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The 41-Year-Old Patient Evaluation & Management Plan

A 41-year-old male patient presents at the community walk-in clinic with complaints of severe elbow pain radiating into the forearm. His 13-year-old daughter is serving as a translator because her father is unable to speak English and understands only a few words in English. The daughter explains that he has been taking Tylenol to manage pain, but the pain is getting worse and is keeping him from working. You ask the daughter to describe the type of work her father does, and you notice she is hesitant to respond, first checking with her father. He responds, and she translates that he works in construction. Based on the response and the apparent concern, you suspect that the patient may be an undocumented worker. Further conversation reveals that several members of the family are working with the same local construction company.

You suspect the pain reported as coming from the elbow and radiating down the forearm is caused by repetitive motions, perhaps indicating lateral epicondylitis. What can you do to confirm this diagnosis?
While performing the physical examination, you ask the patient, through his daughter, if he has reported this injury to his employer, because the injury is most likely work-related. The daughter responded without consulting her father that this is an old injury that happened before he started working at his current place of employment. You could tell that she was becoming more distressed. What is the most likely explanation for her concern?
Visual inspection reveals erythema around the affected area with no evidence of overlying skin lesions, scars, or deformities. What other assessments should you perform?
How is lateral epicondylitis treated?
When discussing possible treatment approaches, you notice that the patient is very worried and seems to suggest to his daughter that they should leave. The daughter begins trying to explain why they have to leave right away. What would you tell the patient and his daughter to help them feel comfortable staying for treatment?

Full Answer Section

Empathy and Understanding: Acknowledge their concerns and reassure them that their well-being is the priority.
Confidentiality: Explain that the information shared will be kept confidential.
Non-Judgmental Approach: Avoid making assumptions or judgments about their immigration status.
Offer Resources: Provide information about local resources, such as worker's compensation or legal aid, that may be helpful.

Treatment Plan:

Rest: Encourage the patient to avoid activities that aggravate the condition.
Ice Therapy: Apply ice packs to the affected area for 15-20 minutes, several times a day.
Over-the-Counter Pain Relief: Recommend over-the-counter pain relievers like ibuprofen or naproxen.
Physical Therapy: Refer the patient to a physical therapist for specific exercises to strengthen the forearm muscles and improve flexibility.
Occupational Therapy: An occupational therapist can provide guidance on work modifications and ergonomic strategies to prevent future injuries.

Long-term Management:

Ergonomic Assessment: Assess the patient's work environment and recommend ergonomic changes to reduce strain on the elbow.
Education: Educate the patient about proper body mechanics and techniques to prevent future injuries.
Follow-up: Schedule follow-up appointments to monitor the patient's progress and adjust the treatment plan as needed.

By addressing both the physical and emotional needs of the patient, you can help them recover from their injury and prevent future complications.

Sample Answer

Diagnosing and Treating the Patient

Confirming the Diagnosis:

To confirm the diagnosis of lateral epicondylitis, you should perform specific physical examination maneuvers:

Cozen's Test: Resisted wrist extension with the forearm pronated.
Mill's Test: Passive wrist flexion and pronation.

Addressing the Patient's Concerns:

The daughter's concern about leaving may stem from fear of immigration consequences or potential workplace retaliation. It's essential to create a safe and non-judgmental environment. Here are some strategies to reassure them: