[##]-year-old [male/female] with [right/left] elbow pain [and swelling]
with history and exam consistent with medial epicondylitis (“golfer’s elbow”).
Initial consideration in this patient included medial epicondylitis, distal
humeral, radial head, olecranon and other elbow fractures, lateral
epicondylitis, biceps tendon rupture, and septic bursitis among others.
Patient presented with [right/left] elbow pain with tenderness to
palpation noted over the medial epicondyle on exam. Patient noted to have [golf/pitching/rock
climbing/describe activity] predisposing to overuse syndrome. Patient noted to have reproduction of pain
with forced flexion and pronation of the [right/left] forearm and wrist. 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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