There have been some good differentials supplied for my two new cases from yesterday. One of them has already been correctly diagnosed. THe other is ‘oh so close!’ Here is some additional informaiton i.e. physical exam findings that should help. One case should be easily diagnosed with this information, the other may remain elusive but with the differential narrowed with this info. Post any additional thoughts and tomorrow (unless my 12 hour flight shift prevents it) I will provide the correct answers. Winners will receive special highlight Mr. Hassle entries with tons of accolades and complements.
Case A) Summary”2 year old boy comes in after pulling on his fathers arm. Dad refused to let his own hand move, playing a game of “I’m stronger than you” with his son. Suddenly, he starts crying and refuses to use the arm he was tugging with. ”
Physical exam: He is crying, clinging to his mother with his right arm. His left arm hangs limp at his side. He is able to squeeze my hand on command (impressive for a 2 year old), his arm, shoulder, elbow and wrist display no swelling, echymosis, deformity, contusion or discoloration. He has full range of motion in all ranges of motion including pronation, supination, extension and flexion of the elbow, although he screams like a banshee when I do so. He has improved usage of his left arm and hand after my exam. At this point, I consulted the attending (with a #1 diagnosis in mind) and ordered x-rays, even though I was fairly certain they were not needed.
Case B) Sumary ” 74 year old lady unable to bear weight after slipping on wet leaves in her yard. Complains of pain right at the lateral junction of the tibia and femur. ”
Physical exam: She is seated in a wheelchair, in no distress. Her right knee displays full range of motion if she is allowed to bend and extend at her own pace. She has a very small knee effusion on exam. There is no popliteal mass or tenderness. she has intact quadriceps reflexes. There are no obvious deformities. Ankle exam is unremarkable. She has tenderness to palpation along the lateral joint line, just superior to the patellar tendon insertion, but not tibial tuberosity tenderness or deformation. AT this point I ordered an X-ray and the diagnosis was confirmed.