Chapter 1: What is the new book about that is mentioned in the episode?
Clinical Problem Solvers, our new book, will be out in a few weeks.
It is going to be epic, and we think you're going to love it. Welcome back, clinical problem solvers.
There's three clinical problem solvers right now. Three of them. Do you know why I was so energetic? How can I not be energetic when I'm seeing the beautiful, intelligent, and incredible Zobin?
Thank you. Don't stop, Reza. Keep going.
No, Robby, I've known Zalvin. Zalvin, has it been probably a decade almost? Yeah. I feel like early and... Crazy. I just always have been so impressed by you, my friend. And not only about your intellect, but how kind you are and how caring you are. The one person who always checks in on me, Robby, is Zalvin. I'm not even joking. I'll never forget that.
It's actually caused me to check in on other people because I'm like, man... Zalvin, who I don't see like every week, checks in on me. I'm going to check in on other people because I know how much it means. So thank you for that, Zalvin. How did you guys first meet? I don't know the story. So we were at this club and the dance floor, I see this handsome stud that I approached.
What was it? Was it maybe online first through like HumanDX and then SHM 2016-ish?
Yes, yes.
We're so few and far between people who are like as far along in Zabin's career who's still obsessed with diagnosis and clinical raising. It's really a really cool thing and a real gem.
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Chapter 2: How did the hosts meet and what is their relationship?
And I honestly would love to pass the mic to Prof for us to see what he's making of that.
Gosh, when he said he has a kid to present, I got really nervous. Zalman doesn't know how poorly I did on my Pete's rotation.
At least I'm that old now. We're like friends. Kids are nice. So that's that's how you got. That's your saving grace is our geriatric status.
It's so, so true. Yeah, I think that I'm viewing this as someone presumably healthy until Zobin shares more information. And the sudden onset often to me means that something has been obstructed, ruptured of that nature. So it's quite odd. And already Zobin, like I'm framing this as an atraumatic person. hip pain.
But as Robbie said, we have to understand the lay of the land to see exactly where this patient is experiencing discomfort and be open to the possibility that this can be referred. But the acuity, the hyperacuity just makes me worried that something rupture or get obstructed.
Cool. Okay. So here's a little bit more of the story. The pain is in the anterior part of the body, in sort of the groin anterior hip area. And again, he sort of felt this horrible pain and then like fell back in bed, like waited it out for a minute, I guess. And it did sort of settle down to a milder ache. But then when he tried to move again, same thing.
Eventually, he was able to kind of get up, go sort of, you know, wash up and hobble to his first class. And he took some ibuprofen on the way, but was sort of surprised at what this was. This really seemed to kind of come out of nowhere. He hadn't had any trauma, injury, hadn't fallen, hadn't even like played sports, um, uh, the last few days never happened before.
Um, and, uh, and then later that day, basically trying to like get up from sitting down in class, same thing, like it was bearable, but then that first movement was really bad. And then when he, once, once he'd start moving, it would actually like, it would still hurt, but it sounded like it was, it was better. And he was able to like, you know, kind of limp
limp around a little bit um that was the rest of the day basically and um we can be quick here i don't know if there's sort of too much more to say but um any comment on that sort of a feature of really bad first movement and then seems to like be a little more tolerable
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Chapter 3: What clinical case is presented in this episode?
But the hip pain actually lasts another day, day and a half. And then you get a text saying that the pain's gone, like it's better. It just sort of went away. He was taking like ibuprofen a few times a day. But other than that, you know, there wasn't any treatment or anything. It just kind of like petered out.
But the fever is actually, you get another call the next day that they keep going and they're actually like really high and really bothersome every night. 102, 103, 104. He sort of loads up on acetaminophen, ibuprofen, and eventually it kind of breaks. And then he just sleeps all night, kind of later into the morning than usual. but no other symptoms anywhere else.
So no new information here other than the fact of this hip pain that was so severe and prominent and the only localizing symptom kind of goes away after two days or so while the fevers continue.
Yeah, I think, Zalman, this is really helpful because now we can say the patient's inflamed. And I think once this case completely, you know, you tell us what happens, maybe this hip pain and its acute onset is going to be related to the fever. At time point zero, all our attention would be to the joint and making sure the patient doesn't have a septic joint.
But now that the pain has completely resolved, that is inconsistent with the possibility that you have an intra-articular infection. So now we have fever with no localizing symptoms. And probably no localizing sign. And it's persisted for a couple of days. And so I think the question that the patient's father would ask, he was like, does he need to go to the emergency department?
Is there something sinister that is brewing beneath? And he's a young guy. And I think if there is, I would actually be more worried about a fever without a localizing symptom than a fever with a localizing symptom. Because if you told me this kid is having upper respiratory symptoms or is having diarrhea, I'd be like, that's okay. Like it's going to hopefully resolve and you can monitor.
But when you say hip pain, that's gone away. And now fever, but otherwise feels fine. That makes me worried. And actually, honestly, it would prompt me to ask more about the social history. Particularly, what kind of activities does he do? Is he outdoors? Is he sexually active?
And if someone had fever for a number of days without an answer and is young, and like Robbie alluded to this, this patient probably has so much cardiovascular reserve being 19 years old and healthy. I'm very, very curious to see what his CBC shows, what his liver chemistry test shows, specifically with an attention to the ASC, ALT, and the platelet.
And then just getting a little more in terms of his social history, because we have inflammation without symptom, though the hip may ultimately... give us a sense of what this answer is. And that just makes me want to look internal. Is there anything else I can use as a clue to what might be driving this nonspecific inflammation? And I just, I would love to see what Robbie has to add.
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Chapter 4: What symptoms does the 19-year-old patient present with?
And your approach to that will be superb, but it'll be really interesting to back-talk and see what was the thing at the hip. And I'm wondering if it was something at the surface, because I have a hard time imagining that torsion, septic arthritis, has the ability to spontaneously fix itself. There are, of course, diseases that can do that, like crystalline diseases that I'm thinking of.
But yeah, I'm very, very intrigued by this sequence of events. It's certainly something I've never encountered or read about before.
Yeah, it's a weird case and it's going to get maybe a little weirder. You know, I think the crystalline hypothesis is great too because the anti-inflammatories could have been the treatment for that, right? But the persistence of the systemic inflammation, which can happen during the arthritis, that's what doesn't fit. I'm going to pause on this case for a second.
I know how much you guys love doing a case within a case. So I'm not going to present another unknown. I'm just going to tell you guys about... just a parallel case with some similarities and differences. Very briefly, that is very interesting. But maybe about a year ago, Simon, older kid, wakes up and he was five then, wakes up and Steph and I are in bed.
But I like, I hear his movement in the hallway. And usually he stomps and romps and runs, right? So it's usually like And then he comes into our room and is like, good morning, whatever. But this time, the sound of his movement is different. And I hear this slight little thudding and then pulling, like friction. And already something's off.
And indeed, he crawls into our room and he says the words, bop. I can't walk so good anymore. And like my heart rate just like jumped up. And I was like, oh, Simo, come on up. He got in bed. And I was like, what's hurting? And his hip was hurting. And I, you know, just sort of, like, kind of did, like, a little internal rotation, sort of rotation of the femur and the hip joint.
And indeed, like, that was the painful thing. And he wasn't letting me do that. And, like, he had femoral joint, like, synovitis. Like, it was... And I was like, oh, no. You know, like, it just immediately got a little worried. But, like, he's otherwise... well, like he wasn't hot, he wasn't anything. And, um, he had been sick the last few days, but just like, you know, another cold. Right.
Um, so, uh, I very quickly, but like some things like very old memories are binging in my, in my brain. And I like quickly Google stuff and, and realize that this is an extremely classic presentation of, um, Transient synovitis that happens in like three, four, five, six year old after a viral illness.
It's just like an inflammatory synovitis, most commonly of the hip, usually just unilateral sort of onset very much like this. So he basically just took ibuprofen for a couple of days and it completely went away. Um, and I talked to some pediatrician friends, like same, uh, you know, very quickly told me extremely classic that like the median age or the modal age is exactly five years old.
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Chapter 5: What are the significant findings from the patient's examination?
Hemoglobin was 11. His platelets are normal. All his chemistries and LFTs normal. UA normal. He gets a set of blood cultures drawn and those are pending for now, but that's all the blood work they did. But in the meantime, these next kind of few days, sort of day, I guess, I don't know, maybe it was five to 10 from initial symptom onset, he developed some more symptoms.
He develops multiple painful oral ulcers. He notices these red-purple bumps on the back of his knuckles, on both hands. They don't bother him. They're like, You know, don't hurt. They're kind of flat, like rubbery. But just like it's there. You know, he sees them. No skin lesions anywhere else.
His dad says that just on the phone, he sounds like just very uncharacteristically like moody and irritable. And in the last two days, his right knee started hurting. Again, like very prominent, painful, barely walking with a limp kind of thing. Looked a little swollen and was warm apparently. But yeah, but again, without any sort of preceding trauma or injury.
No other joints other than this knee. He's got a little headache with the fevers, but nothing sort of very prominent or persistent. And then still no chest, respiratory, urinary, eye, or GI symptoms other than just like not being able to eat well because of how painful the oral ulcers are.
Wow.
I... You know... The medicine is interesting, but I'm just putting myself in the position of this young kid's father and how scared they must be. Because I feel like there's three scenarios in medicine. You find an answer, and you can do something about it, the best case. You find an answer, you can't do something about it, still okay, because you can understand what to expect.
The worst case, where this kid is in right now, You don't have an answer and there's nothing you can do about it yet. This is dread. But as you were speaking, I'm going to definitely need Robbie's help because I don't think anyone recognizes patterns better than him. As you said oral ulcers, and then you said skin findings, my mind automatically converted that to a mucocutaneous illness.
Then you said the joint is swollen, and I was like, okay, mucocutaneous and monoarticular arthritis, and then you said some mood and irritability. Now, we use the word encephalopathy quite broadly, but now I'm wondering, do we have a multisystemic disease? showcasing itself, manifesting on the skin, the mucus, the joint, and the CNS. But there's one more very important element.
And what I'm trying to do deliberately here is create the problem representation. Robbie and I, Zavin, and I am sure you're on this camp, we put more emphasis on identifying the correct problem than ever before. Because a lot of people will just, they'll see the sodium and they'll go into treatment. But no, like you got to first make sure you're solving the right problem. So for me,
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