium 1 % gel: apply a thin film to the affected area TID

Non-medication: Ice therapy. Use counterforce bracing with a forearm strap in the area of the muscle mass of the proximal portion of the forearm can be helpful. Encourage relative rest Modalities, such as massage, ultrasound therapy, and electrical stimulation may be helpful

Patient education: Avoid playing tennis for several weeks.

Consultation/Collaboration: No referral needed at this time.

Follow up:

Follow up in one month to determine treatment effectiveness and to assess whether referral to specialist is warranted.

Determining Treatment Effectiveness

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Determining Treatment Effectiveness