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Chapter 1: What is the main topic discussed in this episode?
Welcome back, Clinical Problem Solvers. Maddie and Yousef here. At CP Solvers, our mission is to make clinical reasoning accessible to learners worldwide. We invite you to join us for our live virtual morning reports, where we break down cases and sharpen our diagnostic reasoning together. Now over to you, Yousef. Thanks, Maddy.
Just a quick reminder, this podcast is for educational purposes only and is not a substitute for medical advice. Patient details have been modified to protect their privacy and the views expressed are our own, not those of our employers. Now, let's dive into the case. Enjoy the show. Hello, friends. This is the CP Solvers podcast. I'm David from Spain.
I'm here today with Zachary, Justin, and Mariana. We're hearing today about a case from Austin. And yeah, we're just going to give a little bit update into our lives. I'm finishing my residency on July. And Yeah, I'm just trying to look for some jobs here in Spain that we have some troubles finding when we finish the residency, but hopefully I found some place to work.
And yeah, Zachariah, what about you? Hi, everyone. Hi, David. Really excited to discuss the case today. I'm actually moving across country. And before the session, we were talking about how moving is probably the worst thing on this planet in many ways. But yeah, excited for it to be over and for new life and to be back in Cape Town, which is one of the most beautiful cities in the world.
And passing it to Austin. Thanks so much. Nothing really new or exciting for me. The weather is starting to warm up here, spending a bit more time outside and in the park with my two-year-old. But yeah, I'll pass it to Mariana to fill us in on how she's been doing. I'm very glad to be here with you all today. And I'm very, very excited about this case. For me, no big changes.
I'm approaching the end of my intern year. Time flew by really, really quickly. And I'm very excited about the next years. And Davida, what are you going to do? Are you going to be a house police? Yes, I will try to. There are some difficulties regarding finding a job when you finish the internship in Spain.
But yeah, I like just generalist and differential diagnosis, so I will try to stay as a hospitalist. And yeah, Austin, let's start the case. Absolutely, and I know you'll succeed no matter what you do, but hopefully the job hunt goes smoothly. But to transition to the case, so for the first aliquot, this is a 60-year-old man who presents with elbow pain. Mariana, what do you think?
Very interesting. So elbow pain. I think I would decide trying to gather more information about this patient and also about his symptoms. So I would ask about the onset and time course because we want to know if the pain is acute or chronic. As acute pain raises concern for trauma or infection,
while chronic pain is more often related to degenerative or overused conditions, such as tendinopathies and osteoarthritis, for example. We can also think about a patient's age, because in a 60-year-old male, degenerative etiologies become much more likely, including OA and chronic tendinopathy, as I mentioned.
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Chapter 2: How does the team begin to assess the patient's elbow pain?
Everything seemed to be aligned appropriately. There was no effusion. The joint spaces were largely maintained, but there was focal soft tissue swelling about the dorsal elbow, which the radiologist labeled as nonspecific. And enthesopathy of the distal triceps insertion was noted. So, David, what do you think of the investigations? Yeah, thank you very much, Austin. Really interesting.
I think I won't invest too much energy on anemia and thrombocytopenia because they seem to be chronic and I think it's unlikely they are related to the current problem given the absence of systemic symptoms. For me, this looks like a problem pretty restricted to the elbow and particularly the olecranon.
The increased alphas makes it interesting and raise the possibility of osteoelastic lesions, but given cirrhosis and increased bilirubin, I think it may be a red herring. Also considering the X-ray is normal, I would wonder about the role of CT here, but I think it'd be useful to have prior labs to see if this is just a recent finding or has been present for a while.
If the R-plus was from bone origin, I would think this would represent more likely high bone turnover in the setting of secondary hyperparathyroidism given the NSAIDs' kidney disease. And I would like to know more about other bone parameters such as phosphate, calcium, and PTH. We've heard some pertinent negatives.
We don't see any leukocytosis in the labs, and I think this lessens a little bit the possibility of infection, but we have to keep in mind that a patient is immunosuppressed, as Zachariah was detailing. The x-ray being normal makes bone pathology less likely, but I think its sensitivity is pretty limited for other structures.
X-ray being normal, I think would exclude extra skeletal calcifications as can be seen sometimes in patients with CKD affecting bursas. The ultrasound being negative excludes DBT, and I think that's with confidence given our pre-test probability for this diagnosis was low.
The swelling is not very well evaluated by the x-ray, and I would try to get an US or an MRI to confirm if there is bursitis or to look for other collections. Yeah. What do you have for Austin? All right. So the way that things were synthesized at this point was that the patient was felt to have olecranon bursitis.
They were given a course of antibiotics, which were cephalexin and doxycycline, as well as some prednisone. They were seen in our primary care clinic about five days later. And unfortunately, they had had no improvement at all, despite the antibiotics and steroids.
Exam at that time noted obvious swelling and warmth over the right olecranon with tenderness to palpation, and now the patient also had pain with extremes of range of motion as far as flexion and extension. Point-of-care ultrasound was done and showed that there was evidence of a fluid collection in that area, and it appeared complex with multiple internal hypoechoic signals.
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