ASSESSMENT 11 HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 42 YO M C/O RIGHT ELBOW PAIN. STARTED 2 DAYS AGO, WARM TO TOUCH, RED AND SWOLLEN. SHARP IN QUALITY, 6/10 INTENSITY, LASTS ALL DAY, ITS GETTING WORSE. AGGRAVATED BY MOVEMENT, ALLEVIATED BY TYLENOL AND REST. PATIENT DENIES FEVER, NUMBNESS, WEAKNESS OR RASH. PATIENT DENIES BOWEL OR BLADDER CHANGES, CHEST PAIN OR DIFFICULTY BREATHING. PATIENT IS AN AVID TENNIS PLAYER, PLAYS 2X A WEEK. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES:DOGS AND CATS MEDICATIONS:TYLENOL PMH: NO PRIOR INCIDENTS, HOSPITALIZED FOR LESS THAN A DAY LAST YEAR WITH INFLUENZA VIRUS PSH: NONE FH: FATHER DIAGNOSED WITH HYPERTENSION, MOTHER DECEASED 5 YEARS AGO FROM A HEART ATTACK SH: DENIES TOBACCO, ETOH, OR DRUG USE. LIVES WITH BOY FRIEND, WORKS AS ADVERTISING EXECUTIVE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS HOLDING HIS RIGHT ARM AND THE VITALS ARE WITHIN NORMAL LIMITS.. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HIS RIGHT ARM HAS RESTRCITED ROM AND UNABLE TO EXAMINE DUE TO PAIN. HIS LEFT ARM IS NONTENDER AND NOT SWOLLEN. THE MOTOR STRENGTH IS 5/5 AND SENSATION TO DULL AND PIN PRICK ARE INTACT BILATERALLY. PULSES ARE 2/4 AND SYMMETRIC BILATERALLY AND ROM ON LEFT ARM IS WITHIN NORMAL LIMITS DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: LATERAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #2: MEDIAL EPICONDYLITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, WARM TO TOUCH -PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT ARM DUE TO PAIN Diagnosis #3: BURSITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -RIGHT ELBOW PAIN, RED AND SWOLLEN PATIENT IS HOLDING HIS -PAIN IS SHARP, 6/10 INTENSITY RIGHT ARM -TENNIS PLAYER -ROM RESTRICTED ON RIGHT SIDE -UNABLE TO EXAMINE RIGHT Diagnostic Studies: ARM DUE TO PAIN -CBC -UA -X-RAY RIGHT EPICONDYLE -CT RIGHT ELBOW -BONE DENSITY SCAN