Question

Case Study: A 52 year old man enters your office complaining of pain in the left elbow after being hit in the elbow with a polo ball while playing in a tournament. It was during the third chukker that he took the hit and continued to play through the pain, completing the tournament. He is in your office on Tuesday morning, after having RICE’d the injury since Sunday. Hint: He is an overweight, outa-shape, smokin’ (before quitting with the help of an acupuncturist in Hong Kong, two years ago), drinkin’ (but can control enough for his job), party animal, an international pilot who flies 757’s.

You will need to describe, in detail, what questions you might ask during the consultation, what procedures you will conduct during the examination and what further testing you will order. In every instance, you will develop and modify a working diagnosis, based on the findings during consultation and examination and after receiving the test results. Depending on what findings are arrived at with each step, your working diagnosis will need to be adjusted. Ultimately, based on the body of information gathered, you will arrive at several possible diagnoses, at which time, you will need to lay out your plan to differentially diagnose the condition. Recall that your diagnosis must satisfy the las of parsimony. Assume the worse. Ultimately, this patient died, needlessly.

Answer 1

Focussed assessment of musculoskeletal system contains the following key components in the checklist

Subjective findings	Yes	No
Ask the patient about any of the following symptoms and note the responses Do you have a feeling of stiffness in your elbow joint? Have you experienced any weakness of the afected extremity? Do you have pain over the joint while moving? Do you have any movement restriction of the affected arm?
Objective: Diagnostic findings X-ray: standard X-ray determines the bone density . Evaluates structural or functional changes of bones and joints. To rule out fracture Dual energy-xray absorptiometry: used to diagnose metabolic bone disease Bone scan: Involves injection of radioisotope that is taken up by the bone . Uniform uptake is normal, increased uptake is seen in osteomyelitis,osteoporosis, primary and secondary malignancies of bone Arthroscopy: used for visualizaton of joints . Can be used for exploratory surgery; repair of joint structures , diagnosis of abnormalities of meniscus,articular cartillage, ligaments or joint capsules Blood studies Alkaline phosphatase: this enzyme produced by osteoblasts of bone is needed for mineralization of bone matrix. Elevated levels are found in healing fractures, bone cancers, osteoporosis,osteomalacia and paget's disease Calcium: provides bone with rigid structure. Decreased serum level is found in osteomalacia , renal disease and hypoparathyroidism Elevated levels are seen in hyperparathyroidism Phosphorus: decreased level is found in osteomalacia. Increased level is found in chronic kidney disease, healing fractures and osteolytic metastatic tumour Serologic studies Rhematoid factor: assess presence of auto antibody in serum. RA factor is not specific for rheumatoid arhtritis , can be seen in other connective tissue disorders and in small population Elevated Sedimentation rate: non-specific index of inflammation. Elevated levels are seen in rheumatoid arthritis, respiratory infections,rhematic fever and osteomyelitis AntinuclearAntibody(ANA): assess presence of antibodies capable of destroying nucleus of body's own cells. Finding is positive in 95% of patients with SLE and may also be positive for patients with sclerodema and rheumatoid arhtritis Uric acid: levels are usually elevated in conditions like gout C-Reactive Protein(CRP): used to diagnose infections, inflammations and wide spread of malignancies
Physical Examination Skeleton and extremities( compare sides) for alignment, contour, symmetry size and gross deformities Joints for Range Of Motion, tenderness or pain, heat, crepitus and swelling Muscles (compare sides) for size, tone , symmetry and tenderness or pain Bone for tenderness or pain

The most possible for the diagnosis of his condition is Lateral Epicondylitis( Tennis elbow)

patient will experience dull pain on outer aspect of elbow , worsens with twisting and grasping motions

Significance: partial tearing of tendon at it's insertion on epicondyle usually caused by repetitive motions of wrist and arm.