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?

Dear writer i need a discussion reply to a fellow classmates class post. I will provide the discussion instructions for the class for guidance so you have an idea to what the student is answering to, you are to reply to the student’s post. Please, do not critique their paper but rather expand to their original point.

Class assignment 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 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?

Students response to case study you are to reply to:

Lateral epicondylitis (LE), commonly known among clinicians as “Tennis Elbow”, is swelling of the tendons that bend the wrist backward away from the palm. Lateral epicondylitis can be caused by trauma to the elbow or, more often, by repeated stress on the elbow tendons such as sports or specific tools. However, many people who suffer from tennis elbow do not play tennis, and the condition can be caused by activities such as painting with a brush or roller, operating a chain saw, and frequent use of other hand tools regularly. Hence the term overuse syndrome. Though lateral epicondylitis is identified as an inflammatory process, the histology does not show many inflammatory cells. Many clinicians consider LE as tendinosis, a symptomatic degenerative process of the tendon (Vaquero-Picado, Barco, & Antuña, 2017).

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?

Often, the diagnosis of lateral epicondylitis is clinically driven. Early imaging provides minimal benefits unless there are calcification deposits present that can be seen on the x-ray. A throughout history is very important, and the physical assessment should include palpating any tender areas and ruling out any particular involvement of pain. Mill’s test is also a fantastic technique to test for lateral epicondylitis. The clinician palpates the patient’s lateral epicondyle with his/her thumb while passively pronating the forearm, flexing the wrist, and extending the elbow. A positive test would be the reproduction of pain near the lateral epicondyle. However, this could also cause stress on the radial nerve, so if positive, it may indicate radial nerve involvement. The Maudley’s test, Thomson’s maneuver, diminished grip strength, and the chair test are some of the tests employed to reproduce the pain of lateral epicondylitis (Vaquero-Picado et al., 2017).

Electromyography (EMG) of the elbow may show if the patient has any nerve problems causing the pain. Also, ultrasound is one of the most useful tools to diagnose or rule out LE. MRI is the diagnostic gold standard for lateral epicondylitis. It is usually done on patients that have failed conservative treatment. However, a CT arthrography has been demonstrated to be more accurate than MRI to diagnose capsular tears. The diagnosis of “Tennis Elbow” most of the time can be diagnosed clinically without the need for an MRI or any other imaging procedure (Vaquero-Picado et al., 2017).

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?

Illegal immigrants may be reluctant to seek care because they believe health care providers will report them to immigration authorities, placing them and their family members at risk of deportation. In this case, the patient’s daughter feels threatened by the provider’s questions, and the more questioning she experiences, the worst her fear of them being reported to the authorities becomes. The clinician must explain that the questions are only linked to medical treatment and not related to their legal status. Unfortunately, the patient’s daughter may be experiencing immigration-related stress, which is an uncontrollable stressor that may trigger uncertainty and fear (Kuczewski, Mejias-Beck, & Blair, 2019).

Visual inspection reveals erythema around the affected area with no evidence of overlying skin lesions, scars, or deformities. What other assessments should you perform?

The described signs and symptoms may be related to an inflammatory disease process. Erythrocyte sedimentation rate, C-reactive protein, and WBC count should be ordered to rule out the presence of low-grade infection caused by agents such as cutibacterium acnes. A careful musculoskeletal assessment must be performed. Aspiration of synovial fluid, followed by culture, should be done as well. In this case, the additional assessments should be focused on ruling out other inflammatory diseases (Vaquero-Picado et al., 2017).

How is lateral epicondylitis treated?

The initial treatment should include protection of the affected site, rest, ice, compression, and elevation. The ice should be applied in intervals of fifteen to twenty minutes and repeated every one to two hours. Depending on the stage and severity, home exercises, or physical therapy may be prescribed, which is a cornerstone of treatment. Immobilization should not be done for more than two days. Frequency and intensity during the use of the injured area must be decreased. However, movement should not be eliminated. Deep heat ultrasound may help increase local circulation. Epicondylar counterforce braces work by reducing tension in the wrist extensors. Elbow straps, clasps, or sleeve orthoses have been demonstrated as superior for pain relief and grip strength (Vaquero-Picado et al., 2017).

Non-steroidal anti-inflammatory drugs (NSAIDs) can be useful for the short-term relief of symptoms. Corticosteroid injections are commonly used to treat LE, they seem to be superior to NSAIDs at four weeks, but no differences are observed at a later stage. Cortisone injections should be avoided in all cases unless a good short-term result is advisable. Autologous blood injections are thought to work by stimulating an inflammatory response, which will bring in the necessary nutrients to promote healing. Platelet-rich plasma injections (PRP) could theoretically enhance tendon healing. However, no differences were seen between PRP and whole blood injections. Non-pharmacological modalities such as acupuncture have demonstrated promising outcomes on short-term follow-up, but long-term results remain unclear. Lastly, for those patients with persistent pain and disability after a course of well-performed conservative treatment, open, percutaneous, and arthroscopic approaches may be indicated (Vaquero-Picado et al., 2017).

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?

The issue of illegal immigrants seeking care in the U.S. is unfortunate. This has been problematic at many clinics and non-profit healthcare facilities in many states where illegal immigration is more severe. Sometimes, the issue may create dilemmas for clinicians and unnecessary tension between their professional, ethical obligations and legal rules to enforce immigration policies. However, the clinician should educate the patient that there is no federal, state, or local law that prevents immigrants, including those undocumented individuals, from accessing health care services (Kuczewski et al., 2019).

The provider must assure the patient that even if he states that he is undocumented, health care providers are not mandated by law to report individuals who are undocumented to legal authorities. The provider should clarify that individuals seeking available services regardless of immigration status, such as Federally Qualified Health Centers, should not be asked or required to provide their immigration status. The clinician must use a friendly language and attitude that may directly address the patient and his daughter’s fears about public charge, reporting their information to immigration authorities, and other myths that can be dispelled through effective communication techniques and education (Kuczewski et al., 2019).

References

Kuczewski, M. G., Mejias-Beck, J., & Blair, A. (2019). Good sanctuary doctoring for undocumented patients. AMA Journal of Ethics, 21(1), 78-85. doi: 10.1001/amajethics.2019.78.

Vaquero-Picado, A., Barco, R., & Antuña, S. A. (2017). Lateral epicondylitis of the elbow. EFORT Open Reviews, 1(11), 391–397. doi:10.1302/2058-5241.1.000049