You have been participating in the annual Yellowstone Ski Festival, in West Yellowstone, MT. This event happens every year over Thanksgiving and provides an opportunity for you to get up on your Nordic skis before most other places in the West. The date is Sunday, November 25th. The festival is over. You and your party are packing up to head home.
Subjective/Summary/Story
The patient, a member of your entourage, is a 40-year-old male who is complaining of dull, achy pain and limited range of motion localized around his left elbow. The pain began on Friday evening, the 23rd, after two days of hard skate skiing--the first of his season. The pain is currently a 5-6 on a 1-10 scale. The elbow is very tender. Pain spikes to a 9 when it is bumped.
Objective/Observation/Findings
Patient is uncomfortable from the pain and is unable to move his arm through his full range of motion. Patient states, “I must have tweaked my elbow over the last couple of days and developed some acute bursitis.”
Patient Exam:
The left elbow is noticeably red and swollen. Swelling seems to extend several inches both distal and proximal to the elbow.
Vital Signs |
TIME |
0800 hrs, Nov 25 |
0800 hrs, Nov 26 |
|
LOR |
A+OX4 |
A+OX4 |
|
|
HR |
84, strong, regular |
86, strong regular (High for this patient. Normally 50-60) |
|
|
RR |
16, regular, easy |
16, regular, easy |
|
|
SCTM |
Pale, Warm, Dry |
Pale, Warm, Dry |
|
|
B.P. |
Not taken |
Not taken |
|
|
Pupils |
PERRL |
PERRL |
|
|
T° |
Not taken |
100°F oral |
|
History |
Symptoms: |
Patient is uncomfortable and fatigued |
|
Allergies: |
None stated |
|
|
Medications: |
Patient began taking 400 mg of ibuprofen every 4-6 hours for pain beginning at 0800 hrs on 11/24. |
|
|
Pertinent Hx: |
Patient denies any similar history. Patient states he has a history of elbow tendonitis and of small lesions on his elbow the week before related to some “eczema-like bumps” he has gotten on/off since childhood. |
|
|
Last in/out: |
Patient has been well-hydrated and his appetite has been good. Reports normal bowel function. Patient urinated clear urine this morning. |
|
|
Events: |
Patient skate skied hard for the first time this season on Nov22 and 23. Pain began evening of Nov23. Patient participated in a ski clinic on Nov24 and the elbow remained sore with limited range of motion throughout the day. |
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