Case Study
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 cannot 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 family members are working with the same local construction company.
Please post your responses to the following questions in the Unit 9 Discussion Board.
Case Questions
- 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?
- What would be the differential diagnoses? The main diagnosis? How is this condition treated?
- To confirm a diagnosis of lateral epicondylitis (commonly known as tennis elbow), you can take the following steps:
a. Detailed History: Continue to communicate through the daughter as a translator and ask the patient about the onset and duration of his symptoms. Specifically, inquire about any activities or movements at work or in daily life that exacerbate the pain, such as lifting, gripping, or repetitive hand movements.
b. Physical Examination: Perform a thorough physical examination of the elbow and forearm. Look for tenderness and swelling over the lateral epicondyle (the bony bump on the outer side of the elbow). You can perform specific tests like the Cozen’s test or Mill’s test, which involve resisted wrist extension to reproduce pain and assess for lateral epicondylitis.
c. Imaging: Consider ordering imaging studies like X-rays or ultrasound to rule out other possible causes of pain, such as fractures or arthritis. While lateral epicondylitis is often a clinical diagnosis, imaging can help rule out other conditions.
- The daughter’s concern may arise from the fear that her father’s immigration status could be compromised if his injury is reported as work-related. Many undocumented workers avoid reporting workplace injuries for fear of deportation or losing their jobs. This fear of repercussions may explain her reluctance to disclose that the injury occurred at the current place of employment.
- Given the erythema (redness) around the affected area, you should consider performing the following assessments:
a. Palpation: Carefully palpate the affected area to check for local tenderness and any swelling. Lateral epicondylitis often presents with localized tenderness over the lateral epicondyle.
b. Range of Motion: Assess the patient’s range of motion in the elbow and wrist. Lateral epicondylitis can limit the extension of the wrist and cause pain during certain movements.
c. Neurological Examination: Check for any signs of nerve involvement, as some nerve conditions can mimic lateral epicondylitis. Assess sensation and strength in the affected arm.
d. Grip Strength: Evaluate the patient’s grip strength, as this can be affected in lateral epicondylitis due to pain during gripping.
- Differential Diagnoses: Possible differential diagnoses for elbow pain radiating into the forearm include:
a. Lateral Epicondylitis (Tennis Elbow): The main diagnosis, characterized by pain and tenderness over the lateral epicondyle.
b. Medial Epicondylitis (Golfer’s Elbow): Similar to lateral epicondylitis but with pain and tenderness over the medial epicondyle.
c. Cervical Radiculopathy: Compression of a nerve root in the neck, which can cause radiating pain into the arm.
d. Osteoarthritis of the Elbow: Degenerative joint disease can cause chronic pain in the elbow.
e. Radial Tunnel Syndrome: Compression of the radial nerve can mimic lateral epicondylitis symptoms.
f. Fracture or Dislocation: Trauma can result in fractures or dislocations, leading to pain and dysfunction.
g. Cubital Tunnel Syndrome: Compression of the ulnar nerve at the elbow, causing pain and numbness.
Treatment: The main treatment for confirmed lateral epicondylitis typically includes:
- Rest: Avoiding activities that exacerbate symptoms.
- Ice: Applying ice to the affected area to reduce inflammation.
- Physical Therapy: Stretching and strengthening exercises.
- Pain Medications: Over-the-counter pain relievers like ibuprofen.
- Bracing: Wearing a brace or splint to reduce strain on the tendon.
- Corticosteroid Injections: In severe cases, corticosteroid injections may be considered.
- Activity Modification: Adjusting work or activities to minimize strain on the affected arm.
- Surgery: In rare cases where conservative measures fail, surgical intervention may be considered.
It’s important to tailor the treatment plan to the individual patient’s needs and consider their work-related concerns, especially in cases involving undocumented workers.