[##]-year-old [male/female] with [right/left] elbow pain [and swelling]
with history and exam consistent with lateral epicondylitis (“tennis elbow”).
Initial consideration in this patient included lateral epicondylitis,
distal humeral, radial head, olecranon and other elbow fractures, medial
epicondylitis, biceps tendon rupture, and septic bursitis among others.
Patient presented with [right/left] elbow pain with tenderness to
palpation noted over the lateral epicondyle on exam. Patient noted to have [tennis/describe
activity] predisposing to overuse syndrome.
Patient noted to have reproduction of pain with forced extension and supination
of the [right/left] forearm. Neurovascular
exam of the distal [right/left] upper extremity [noted to be
unremarkable/notable for findings]. Plain
films were [felt to not be indicated in patient without significant preceding
trauma/bony tenderness/obtained and noted to be unremarkable].
Prior to discharge, we discussed return precautions, specifically for
development of weakness or numbness (especially ulnar neuropathy), symptomatic
treatment with rest, ice, NSAIDs, and compression, stretching exercises
(provided patient with handout from American Academy of Orthopaedic Surgeons
(AAOS)), and follow up with primary care provider for further evaluation and
consideration of referral to physical therapy, and the patient demonstrated
understanding and agreement with this plan.
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