Lateral Epicondylitis Note

Patient:
Date:
Age:                                                             Occupation:
Involved Side:                                              Sports:
Date of Injury:none

Chief Complaint                                                
elbow pain

History of Present Illness
Mr. is a year old who presents for evaluation of the elbow pain.  They have noted gradually worsening elbow pain over several months. The pain is located on the lateral elbow and often radiates into the forearm. There was no injury. It has been slowly progessive and has started to affect their activities of daily living.

Pain Severity:   7/10                                          Pain location: lateral epicondle
Pain at rest: 4/10                                          Exacerbating factors: activity
Pain with activity:  9/10                                         Ameliorating Factors: rest, ice
Pain Duration:constant
Pain night: occasionally
Previous treatment: NSAIDS, injections, PT, icing

PMH: none
PSH: none
Family History: Patient questionnaire was reviewed, signed and dated in the chart and was noncontributory.
Medications: none
Allergies: NKDA
Social History:  no smoking, no alcohol use
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no known metal allergies.

Physical Exam
Height:           Weight:            Pulse:     BP:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): lateral epicondyle markedly tender, reproduces symptoms.
Elbow ROM (R/L): 0-130 / 0-130
Suppination (R/L): 80/80             Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5                              Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5                Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterallyUE Skin (R/L): no rashes or lesions bilaterally
Lymph UE (R/L): no axillary lymphadenopathy
DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+)
Resisted wrist and finger extension with the elbow in full extension exacerbates pain
No pain on resisted suppination (PIN irritation).
Knee Exam (Bilateral)
Inspection / Palpation LE (R/L): non-tender bilaterally
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature: 2+ dorsalis pedis pulse bilaterally
LE Skin: no rashes or lesions bilaterally
Lymph LE: no inguinal lymphadenopathy
DTR LE: Patellar (2+/2+); Achilles (2+/2+) 

Diagnostic Studies
A/P, and lateral views of the elbow dated were personally evaluated by me and demonstrate very minimal joint narrowing.  There are no cystic changes at the lateral epicondyle.  The soft tissues are unremarkable

Assessment
Lateral Epicondylitis

Plan
We discussed the natural history and both operative and non-operative treatment options.  We discussed the risks, benefits and expected rehabilitative course of both operative and non-operative treatments. All questions were answered.  Available links to further peer-reviewed written information on the diagnosis were provided.  We will begin with conservative treatment including icing, a counterforce brace and NSAIDS.  We discussed further treatment if they fail to improve with conservative measure. Further treatment may include casting, injections or surgery. We also discussed surgical treatment and the risks and benefits of surgery.  Risks of surgery discussed include but are not limited to: Persistent pain of varying degree, Infection, Residual strength deficit, Functional limitations, Joint instability,Complex Regional Pain Syndrome and the risks of anesthesia including heart attack, stroke and death.  They will follow-up in 4-6 weeks for continued evaluation and management.  

Occupation:
Follow-up 6-8 weeks
Sport:
Involved Side:
Injury:
HPI: 45y/o male with gradually worsening right elbow pain over several months. 3-7/10 lateral elbow pain. Worse with activity. No noted history of repetitive activities or tennis. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: lateral epicondyle reproduces pain
Resisted wrist and finger extension with the elbow in full extension exacerbates pain
No pain on resisted suppination (PIN irritation).
ROM (R/L): 0-135 / 0-135
Suppination (R/L): 90 / 90
Pronation (R/L): 90 / 90
Negative Tinel's at the Cubital tunnel
no generalized ligamentous laxity
subjective normal M/U/R distal sensation
2+ Radial pulse
Xray: no osseous deformity, no calcifications around lateral epicondyle
MRI: none
ASSESSMENT: Lateral Epicondylitis (726.32)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
activity modifications
ICE
Counterforce brace
NSAIDS