What is the appropriate management for an 84-year-old man presenting with acute left elbow swelling and a history of osteoarthritis?

SOAP Note for 84-year-old Male with Acute Left Elbow Swelling

Subjective

• 84-year-old male presents with 2 days of left elbow swelling
• History of osteoarthritis
• No reported trauma
• Pain with movement

Objective

• Vital signs: Within normal limits
• Physical exam: Left elbow with visible swelling, erythema, warmth
• Range of motion: Limited due to pain and swelling
• Tenderness on palpation of the olecranon
• No obvious deformity or joint instability

Assessment

Acute inflammatory flare of osteoarthritis of the left elbow with possible effusion requiring immediate management with anti-inflammatory medication and consideration for joint aspiration.

Differential diagnoses:

• Osteoarthritis flare (most likely given history)
• Septic arthritis (requires urgent evaluation)
• Crystal arthropathy (gout/pseudogout)
• Olecranon bursitis
• Cellulitis

Plan

1. Imaging:

   • Radiographs of the left elbow (AP and lateral views) to assess for joint space narrowing, osteophytes, loose bodies, and to rule out fracture 1
   • Consider comparison with contralateral elbow if radiographs are inconclusive 1

2. Laboratory studies:

   • Complete blood count with differential
   • ESR and CRP to assess inflammation
   • If septic arthritis is suspected, joint aspiration for cell count, crystal analysis, Gram stain, and culture

3. Pharmacologic management:

   • Begin with ibuprofen 400-600mg orally every 6 hours with food for anti-inflammatory effect (if no contraindications) 2
   • If patient has renal impairment, cardiovascular disease, or GI risk factors, consider acetaminophen 1000mg every 6 hours instead 1
   • Consider intra-articular corticosteroid injection if pain is moderate to severe and infection has been ruled out 1

4. Non-pharmacologic management:

   • Rest and elevation of the affected limb
   • Local cold applications for 15-20 minutes every 2-3 hours to reduce swelling 1
   • Temporary immobilization with sling for comfort

5. Follow-up:

   • Reassess in 3-5 days to evaluate response to treatment
   • If symptoms worsen or fail to improve within 48 hours, consider joint aspiration to rule out infection 3
   • If mechanical symptoms develop (locking, catching), consider MRI to evaluate for intra-articular pathology 1

6. Patient education:

   • Explain that osteoarthritis can have acute flares requiring temporary intensification of treatment
   • Discuss importance of maintaining joint mobility once acute symptoms subside
   • Advise on weight management if applicable
   • Instruct on proper use of medications and potential side effects

7. Long-term management:

   • Consider physical therapy for strengthening exercises once acute inflammation resolves
   • Discuss assistive devices if needed for activities of daily living 1
   • Evaluate need for long-term pain management strategy