Module 6 Discussion: The 41-Year-Old Patient Evaluation and Management Plan
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The 41-Year-Old Patient Evaluation and Management Plan
Proving the Diagnosis of Lateral Epicondylitis
Tennis elbow or lateral epicondylitis is mostly a result of overuse and strain in the forearm muscles during activities such as gripping objects or wrist extension. Several clinical tests can be conducted during the physical examination to confirm this diagnosis. Cozen's and Mill's tests are two common clinical tests used in diagnosing lateral epicondylitis. In Cozen’s test, the patient is instructed to make a fist and then slowly and actively flex the wrist against the pressure applied by the examiner. If the patient experiences pain at the lateral epicondyle while performing this manoeuvre, it could be due to lateral epicondylitis. The Mill’s test is performed by placing the elbow in extension, pronating the forearm and flexing the wrist which passively stretches the forearm muscles. When extending for this stretch, pain at the lateral epicondyle indicates lateral epicondylitis (Soares et al., 2023). Also, one might feel throbbing or pain on the lateral epicondyle during palpation which also confirms the diagnosis. There is no need for routine imaging tests like X-rays or MRI scans, unless there is clinical suspicion for other conditions like fractures or ligament injuries.
Addressing the Daughter's Concern
Several reasons could be attributed to the daughter’s discomfort and reluctance to report the injury at work, including: First, the family might fear legal consequences or losing the job in case of reporting the injury as resulting from work, due to their undocumented status. The patient may also develop a fear that by demanding compensation or reporting the injury, they may lose their job, given that the workplace is most probably in construction where most of the workers are immigrants with limited job security. Further, the daughter could also be concerned about the family’s financial security since her father may be the breadwinner for the household. The distress that one could easily notice on the daughter’s face could be attributed to the emotional stress of having to act as a translator and negotiator. It is paramount to approach this scenario with sensitivity and let the patient and his daughter know that the goal is to offer the best treatment to the patient without contacting authorities and worsening his condition or adding more problems him.
Additional Assessments
Further assessments should be the assessment of the range of motion of the elbow, wrist, and forearm, in addition to observing the feeling of erythema around the affected area during the primary inspection. The strength of muscles used in wrist extension and supination of the forearm needs to be evaluated to know the severity of the injury. There is a need to do neurological examination as tests which show whether the nerve is affected, possibly the radial nerve due to lateral epicondylitis that has advanced to its severe state. Palpating the skin for localized areas of tenderness over the extensor muscles and tendons will guide the practitioner in identifying a more defined area of inflammation (Johns & Shridhar, 2020). In addition, it is important to ask if the patient has previously attempted any form of treatment including pharmacological and psychological therapy and their outcomes. Since the patient has been using Tylenol, the efficacy of this analgesic ought to be evaluated, and it should also be determined whether there is a need for a stronger analgesic.
Treatment of Lateral Epicondylitis
The treatment of lateral epicondylitis therefore focuses on the reduction of pain and inflammation, promotion of tissue healing and possible avoidance of recurrent injury. Rest and activity modification are important, the patient should be encouraged against activities that elicit pain, such as lifting heavy objects or performing repetitive movements. Prescribing of other drugs particularly Nonsteroidal Anti-Inflammatory Drugs- NSAIDS like ibuprofen is helpful in the management of pain and inflammation (Ma & Wang, 2020). Physiotherapy is usually recommended as soon as possible because this entails bending the hand to minimize pressure on the tendon as well as strengthening exercises on the forearm muscles. An example of bracing support that can be worn when participating in physical activities is a counter-force brace which can be used to alleviate the tension of the troubled tendon (Landesa-Piñeiro & Leirós-Rodríguez, 2022). For conditions that have not improved through other treatments, injections containing corticosteroids may be provided; however, these injections should be utilized very carefully because the side effects of the drug are quite serious. Other factor that goes along with the management of these disorders include; teaching patients how to prevent the development of ergonomic practices and techniques to use during activities.
Addressing the Patient's Concerns
When the patient and his daughter are suggesting that they want to leave, safety and providing more reassurance should be encouraged. I would first listen to his complaints and assure him that our main objective is to provide the best treatment for his condition. I would clarify that the treatment plan aims to relieve the pain and assist him in resuming his work and everyday life without contacting other people and authorities. Furthermore, I would assure them that the clinic services are private, and our role is to enhance health and welfare not harm them in any way, or endanger their ability to work. It may also be beneficial to inform the patient about the likely symptoms that could arise in the future if the condition is left unattended such as an increase in pain and probable disability to compel them to continue with their treatment. If needed, I could suggest the locations of the cheaper or even free clinics and assure them that we are here to assist regardless of their ability to pay or their legal status.
References
Johns, N., & Shridhar, V. (2020). Lateral epicondylitis: Current concepts. Australian journal of general practice, 49(11), 707-709.
Landesa-Piñeiro, L., & Leirós-Rodríguez, R. (2022). Physiotherapy treatment of lateral epicondylitis: A systematic review. Journal of back and musculoskeletal rehabilitation, 35(3), 463-477.
Soares, M. M., Souza, P. C., & Ribeiro, A. P. (2023). Differences in clinical tests for assessing lateral epicondylitis elbow in adults concerning their physical activity level: test reliability, accuracy of ultrasound imaging, and relationship with energy expenditure. International Journal of Environmental Research and Public Health, 20(3), 1794.
Ma, K. L., & Wang, H. Q. (2020). Management of lateral epicondylitis: a narrative literature review. Pain Research and Management, 2020(1), 6965381.