AMD: DNIF NO FR/DR/MR MEMBER TO SEE LOCAL FSO FOR RTFS
RTFS
RTFS – Patient doing well without residual symptoms. Will return patient to flight status. Up 2992 issued. Pt
instructed to rtc if sx return. Otherwise f/u prn.
AMBIEN
Cont FLY - Will dispense ambien for operational use. Member ground trialed with out adverse effects. Admin 6 hr
verbal DNIF after last dose.
DRHA
Pt is a XX y/o ADAF Flyer presenting for DRHA. No acute deployment concerns. IMR up to date. No active FR
Profiles. No active waivers. DRHA3 Completed s/p deployment to Qatar via telephone.
DX: Z02.89
96160
96127
98969 (no physical exam – phone)
Ortho Assessment and Plan
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Tylenol PRN for pain. Note pt reports no allergy to Tylenol
Discussed rest, ice, elevation
Educated on Physical Therapy
Recommended avoiding positions that cause pain
Recommended against exercising through pain, but may exercise otherwise
Follow up in one month or earlier if symptoms worsen
Handout provided with stretching and strengthening techniques
F/U PRN or for increased pain
Low Back Assessment and Plan
Suspect paraspinal muscle spasm with SIJ pathology. Benign history. No neurologic deficits or midline tenderness
to indicate need for imaging. Recommended (Torodol 60 mg IM x 1 in clinic now, Ultram 1-2 tabs po q6 for next four
days, Flexeril 10mg qhs. Document quarters and need for profile. F/U in 6-8 wks if no change or sooner if sx persist
or worsen.
Or
SI Joint Dysfunction
CONT FLY – Suspect SIJ pathology. Benign history. No neurologic deficits or midline tenderness to indicate need
for imaging. Pt declines fitness restriction at this time, still has ability to run over 100 yards. Recommend: NSAID for
pain, heat/ice to reduce inflammation/pain, avoiding positions that cause discomfort. Handout given addressing SIJ
dysfunction and stretching techniques to use for home rehab. Resistance bands given with strength exercises
explained and demonstrated in clinic. Discussed benefit of OMT and massage. Pt to f/u in clinic in 2 weeks if sx not
improved or sooner for increased pain or loss of function.
Myofascial Pain
Suspect myofascial pain today, likely due to overuse. Benign history. No neurologic deficits or
midline tenderness to indicate need for imaging. Recommended Naproxen 500 mg bid prn.
Down 2992 with RTFS instructions given. F/U with medics on site if increased pain, loss of
sensory/motor function develop, or if sx worsen.
General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without
difficulty.
Skin: Good turgor, no rash, unusual bruising or prominent lesions
MSK: Normal gait and station. No misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal
strength or tone in the spine, ribs, pelvis or extremities.
Neuro: Sensation to pain, touch, and proprioception normal. DTRs normal in lower extremities. No pathologic
reflexes.
Heart: Regular rate and rhythm, no murmurs, gallops, or rubs
Resp: Clear to auscultation no adventitious sounds
Back: Spasm of left lower paraspinal muscles noted. Spine normal without deformity or tenderness, no CVA
tenderness
Carpal Tunnel
Suspect pain due to exposure to repetitive motions of the hand and wrist. Reassuring no
paresthesia, motor deficits, or nocturnal pain. No indications for imaging today. If symptoms
persist then consider evaluation for carpal tunnel as thenar atrophy observed on PE with positive
Phalen test. Conservative management to include NSAID for pain, neoprene wrist splint to
provide support during training, and pt educated on avoiding positions/activities increasing
symptoms. Encourage alternating ice/heat prn for comfort. Down 2992 issued with RTFS
procedures briefed. Pt to RTC if numbness, tingling, loss of motor function, or pain increases. If
in the field then f/u with SERE medics on site.
PHA
No critical or priority items. Pt states he read and understands the WEB HA counseling. No health concerns or
issues at this time. Medical record and 2766 were reviewed and updated.
Or
Patient is here today for annual PHA. He has no chronic medical conditions or issues and is not currently on any
medications. Physical exam is unremarkable. ASIMS update accomplished
Or
Isolated Elevated BP
Consistent elevated BP over ? years. Initiate 5 day BP check over 2 weeks and re-evaluate. Discussed need for
weight loss, diet change, and cardiovascular activity X3 per week. If BP consistently high then consider therapeutic
mgt with medication.
Elevated BP. Member is a healthy male/female participating in SERE training. No cardiac risk
factors identified. Pain, increased activity, and decreased access to food/water contributing
factors. If BP elevated at next visit, consider further evaluation.
Essential Hypertension
Dx made after significant history and 5 day BP check. Will start on ACE I inhibitor today (Lisinopril 10mg), EKG
added to note, and will accomplish BMP 7-10 days after medication therapy initiated. Discussed side effects of
medication needing immediate f/u to include urinating more or less than usual/not at all, fever/chills/body aches, tired
feeling, muscle weakness, pounding heartbeats, chest pain, swelling, or rapid weight gain. Less serious side effects
to include cough, dizziness/drowsiness/headache, depressed mood, nausea/vomiting/diarrhea/upset stomach, or
mild skin itching/rash are possible but unlikely. Pt to f/u if any of these sx develop. Will recheck BP after 2 weeks of
medication therapy accomplished.
HTN TX
Hey dude, according to the new JNC8 guidelines, the first line therapy for
HTN should be
1) HCTZ
Then add
2) ACEI or ARB if max on HCTZ and not controlled.
Then add
3) CCB if still not controlled
Its ok to start with CCB or ACEI/ARB if AfAm, as they tend to respond better
to these.
NEVER use ACEI and ARB together without consulting a nephrologist first.
Remember to check a BMP at the 7-10day mark to look for 30% cr bump, no
more.
All these people need Low salt diet counseling, exercise counseling, and a
microalbuminuria check annually.
Additionally, we need to make sure that once we diagnose HTN, we screen for
other comorbidities that can increase CV risk (DM2, Hyperlipid, tob use).
Urinary Tract Infection
CONT DNIF - Suspect UTI, verified with lab results. Recommend bactrim twice daily x 3 days and pyridium prn for
pain. Discussed importance of hydration and frequent urination as well as ways to prevent future infections. Down
2992 currently in system for other medical reason. Pt to rtc if blood in urine, fever develop, or sx worsen.
Travelers Diarrhea VS Gastroenteritis
Suspect a viral gastroenteritis vs travelers diarrhea. Although pt traveled do an endemic region for malaria, low
concern for malaria without cyclic fevers, no hepatomegaly, and development of diarrhea, especially in a patient who
was adequately prophylaxed and is currently taking daily doxy dose. Recommended: Imodium – patient
declines/accepts give dose
Offered Tylenol – patient declines/accepts give dose. Encourage aggressive hydration, slow/clear diet advancement,
and frequent handwashing FU/RTC for worsening, changes, or developments
Benign history with benign non-surgical abdominal exam. Suspect viral gastroenteritis. Reassuring no hematochezia
or focal pain or fevers. Orthostatic, but still tolerating PO hydration. Recommended: soft/liquid diet with slow
progression as tolerated, no caffeine, sugar drinks or spicy food until sx resolved. Offered Imodium, Zofran prn for
n/v, Tylenol for body aches – follow up prn for fever, worsening pain, or change in sx.
ENTERITIS
DNIF x 3 - Benign history with benign non surgical abdominal exam. Suspect viral enteritis. Reassuring no
hematemesis or focal pain or fevers. Not orthostatic, but currently not attempting PO hydration. Recommended: IV
fluids which pt declines, Zofran prn for n/v, Tylenol/motrin for HA/body aches which pt has at home, soft/liquid/BRAT
diet with slow progression as tolerated, including gatorade, no caffeine, sugar drinks or spicy food until sx resolved.
Down 2992 issued, 48 hr qtrs given. Follow up prn for fever, abdominal pain, change/worse sx.
URI with ETD
DNIF x 5 – Suspect natural progression of viral URI with eustation tube dysfunction without progression to
bronchitis/pneumonia/gastro at this time. Reassuring vitals, normal pulse ox, and pulmonary exam however will
continue to monitor right ear pain as it was red and dull upon visual inspection. Discussed expected
duration/progression of condition. Symptomatic mgt to include analgesic, which pt has at home, sudafed, mucinex,
cepacol loz, and saline nasal spray today. Down 2992 issued. Discussed means to manage possible throat pain via
warm tea with honey or salt water gargles. Encouraged utilization of sinus rinse, which can be purchased on the
local economy, and warm air humidifier in the home. Pt to return to clinic if fevers, continued ear pain, worsening sx,
persistant cough X 3 mo. For routine issues f/u with provider.
Upper Respiratory Infection
Suspect natural progression of viral URI without progression to bronchitis/pneumonia/gastro at this time. Reassuring
vitals, normal pulse ox, and pulmonary exam. Discussed expected duration/progression of condition. Symptomatic
mgt to include analgesic and decongestant today and 48 HR quarters given. Discussed means to manage possible
throat pain via warm tea with honey or salt water gargles. Pt to return to clinic if fevers, worsening sx, persistant
cough X 3 mo. For routine issues f/u with provider.
Acute Sinusitis
Suspect acute sinusitis today. Reassuring vitals, normal pulse ox, and lung exam. Discussed pathophys and
expected duration/progression of condition. Recommended: pseudophed for congestion, mucinex, flonase, nasal
wash, and motrin for pain. Down 2992 issued. Discussed means to manage throat discomfort to include warm tea,
honey, and salt water gargles. TRC/call for fevers or worsening sx.
Acute Pharyngitis
Suspect acute viral pharyngitis today. Reassuring vitals, normal pulse ox, and negative centor criteria. Discussed
pathophys and expected duration/progression of condition. Recommended: pseudophed for congestion, nasal
wash, and Tylenol prn for pain/fevers which pt has at home. Down 2992 given. 24 hours QTRS given. Discussed
means to manage throat discomfort to include warm tea, honey, and salt water gargles. Encourage hydration.
TRC/call for fevers or worsening sx.
Labyrinthitis
DX made after assessment of sx. Benign hx, no neuro deficits to indicate further work up. Negative Dix-Hallpike test.
Symptomatic mgt to include meclizine, zofran, and nasal saline spray as well as 48 hr QTRS. Discussed expected
duration/progression of condition. ASIMS reviewed, no down 2992 issued as pt DNIF for other reasons. Quarters
form printed and given to member in clinic. Pt to rtc/ER if unilateral sensory/motor dysfunction, slurring of speech,
headache, or sx worsen. For routine issues f/u with provider.
Herpangina
Suspect herpangina after development of ulcerations on tonsillar pillar, upper pallet, posterior pharyngeal wall, and
buccal mucosa. Rapid strep test preformed with negative results. Discussed DC sudafed and motrin use due to
current daily therapy of naproxen. Discussed pathophys and expected duration/progression of condition.
Recommend: viscous lidocaine, cardiac precautions given. Pt to continue salt water gargles, warm tea with honey to
manage throat pain. Encourage continued hydration. No down 2992 given as pt currently DNIF, 48 hour QTRS
given today. TRC/call for fevers, inability to tolerate fluids po, or worsening sx.
Conjunctivitis
DNIF x 3 days - Suspect conjunctivitis. Reassuring no change in vision, no abrasions to cornea visualized during
woods lamp with fluorescein stain exam. Recommend polymyxin gtts. Down 2992 issued, 24 hour QTRS given to
prevent spread of infection. Discussed importance of frequent hand washing and disinfection of home/work areas.
F/U if vision change or sx worsen.
Subconjunctival hemorrhage
Suspect subconjunctival hemorrhage secondary to trauma today. Reassuring no change in vision, no abrasion to
cornea visualized during fluorescein stain exam. Due to field conditions recommend erythromycin ophthalmic
ointment bid for 5 days as preventative, natural tears prn to promote comfort and healing. Stressed importance of
abstaining from touching eye with hands to prevent infection. Cosmetic appearance of eye should resolve in 2-3
weeks and pt can expect slight yellow appearance as the injury heals. Down 2992 issued with RTFS instructions
given. Pt encouraged to contact IDMTs if vision change or symptoms worsen.
Acne Vlugaris
Sx not resolved with oral/topical antibiotic therapy. Will try course of Accutane X 16 wks to prevent further scarring.
Will order base line labs today of LFT, CBC, and Lipids. Pt denies HI/SI today - will monitor labs/affect monthly.
Specifically discussed risks and benefits of medication. Pt informed to research medication on his own to be fully
informed of side effects. Pt to dc medication and return to clinic if depression/mood disturbance, change in vision,
SOB/chest/AND pain, bleeding, muscle pain, blood in stool/urine, HI/SI. Pt to return to clinic monthly for repeat LFT,
CBC, Lipids and evaluation after medication therapy initiated.
ACCUTAINE 20mg: T1T PO QAM / T2T QHS daily FOR TREATMENT OF ACNE NOT TO EXCEED 60MG PER
DAY. RF: 3 QTY: #90
Obesity
Discussed risks of obesity and health benefits of weight loss. Discussed risk associated with supplements and
weight loss aids. Offered nutrition and exercise assistance. Pt declines at this time.
Insomnia
***Shift Work Insomnia
Shift work with swing shifts. Denies Depression, SI/HI. Never before tried, so will try on an off day to watch for
parasomnias. Does not carry firearms.
-- Discussed proper sleep hygiene and routines.
-- Discussed r/b/a of Ambien and possible side effects.
-- Never with alcohol.
Follow up as needed.
***Sleep Initiation Insomnia
Sleep Initiation Insomnia. Low suspicion for PTSD association or anxiety or depression. no SI/HI. May be
exacerbated by alcohol use.
AUDIT C Expanded Score of 5 --> Normal
Discussed appropriate Sleep Hygiene
-- Scheduled bedtime with prebed routine
-- Only Sleep/Sex in bed, no other activities
-- No TV/Reading in Bed
-- Only allow 20mins to sleep, then get out of bed to perform a non-stimulating activity (read, etc)
-- No exercise within 4 hours of bedtime
-- No eating within 2 hours of bedtime
-- No Caffeine after 4PM
Follow up with me after trial of strict Sleep Hygiene for 4 weeks. If still no improvement, may consider:
-- Ambien for Initiation Insomnia
NO ETOH USE/DRIVING/WEAPONS WHILE TAKING THIS MEDICATION. TRY MEDICATION WHEN YOU ARE
ABLE TO DEDICATE 8 HOURS TO SLEEP AND DO NOT NEED TO BE RELIABLE THE NEXT DAY. STOP FOR
DEPRESSION, PARASOMNIAS.
***Sleep Maintenance Insomnia
Sleep Maintenance Insomnia. Low suspicion for PTSD association or anxiety or depression. no SI/HI.
Discussed appropriate Sleep Hygiene
-- Scheduled bedtime with prebed routine
-- Only Sleep/Sex in bed, no other activities
-- No TV/Reading in Bed
-- Only allow 20mins to sleep, then get out of bed to perform a non-stimulating activity (read, etc)
-- No exercise within 4 hours of bedtime
-- No eating within 2 hours of bedtime
-- No Caffeine after 4PM
NO ETOH USE/DRIVING/WEAPONS WHILE TAKING THIS MEDICATION. TRY MEDICATION WHEN YOU ARE
ABLE TO DEDICATE 8 HOURS TO SLEEP AND DO NOT NEED TO BE RELIABLE THE NEXT DAY. STOP FOR
DEPRESSION, PARASOMNIAS.
Low suspicion for PTSD association or anxiety or depression. No HI/SI. May be exacerbated by weekly travel to
multiple time zones as he travels on staff with the General. Discussed proper sleep hygiene and routines to include
schedule bedtime with pre bed routine, only sleep/sex in bed. No other activities, no tv/reading in bed, only allow
20min to sleep, then get out of bed to perform a non-stimulating activity (reading/yoga), no exercise within 4 hours of
bedtime, no eating within 2 hours of bed time, and no Caffeine after 4 PM. F/B/A of ambien and possible side effects.
Pt has used Ambien 10mg in the past with success and requests medication today to take when he arrives back on
station and needs to reset his circadian rhythm. Pt informed of NO ETOH USE/DRIVING/WEAPONS WHILE
TAKING MEDICATION. USE MEDICATION WHEN HE IS ABLE TO DEDICATE 8 HRS TO SLEEP AND DO NOT
NED TO BE RELIABLE THE NEXT DAY. STOP FOR DEPRESSION, PARASOMNIAS. Pt to f/u as needed.
Pt unable to sleep due to noise from CPAP and results in fatigue the next day. Was given 50mg Trazodone by
provider at last base for this reason, as of now pt is not using CPAP. Low suspicion for PTSD association or anxiety
or depression. no SI/HI. May be exacerbated by alcohol use.
-- Discussed proper sleep hygene and routines.
-- Discussed r/b/a of Trazodone and possible side effects.
-- Never with alcohol.
Pt to f/u as needed
Tobacco Cessation
Tobacco cessation. Completed first cessation class. Low suspicion for PTSD association or anxiety/depression. No
SI/HI. Pt will begin rx therapy 2 wks prior to quit day then apply 1 patch daily to replace dip. Pt to begin with 1/2 dose
zyban then increase to full dose after 3 days. Stop therapy if depression/anxiety, extreme agitation, insomnia,
persistent headache, nausea, tremor, or seizure occur. For routine issues f/u with provider.
STD
Full STD panel drawn today. Discussed s/s of disease process, how spread, how soon sx appear, treatment, and
prevention. Stressed importance of safe sex practice. Will contact patient with positive results. Pt to return to clinic if
s/s of infection, rash on palms/soles, urethral discharge, or fever develop. For routine issues f/u with provider.
STI Check (PRO)
Member requesting routine STI labs. Pt does not have any symptoms of STI’s. Member is in a monogamous
relationship and both partners wish to transition to non-barrier contraceptive methods. Counseled on safe sex
practices. Will follow up with results. No DNIF.
Long Term NSAID use
Discussed long term risks of NSAID use including bleeding, dyspepsia, peptic ulcer disease, bleeding of stomach,
liver damage, kidney toxicity, increase risk of hypertension and cardiovascular disease
Laceration Repair
Closure performed. Risks, benefits, alternatives discussed. Consent obtained. Prepped and draped in usual sterile
fashion. Anesthesia: 1% Lidocaine without epi, 5-0 nonabsorbable suture x ?? placed. Good hemostasis, good
cosmetic results, patient tolerated procedure well., topical antibiotic applied, sterile dressing applied, splint applied
and secured with ace wrap in buddy tape fashion in position of function to prevent movement due to wound oriented
over joint. No complications, less than 1 ml blood loss. Local wound care discussed. Motrin prn for pain which pt has
at home. Profile offered which pt declined. Observe for signs of infection, bleeding, and follow up promptly if these
symptoms occur. Suture removal in 7-10 days.
Allergic Reaction to Bee Sting
Reaction is considered mild today as swelling localized to site of sting. Possible sensitization however reassuring no
tachycardia, wheezing, or systemic rash. Recommend Benadryl 25 mg po tonight and prn if sx persist to mitigate
histamine response, hydrocortisone 1% topical bid for pruritus. Consider systemic steroid if sx persist. Down 2992
issued. Discussed pathophysiology and concern for increased risk of systemic reaction with future bee stings. Pt
educated on s/s of anaphylaxis, avoiding insect stings, dress in layers while outside, avoid swatting at bees, and
when current symptoms expected to resolve. RTC if sx persist or worsen. ER precautions given. Follow up with
home station FSO for RTFS.
Deployment Chemoprophylaxis/Afghanistan
CONT FLY – Pre-deployment malaria chemoprophylaxis needed prior to deployment to Afghanistan. Member has
normal G6PD and immunizations are all up to date. Use of Doxy will be initiated 2 days prior to departure/through
entire deployment and 28 days after return. Discussed preventative measures and side effects of RX. Pt to f/u with
forward location if adverse s/s occur.
SIG: T1T PO QD for prevention of malaria. Begin 2 days prior to departure and 28 days after return.
CONT FLY - Pre-deployment malaria chemoprophylaxis needed prior to deployment to Qatar. Member has normal
G6PD and immunizations are all up to date. Use of Malarone/Primaquine to be given in case forward deployment to
Afghanistan. Discussed preventative measures and side effects of RX. Pt to f/u with forward location if adverse s/s
occur.
ROS
GENERAL: fever, chills. body aches, fatigue, any recent weight change
HEENT: HA, dizziness, vision/hearing changes, glasses/contacts, hoarseness, ear pain, sore throat, sinus pain
NECK: stiffness, pain, swollen glands
RESP: cough, wheeze, shortness of breath
CARDIO: chest pain, palpitations, edema
GI: N/V/D, constipation, abdominal pain, stool changes, appetite changes, rectal bleeding
GU: urine changes, pain with urination, discharge, last urine output: today
MS: joint pain, joint swelling, bone pain, muscle pain, decreased mobility
SKIN: itching, dry skin, erythema, warmth, rashes, lesions, skin changes
NEURO: numbness, tingling, strength changes, tremors, loss of balance
PSYCH: anxiety, depression, SI/HI.
OBJECTIVE
General:
WDWN, NAD, AOx3
Integumentary
Size, distribution, color, shape, (macule, papule, pustule, etc), location, and secondary findings (crust, scale, exudates, etc)
Head
Normocephalic with even hair distribution; no masses or swelling.
Hair texture is normal without infestations; scalp has no scaling or lesions. Mastoid is non-tender and without discoloration
bilaterally.
TMJ non-tender and without swelling bilaterally. No pain, popping or locking with ROM bilaterally. Able to clench teeth with
temporalis and masseter
Muscles, CN V intact. Able to smile, raise eyebrows, show teeth, frown, puff out cheeks, and keep eyes closed with resistance CN
VII intact.
Eyes
No exophthalmos, ptosis, periorbital discoloration, edema, or skin lesions of eye, brows, lashes or lids bilaterally.
No injection, icterus, lesions, edema or foreign bodies of conjunctiva or sclera bilaterally.
No swelling and no regurgitation of lacrimal ducts bilaterally.
Visual fields are full and equal to examiner bilaterally,
CN II intact
EOMs intact and equal without nystagmus, no lid lag bilaterally
Eyes converge equally and pupils constrict with near focus bilaterally
No strabismus observed with cover/uncover and Hirshberg test bilaterally
Pupils are equal, round, and reactive to light and accomodation bilaterally (PERRLA), CN III, IV and VI intact
No crescent shadow bilaterally
Eyes: Fundoscopic Examination
Red reflex present bilaterally
Cornea, anterior chamber, lens, and vitreous are clear without opacities, haze or encroachments bilaterally.
Disc color is ______, margins are sharp, and cup-to-disc ratio is 1:2 bilaterally.
AV ratio is 2:3 without nicking or spasms bilaterally
There are no hemorrhages or exudates of the fundus bilaterally
No lesions on macula bilaterally
Ears
Auricles and Tragus are without lesion or discoloration and are non-tender bilaterally
EAC without swelling, redness, or obstruction bilaterally
TMs are pearly gray and translucent; light reflex is ant-inf. quadrant; pars tensa, pars flaccida, umbo, handle of malleus visualized
and undistorted
bilaterally
No fluid behind TM bilaterally
No deficit with whisper test, CN VIII Intact; Weber equal bilaterally; Rinne AC>BC bilaterally
Nose and Sinuses
Nose is midline and without lesions or tenderness
Nasal passageways are patent bilaterally
Able to discriminate between odors, CN I intact
mucosa is pink and moist without lesions; septum is without perforations; Unable to visualize superior turbinate, middle, inferior
turbinates without polyps, edema, exudates or discharge bilaterally
No maxillary or frontal sinus tenderness bilaterally
Mouth and Throat
Lips are pink, mucosa moist without lesions, swelling or discoloration
Tonsils are [grade size] and equal with midline uvula; no exudates or lesions
No discoloration or lesions of the tongue
No stones or obstructions in Stenson’s/Wharton’s ducts bilaterally
Lips, tongue, gingival, and buccal mucosa without edema, masses, or lesions
Tongue is midline and able to move side to side, CN XII intact
Teeth are in good repair and nontender
Uvula rises with phonation and gag reflex is present, CN IX, CN X intact
Neck
Neck is without lesions, swelling, discoloration and musculature is symmetrical
Trachea is midline and mobile
No lymphadenopathy/tenderness of the occipital, pre and postauricular, submental, submandibular, tonsillar, superficial cervical,
deep cervical, posterior cervical, supra and infraclavicular lymph nodes bilaterally
Thyroid is normal size, shape, and consistency without nodules or tenderness
Neck has full active ROM without pain with flexion/ extension/ righ and left lateral bending, and right and left rotation
Head rotation and shoulder shrug strength __/5 bilaterally,
CN XI intact
Basic Respiratory and Cardio exam
A/P chest is CTAB without adventitious sounds
RRR without M/G/R
Respiratory
A/P chest is symmetric without lesions, cyanosis, or deformities
A/P diameter is less than lateral diameter
A/P chest without masses, crepitus, or tenderness, symmetric expansion with inspiration
A/P tactile fremitus equal in all fields
A/P resonant with no areas of dullness (percussion)
A/P CTAB with no adventitious sounds.
No egophony, bronchophony or whispered pectoriloquy of the A/P chest
Cardiovascular
No lifts or heaves, PMI non-displaced
No vibrations/thrills
RRR without M/R/G, no fixed splits
No murmur of aortic regurgitation
Carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibialis pulses are graded _____ bilaterally
No cyanosis/clubbing/Edema of fingers/toes. Cap refill less than 2 seconds
Abdominal aorta is ___cm without lateral pulsations
No tibial edema bilaterally, skin temp is warm bilaterally
No carotid, aortic, renal, iliac, or femoral bruits bilaterally
Abdomen
No discoloration, lesions, or scars. Contour is ____ with visible aortic pulsations
NABS in the 4 abdominal quadrants and epigastrium
No discomfort or large areas of dullness with percussion in the 4 abdominal quadrants. No dullness to percussion in the stomach or
bladder
Liver size estimated at _____cm at R MCL
No areas of dullness with percussion anterior to midaxillary line, no change in tympani with inspiration
No tenderness, guarding, or rigidity in all 4 quadrants with light palpation. No masses or rebound tenderness with deep palpation
Liver edge is smooth and nontender
Spleen is nontender and not enlarged
Negative Psoas
Negative Obturator
No CVA tenderness
SOAP Notes Format in EMR
SOAP stands for Subjective, Objective, Assessment, and Plan
Standard Elements of SOAPnote
Date: 08/01/02
Time:
Provider:
Vital Signs:
Height, Weight, Temp, B/P, Pulse
S: This ___ yr old fe/male presents for ____
History of Present Illness symptoms:
Review Of Symptoms/Systems: (For problem-focused visit, document only pertinent information)
Past Medical History: (For problem-focused visit, document only pertinent information)
Current Medications:
Medication allergies:
Social History: (For problem-focused visit, document only pertinent information)
Family History: ((For problem-focused visit, document only pertinent information)
Genogram: 3 generations with health problems, causes of deaths, etc.
or
History of major health or genetic disorders in family, including early death, spontaneous abortions
or stillbirths.
History of Present Illness:
Location:
Quality
Severity:
Duration:
Timing (Onset):
Timing (Frequency):
Context:
Relieved by:
Worsened by:
Associated signs and symptoms:
Social History:
Cultural Background:
Education Level:
Economic Condition:
Housing:
Number in household:
Marital Status:
Lives with:
Children:
Occupation:
Occupational Health
Hazards:
Nutrition:
Exercise:
Tobacco use:
Caffeine:
Sexual activity:
Contraception:
Alcohol/recreational drug
use:
Past Medical History
Hospitalizations:
Surgical History:
T&A:
Appendectomy:
Hysterectomy:
Hernia:
Coronary Artery Bypass:
Other:
Chronic Medical Problems:
Hypertension
Diabetes
Coronary Heart Disease
Cerebrovascular Disease
Asthma or other COPD
Arthritis
Gout
Renal Disease
Thyroid Disease
Other:
Psychiatric History:
Depression
Anxiety
Substance Abuse
Other:
Immunizations:
Polio
Tetanus
Last PPD
Cholera
Childhood Illnesses:
Transfusions:
Allergies:
Review Of Symptoms (Systems):
Constitutional:
Eyes:
Ears, Nose, Mouth, Throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Skin and/or breasts:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Family History
Is there a family history of
Cancer:
Hypertension:
Hyperlipidemia:
Diabetes Type II:
Coronary Artery Disease:
Stroke:
Alzheimer's:
Depression:
Osteoporosis:
Domestic violence:
\\cluster1\home\nancy.clark\1 Training\EMR\SOAP Note.doc
O: (listed are the components of the all normal physical exam)
General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect .
Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising or prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi
have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant
resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: RRR no murmurs gallops or rubs.
Lungs: Clear to auscultation no adventitious sounds
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses
intact
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal
strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, normal mood
and affect.
Pelvic: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametria nontender
without masses.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or
supraclavicular adenopathy.
G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes
and epididymides normal size without masses, scrotum without lesions.
A:
Assessment:
Includes health status and need for lifestyle changes.
Diagnosis and differential diagnosis:
P:
Laboratory:
X-Rays:
Medications:
Patient Education:
Other:
Follow-up:

o
general shoulder exam
 inspection
 palpation


o
o
o
o
o
o
o
ROM
neurovascular exam
impingement tests
rotator cuff tests
labral injury tests
biceps injuries tests
AC joint
instability
other
Inspection
 Skin
 Scars
 Symmetry
 Swelling
 Atrophy
 Hypertrophy
 Scapular winging
Palpation
 All bony prominences around shoulder girdle (AC joint)
 Muscles and soft tissues including
o deltoid
o rotator cuff tendon insertion / greater tuberosity
o trapezius
o biceps tendon in groove
Range of Motion (patient supine)
 Compare active and passive motion, both sides, with the patient in
seated or standing position
 Six planes of motion should be examined and documented
o forward elevation (150-180° considered normal)
 active
o external rotation at 90 degrees abduction
 active
o external rotation at side
 active
o abduction
 active
o internal rotation to vertebral height (T4-T8 considered normal)
 active
o internal rotation at 90 degrees abduction
Neurovascular Exam




Sensation
o check dermatomes of following nerves
 axillary
 musculocutaneous
 medial Brachial/Antebrachial Cutaneous
 median
 radial
 ulnar
Motor
o Deltoid, Biceps, Triceps, Extensor Pollicis Longus, Flexor
Digitorum Profundus, Dorsal Interossei
Vascular
o brachial, radial, ulnar artery pulses
Differential
o cervical radiculopathy
o suprascapular neuropathy
o brachial neuritits
Impingement
 t Sign
o indicative of impingement of rotator cuff tendon/bursa against the
coracoacromial arch

technique
 use one hand to prevent motion of the scapula
 raise the arm of the patient with the other hand in forced
elevation (somewhere between flexion and abduction)
 pain is elicited (positive test) as the greater tuberosity
impinges against the acromion (between 70-110°)
 note you must have full range of motion for "positive"
finding.
Neer Impingement Test
o positive when there is a marked reduction in pain from
above impingement maneuver following subacromial lidocaine
injection
o technique
 usually a combination of
 4cc 1% Lidocaine
 4cc 0.50% Bupivicaine (Marcaine)
o

other abnormalities can produce a positive test including
 stiffness
 OA
 instability
 bone lesions




2cc corticosteroid)
Hawkins Test
o positive with impingement
o technique
 performed by flexing shoulder to 90°, flex elbow to 90°, and
forcibly internally rotate driving the greater tuberosity farther
under the CA ligament.
Jobe’s Test
o positive with supraspinatus weakness and or impingement
o technique
 abduct arm to 90°, angle forward 30° (bringing it into the
scapular plane), and internally rotate (thumb pointing to
floor).
 then press down on arm while patient attempts to maintain
position testing for weakness or pain.
Internal Impingement
o patient supine or seated
o abduct affected side to 90° and maximally externally rotate
(throwing position-late cocking phase) with extension
o if this maneuver reproduces pain experienced during throwing
(posteriorly located) considered it is considered positive.
o further confirmed with relief upon performing relocation test
o re-perform test in abduction/max
o ER with elbow in front of plane of body and pain disappears.
Rotator Cuff Pathology
Subscapularis Tests
 Subscapularis Strength
o do not test with isolated IR strength with the arm at the side due
to contribution of pectoralis major and latissimus dorsi
 Internal Rotation Lag Sign
o this tests is the most sensitive and specific test for subscapularis
pathology.
o technique
 stand behind patient, flex elbow to 90°, hold shoulder at 20°
elevation and 20° extension. Internally rotate shoulder to
near maximum holding the wrist by passively lifting the
dorsum of the hand away from the lumbar spine – then
supporting the elbow, tell patient to maintain position and
release the wrist while looking for a lag.

Increased Passive ER
o

a person with a subscapularis tear may have increased Passive
ER rotation when compared to contralateral side
Lift Off Test
more accurate for inferior portion of subscapularis.
o technique
 hand brought around back to region of lumbar spine, palm
facing outward; Test patient’s ability to lift hand away from
back (internal rotation). Inability to do this indicates
subscapularis pathology. Is confounded by other muscles.
More accurate if the tested hand can reach the contralateral
scapula.
Belly Press
o test positive with subscapularis pathology
 more accurate for superior portion of subscapularis
o technique
 patient presses abdomen with palm of hand, maintaining
shoulder in internal rotation. If elbow drops back (does not
remain in front of trunk)
o

Supraspinatus Tests
 Supraspinatus Strength
o strength is assessed using Jobe’s Test (see below) – pain with
this test is indicative of a subacromial bursitis/irritation – not
necessarily a supra tear. Only considered positive for tear with a
true drop arm. i.e. arm is brought to 90° and literally falls down.
 Jobe’s Test
o tests for supraspinatus weakness and/or impingement
o technique
 abduct arm to 90°, angle forward 30° (bringing it into the
scapular plane), and internally rotate (thumb pointing to
floor). Then press down on arm while patient attempts to
maintain position testing for weakness or pain.

Drop Sign
o
o
tests for function/integrity of supraspinatus
technique
 passively elevate arm in scapular plan to 90°. Then ask the
patient to slowly lower the arm. The test is positive when
weakness or pain causes them to drop the arm to their
side.
Infraspinatus


Infraspinatus Strength
o external rotation strength tested while the arm is in neutral
abduction/adduction
External Rotation Lag Sign
o positive when the arm starts to drift into internal rotation
o technique
 passively flex the elbow to 90 degrees, holding wrist to
rotate the shoulder to maximal external rotation. Tell the
patient to hold the arm in that externally rotated position. If
the arm starts to drift into internal rotation, it is positive.
Teres Minor
 Teres Minor Strength
o external rotation tested with the arm held in 90 degrees of
abduction
 Hornblower's sign
o positive if the arm falls into internal rotation it may represent teres
minor pathology
o technique
 bring the shoulder to 90 degrees of abduction, 90 degrees
of external rotation and ask the patient to hold this position
Pectoralis
 Axillary Webbing
o
look for a defect in the normal axillary fold. A deformity may be indicative of an pectoralis major
muscle rupture
Labral Injuries and SLAP lesions
 Active Compression test ("O'Brien's Test")
o positive for SLAP tear when there is pain is "deep" in the
glenohumeral joint while the forearm is pronated but not when the
forearm is supinated. technique


patient forward flexes the affected arm to 90 degrees while keeping the elbow fully
extended. The arm is then adducted 10-15 degrees across the body. The patient then
pronates the forearm so the thumb is pointing down. The examiner applies downward
force to the wrist while the arm is in this position while the patient resists. The patient then
supinates the forearm so the palm is up and the examiner once again applies force to the
wrist while the patient resists.
Crank Test
o positive when there is clicking or pain in the glenohumeral joint
o technique
 hold the patient's arm in an abducted position and apply
passive rotation and axial rotation.
Biceps Injuries
 Bicipital Groove Tenderness
o may be present with any condition that could lead to an inflamed
long head biceps tendon and a SLAP lesion
 Speed's Test
o positive when there is pain elicited in the bicipital groove
o technique
 patient attempts to forward elevate their shoulder against
resistance while they keep their elbow extended and
forearm supinated.
 Yergason's Sign
o positive when there is pain in the bicipital groove
o technique
 elbow flexed to 90 degrees with the forearm pronated. The
examiner holds the hand/wrist to maintain pronated position
while the patient attempts to actively supinate against this
resistance. If there is pain located along the bicipital groove
the test is positive for biceps tendon pathology.
 Popeye Sign
o present when there is a large bump in the area of the biceps
muscle belly. Consistent with long head of biceps proximal tendon
rupture.
AC Joint
 Acromioclavicular joint tenderness
o tenderness with palpation of the acromioclavicular joint
 Cross-Body Adduction
o positive when there is pain in the AC joint
o technique
 patient forward elevates the arm to 90 degrees and actively
adducts the arm across the body.
 Obrien's Test (Active Compression test)
o positive when there is pain "superficial" over the AC joint while the
forearm is pronated but not when the forearm is supinated
o technique
 patient forward flexes the affected arm to 90 degrees while
keeping the elbow fully extended. The arm is then adducted
10-15 degrees across the body. The patient then pronates
the forearm so the thumb is pointing down. The examiner
applies downward force to the wrist while the arm is in this
position while the patient resists. The patient then supinates
the forearm so the palm is up and the examiner once again
applies force to the wrist while the patient resists.
Instability
GRADING OF TRANSLATION OF
HUMERAL HEAD
1+ translation to glenoid rim
2+ translation over glenoid rim but reduces
3+ translates and locks out of glenoid
Anterior Instability

Anterior Load and Shift
positive when there is increased translation compared to the
contralateral side
o technique
 have the patient lie supine with the shoulder at 40-60
degrees of abduction and 90 degrees of forward flexion.
Axially load the humerus and apply anterior/posterior
translation forces. Compare to the contralateral side.
Apprehension and Relocation
o positive test if the patient experiences the sensation of instability
o
technique
 have the patient lie supine. Apprehension test performed by
bringing the arm in 90 degrees of abduction and full
external rotation and patient experiences sense of
instability. Relocation test performed by placing examiner's
hand on humeral head applying a posterior force on the
humeral head. Patient will experience reduction or
elimination of sense of instability.
Anterior Release
o positive test if the patient experiences instability when examiner's
hand is released
o technique
 have the patient lie supine. Examiner places hand on
humeral head to keep reduced as arm is brought into
abduction/external rotation. Examiner's hand is removed
and the humeral head subluxes causing sense of instability.
NOTE: positive anterior release is really a "3 in 1" test - if it
is positive, apprehension and relocation are also positive.
Anterior Drawer
o



o
o
positive if there is sense of instability when compared to the
contralateral side
technique
 stablize the scapula and apply an anteriorly directed force
against the humeral head with the contralateral hand.
NOTE: graded 1+, 2+, and 3+ but this only documents
amount of laxity, not pathologic unless causes symptoms.
Posterior Instability
 Posterior Load and Shift
o positive if there is increased translation compared to contralateral
side
o technique
 lie the patient supine with the shoulder in 40-60 degrees of
abduction and 90 degrees of forward elevation. Load the
humerus with an axial load and apply anterior/posterior
forces to the humeral head. Compare the amount of
translation with the contralateral side.
 Jerk Test
o positive if there is a 'clunk' or pain with the maneuver
o technique
 have the patient sit straight up with the arm forward
elevated to 90 degrees and internally rotated to 90 degrees.
Apply an axial load to the humerus to push it posteriorly.
 Posterior Drawer
o positive if there is increased translation when compared to the
contralateral side
o technique
 stabilize the scapula and apply a posteriorly directed force
against the humeral head with the contralateral hand.
 Posterior Stress Test
o positive if there is pain and sense of instability with the maneuver
o technique
 Place the patient's arm in flexion, adduction, and internal
rotation and apply a posteriorly directed force.
 Loss of External Rotation
o a shoulder that is locked in internal rotation may be subluxed
posteriorly.
Multidirectional Instability (MDI)
 Sulcus Sign
o
have the patient stand relaxed with their arms at their side. Grab
their affected arm and pull it inferiorly. If there is a sulcus that
forms at the superior aspect of the humeral head, the test is
positive. Sulcus is considered positive if it stays increased (2+ or
3+) with ER at side (pathologic rotator interval).
1+
2+
3+
Sulcus grading
acromiohumeral interval < 1cm
acromiohumeral interval 1-2
cm
acromiohumeral interval > 2cm
Other
 Wright's Test
o test for thoracic outlet syndrome.
o positive if the patient losses their radial pulse
o technique
 passively externally rotate and abduct the patient's arm
while having the patient turn their neck away from the
tested extremity.
 Medial Scapular Winging
o test for serratus anterior weakness or long thoracic nerve
dysfunction.
o positive if the inferior border of the scapula migrates medially
o technique
 while standing, have the patient forward flex their arm to 90
degrees and push against a wall (or other stationary object).
 Lateral Scapular Winging
o test for trapezius weakness or spinal accessory nerve (CNXI)
dysfunction
o positive if the inferior boarder of the scapula migrates laterally
o technique
 while standing, have the patient forward flex to 90 degrees
and push against a wall (or other stationary object).
Elbow…

A traumatic injury pattern of the elbow characterized by
elbow dislocation (often associated with posterolateral dislocation
or LCL injury )
o radial head or neck fracture
o coronoid fracture
Pathophysiology
o mechanism
 fall on extended arm that results in a combination of
 valgus, axial, and posterolateral rotatory forces
 produces posterolateral dislocation
o pathoanatomy
 structures of elbow fail from lateral to medial
 LCL disrupted first
 anterior capsule injured next
 possible MCL disruption
Prognosis
o historically poor outcomes secondary to
 persistent instability
 stiffness
 arthrosis
o


Anatomy
 Radial head
o a primary restraint to posterolateral rotatory instability (PLRI)
o secondary valgus stabilizer
o forearm in neutral rotation, lateral portion of articular margin
devoid of cartilage
 roughly between radial styloid and listers tubercle
 Coronoid process
o provides an anterior and varus buttress to ulnohumeral joint
o resists posterior subluxation beyond 30 deg of flexion
o fracture fragment typically has some anterior capsule attached
 useful in repair
 Medial collateral ligament
o three components
 anterior bundle
 most important to stability, restraint to valgus and
posteromedial rotatory instability
 inserts on sublime tubercle (anteromedial facet
of coronoid)
 specifically inserts 18.4mm dorsal to tip of
coronoid process
posterior bundle
 transverse ligament
Lateral collateral ligament
o inserts on supinator crest distal to lesser sigmoid notch
o the primary restraint to posterolateral rotatory instability
o four components
 lateral ulnar collateral ligament (most important for stability)
 radial collateral ligament
 annular ligament
 accessory collateral ligament
o when injured is usually avulsed off of the lateral epicondyle


Presentation
 Symptoms
o patients complain of pain, clicking and locking with elbow in
extension
 Physical exam
o possible varus / valgus instability patterns
o distal radial ulnar joint must be evaluated for possible EssexLopresti injury
Imaging
 Radiographs
o evaluate for concentricity of ulnohumeral and radiocapitellar joints
o line drawn through center of radial neck should intersect the
center of the capitellum regardless of radiographic projection
o evaluate lateral radiograph for coronoid fracture
o need prereduction and postredcution films
o consider PA and lateral films of wrist and forearm when indicated
 CT
o often utilized for better evaluation of coronoid fracture
o 3D imaging for determining fracture line propagation
Treatment
 Nonoperative
o immobilize in 90 deg of flexion for 7-10 days
 indications (rare)
 ulnohumeral and radiocapitellar joints must be
concentrically reduced
 radial head fx must not meet surgical indications
 coronoid fx must be small
elbow should be sufficiently stable to allow early ROM
technique
 one week of immobilization followed by progressive
ROM
 active motion initiated with resting splint at 90
degrees, avoiding terminal extension
 static progressive extension splinting at night after 4-6
weeks
 strengthening protocol after 6 weeks



Operative
o ORIF versus radial head arthroplasty, LCL reconstruction,
coronoid ORIF, possible MCL reconstruction
 indications
 terrible triad elbow injury that includes an unstable
radial head fracture, a type III coronoid fracture, and
an associated elbow dislocation
 coronoid fractures involving less than 10% of the
coronoid do not confer elbow stability in cadaveric
studies and therefore do not require repair
 should instability persist after addressing the
radial head and the LCL complex in the
presence of a small coronoid fracture, the next
best step is MCL reconstruction
Techniques

ORIF vs replacement of radial head, coronoid ORIF, LCL
reconstruction, and possible MCL reconstruction
o approach
 posterior skin incision advantageous
 allows access to both medial and lateral aspect of
elbow
 lower risk of injury to cutaneous nerves
 more cosmetic
o technique
 radial head ORIF vs. arthroplasty
 radial head ORIF indicated if non comminuted
fractures that involve < 40% articular surface
 1.5, 2.0, or 2.4mm countersunk screws
 plate if necessary; 2.0 plates cause minimal
loss of motion even when placed on radial neck
 plate position should be posterolateral
safe zone: 90-110 arc from radial styloid
to Lister's tubercle with arm in neutral
rotation
 radial head arthroplasty indicated for comminuted
radial head fxs
 implant should articulate 2mm distal to the tip of
the coronoid process
 radial head resection without replacement is
NOT indicated in presence of Essex-Lopresti
lesion or in ligamentously injured elbows
 if <25% head damaged or fragments not
reconstructable and nonarticulating, can excise
fractured portion if elbow stable (rarely
indicated)
 coronoid ORIF
 can be fixed through radial head defect laterally
 sutures, suture anchors, screws, or rarely plate
fixation.
 suture passed through 2 drill holes
 posterior to anterior lag screws if fragment large
 basal coronoid fxs (rare) fixed with
anteromedial or medial plate on proximal ulna
 LCL repair
 usually avulsed from origin on lateral epicondyle
 reattach with suture anchors or transosseous
sutures
 must be reattached at center of capitellar
curvature on lateral epicondyle
 if MCL is intact, LCL is repaired with forearm in
pronation
 if MCL injured, LCL is repaired with forearm in
supination to avoid medial gapping due to
overtightening
 repairs are performed with elbow at 90 degrees of
flexion
 MCL repair
 indicated if instability on exam after LCL and fracture
fixation, especially with extension beyond 30 degrees
postoperative
 elbow fixators - hinged or static

o
consider when instability is noted after complete bone
and soft tissue repair
immobilization
 immobilize elbow in flexion with forearm pronation to
provide stability against posterior subluxation
 if both MCL and LCL were repaired, splint in flexion
and neutral rotation


Complications





Instability
o more common following type I or II coronoid fractures
Failure of internal fixation
o most common following repair of radial neck fractures
 poor vascularity leading to osteonecrosis and nonunion
Post-traumatic stiffness
o very common complication
o initiate early ROM to prevent
Heterotopic ossification
o consider prophylaxis in pts with head injury or in setting of
revision surgery
Post-traumatic arthritis
o Due to chondral damage at time of injury and/or residual
instability
Next
Introduction
Overuse injury involving eccentric overload at origin of common extensor tendon
leads to tendinosis and inflammation at origin of ECRB
Epidemiology
incidence
most common cause for elbow symptoms in patients with elbow pain
affects 1-3% of adults annually
commonly in dominant arm
demographics
up to 50% of all tennis players develop
risk factors
poor swing technique
heavy racket
incorrect grip size
high string tension
common in laborers who utilize heavy tools
workers engaged in repetitive gripping or lifting tasks
most common between ages of 35 and 50 years old
men and women equally affected
Pathophysiology
mechanism
precipitated by repetitive wrist extension and forearm pronation
common in tennis players (backhand implicated)
pathoanatomy
usually begins as a microtear of the origin of ECRB
may also involve microtears of ECRL and ECU
pathohistology
microscopic evaluation of the tissue reveals
angiofibroblastic hyperplasia
disorganized collagen
Associated conditions
radial tunnel syndrome
is present in 5%
Prognosis
non-operative treatment effective in up to 95% of cases
Anatomy
Common extensor origin
muscles that originate from lateral supracondylar ridge
extensor carpi radialis longus
muscles that originate on lateral epicondyle
extensor carpi radialis brevis
extensor carpi ulnaris
extensor digitorum
extensor digiti minimi
anconeus
shares same attachment site as ECRB
Ligaments
lateral ulnar collateral ligament
Nerves
posterior interosseus nerve (PIN) enters the supinator just distal to the radial head
compression can lead to radial tunnel syndrome (may co-exist with lateral epicondylitis)
Presentation
Symptoms
pain with resisted wrist extension
pain with gripping activities
decreased grip strength
Physical exam
palpation & inspection
point tenderness at ECRB insertion into lateral epicondyle
few mm distal to tip of lateral epicondyle
neuromuscular
may have decreased grip strength
neurological exam helps to differentiate from entrapment syndromes
provocative tests
the following maneuvers exacerbate pain at lateral epicondyle
resisted wrist extension with elbow fully extended
resisted extension of the long fingers
maximal flexion of the wrist
passive wrist flexion in pronation causes pain at the elbow
Imaging
Radiographs
recommended views
AP/Lateral of elbow
findings
usually normal
may reveal calcifications in the extensor muscle mass (up to 20% of patients)
may reveal signs of previous surgery
MRI
not necessary for diagnosis
increased signal intensity at ECRB tendon origin may be seen (up to 50% of cases)
thickening
edema
tendon degeneration
Ultrasonography
requires experienced operator (variable sensitivity/specificity)
most useful diagnostic tool in experienced operator hands
ECRB tendon appears thickened and hypoechoic
Studies
Histology
histopathological studies of the ECRB tendon tissue shows
fibroblast hypertrophy
disorganized collagen
vascular hyperplasia
Diagnosis
diagnosis is primarily based on symptoms and physical exam
Differential
Posterolateral plica
Posterolateral rotatory instability
Radial tunnel syndrome
palpation 3-4 cm distal and anterior to the lateral epicondyle
pain with resisted third-finger extension
pain with resisted forearm supination
Occult fracture
Cervical radiculopathy
Capitellar osteochondritis dissecans
Triceps tendinitis
Radiocapitellar osteoarthritis
Shingles
Treatment
Nonoperative
activity modification, ice, NSAIDS, physical therapy, ultrasound
indications
first line of treatment
techniques
tennis modifications (slower playing surface, more flexible racquet, lower string tension, larger grip)
counter-force brace (strap)
steroid injections (up to three)
physical therapy regimen
acupuncture
iontophoresis/phonophoresis
extracoproeal shock wave therapy
outcomes
up to 95% success rate with nonoperative treatment, but patience is required
Operative
release and debridement of ECRB origin
indications
if prolonged nonoperative (6-12 months) fails
clear diagnosis (isolated lateral epicondylitis)
intra-articular pathology
contraindications
inadequate trial of nonsurgical treatment
patient noncompliance with the recommended nonsurgical treatment
Techniques
Release and debridement of ECRB origin
open
incision is positioned over the common extensor origin
lift ECRL off of ECRB (located deep and posterior to ECRL)
excise degenerative tissue
decorticate epicondyle
repair capsule if breached
side-to-side closure of tendon
arthroscopic
advantages include visualization and ability to address and intraarticular pathology
resect lateral capsule anteriorly (do not pass midradial head to protect LUCL)
release ECRB from origin (where muscle tissue begins)
decorticate lateral epicondyle
Complications
Iatrogenic LUCL injury
excessive resection of the LUCL
should not extend beyond equator of radial head
may lead to posterolateral rotatory instability (PLRI)
Missed radial nerve entrapment syndrome
common in up to 5% of patients with lateral epicondylitis
Iatrogenic neurovascular injury
radial nerve injury
Heterotopic ossification
decrease risk with thorough irrigation following decortication
Infection
Missed concomitant pathology (i.e. PLRI, radial tunnel)