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Case - July 18, 2007 8:09:15 AM
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Dr.Wagner
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A 67-year-old woman presents to the Emergency Department with pain in her chest and right shoulder after falling out of bed while on vacation. She states that she has problems with "fragile bones" and has had several previous fractures caused by apparently minimal or incidental trauma. The patient’s medical history is significant for avascular necrosis of her right hip, for which years ago she underwent a total hip arthroplasty. The patient reports that she routinely takes pills to control inflammation and pain. She has no history of smoking or alcohol abuse.
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RE: Case - July 18, 2007 9:05:17 AM
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FLAOrthoPT
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From: West Palm Beach
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contol inflammation: steroids or non steroidal?
let's get an x-ray of chest and shoulder
any bruising or any thing else that alerts to abuse?
what are vitals like?
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RE: Case - July 18, 2007 11:39:07 AM
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SJBird55
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Where and when did previous fractures occur?
Is there chronic steroid use in medication history?
What medications has she been prescribed, what medications is she taking, what over the counter stuff is she taking, what herbs/supplements is she taking? Has there been a change in her medications?
Why did she fall out of bed?
Has she been diagnosed with osteoporosis or osteopenia?
Has her Vitamin D level been assessed recently?
Did the pain in her right chest/shoulder begin after falling out of bed and the complaint coincides with the accident? When was she on vacation? How long after her falling incident is she now seeking emergency services?
Does she have any shortness of breath, difficulty breathing, fatigure, nausea?
Any constitutional symptoms?
Does she use an assistive device for ambulation?
How is her shoulder position maintained? How well does she move her shoulder actively?
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RE: Case - July 18, 2007 1:15:21 PM
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jma
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What were the results of the chest and shoulder x-rays, if they were done? Where were the previous fractures and when did those occur. How many times has she fallen in the past?
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RE: Case - July 18, 2007 3:05:40 PM
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Dr.Wagner
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On physical examination, the patient is awake and alert. Her heart rate is 100 bpm, her blood pressure is 174/82 mm Hg, her respiratory rate is 12 breaths per minute, and her oral temperature is 98.9°F (37.2°C). The patient’s heart rhythm is regular, no murmurs or gallops are heard, and the lungs are clear to auscultation. The abdomen is soft with normal bowel sounds. The skin examination reveals several hard nodules in the subcutaneous fat. One of the nodules appears to have resulted in a laceration associated with bleeding near the impact point of the fall.
Describe the xray, give the pathophysiology, and name the underlying condition.
 Attachment (1)
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RE: Case - July 18, 2007 7:08:40 PM
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SJBird55
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Wags, Wags, Wags... you aren't even answering any questions. Geesh. You jump right to a radiograph. Radiographs don't always diagnose, but they help confirm what you think might be going on and you haven't even entertained what might be going on to in thought processes with clinical findings and radiograph results.
Hard nodules in the subcutaneous fat where? What is her clinical presentation in the axillary area? What's it look like, what's it feel like?
The radiograph shows something more widespread than some bony problem with a history of multiple fractures.
Beats me what's going on and not being able to physically see the patient doesn't help. So, she's got nodules... not sure if on the radiographs if all that crap is superficial or deep... in the subcutaneous tissue? lymph nodes? I would guess probably not vascular in nature. There is a gray mass or something between her clavicle and cervical spine. Granted, Wags, you have to remember we are physical therapists. We don't diagnose diseases, but we do need to know when to treat and when to refer.
If there is a fracture or something with the humerus, I prefer 2 views. I can't tell much with the humerus.
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RE: Case - July 18, 2007 9:21:38 PM
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jma
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From: NY
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Wow, something look systemic on that radiograph! I'm sure Alex knows what that entails. Has there ever been a skin biopsy of any of those nodules?
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RE: Case - July 18, 2007 9:41:40 PM
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jlharris
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From: Nebraska
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Hyperparathyroidism?
PTH is released in too great of amount, calcium absorbtion from bone (and digestive track) is excessive (c/o fragile bones and osteoporosis), Calcium circulates in the blood stream and is deposited heterotophically. Bone pain is a common c/o which maybe the cause of her chronic antiinflammatory use.
Am I even close?
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Case - July 18, 2007 10:25:33 PM
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Dr.Wagner
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From: Indianapolis
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The answer tomorrow...hint...she takes medications for an underlying condition. These medications are predisposing her to fracture. Based on the radiograph, the osteoporosis on the film, the nodules on her skin...what might she be on chronically to treat disease?
Part two: describe the fracture.
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RE: Case - July 18, 2007 10:28:21 PM
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jma
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From: NY
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She might have been on a steroid for a long period of time, perhaps prednesone?
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RE: Case - July 19, 2007 6:42:47 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Is she on any stomach ulcer or acid-supressing medication?
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RE: Case - July 19, 2007 8:25:09 AM
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Shill
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From: Madison WI USA
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My guesses.
She seems to have a proximal humeral fx, minimally displaced, noticed at the lateral portion of the surgical neck. Obviously, the misshapen/deformed humeral head is severely degenerative. Perhaps the skin/cutaneous condition is scleroderma? Psoriatic arthritis? Graft versus host disease? (although I imagine you would have mentioned the BMT and/or AML/ALL history). Is there significance to the gray area over the anterior cervical triangle on the right? Yikes.
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RE: Case - July 19, 2007 8:27:39 AM
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Shill
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From: Madison WI USA
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Your attachment is entitled dermatomyo.jpg, so it must be dermatomyositis. You are going to have to be a bit more stealthy than that. Therefore I retract my prior guesses to dermatomyotis. Im just glad its not uromysotysis poisoning. (another Seinfeld ref).
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RE: Case - July 19, 2007 9:11:08 AM
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Dr.Wagner
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From: Indianapolis
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Don't read my attatchments...good grief...you cheated, regardless of my stealth-like ability.
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RE: Case - July 19, 2007 9:14:11 AM
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Dr.Wagner
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From: Indianapolis
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Dermatomyositis with a fracture through osteopenic bone secondary to steroid use: Further clinical investigation after the radiographs were viewed revealed that the patient was taking high doses of corticosteroids to treat her underlying medical condition of dermatomyositis. An idiopathic inflammatory myopathy, dermatomyositis is thought to have an autoimmune etiology. Dermatomyositis and polymyositis are commonly linked because of their overlapping symptoms, signs, and treatment. Their incidence is approximately 5.5 cases per 1,000,000, as Callen reported in 2006. The age distribution appears to be bimodal, with one peak at approximately 10 years of age and a second peak at approximately 50 years of age. Women are affected more often than men. In adults, dermatomyositis has been linked to an increased likelihood of cancer, particularly cancer of the lungs, breasts, ovaries, and GI tract.
Patients with dermatomyositis usually present with progressive proximal muscle weakness that affects the thighs, neck, upper back, and shoulders.
How to describe this fracture: Closed sub-capital proximal humerous fracture with minimal angulation.
Attachment (1)
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RE: Case - July 19, 2007 11:59:11 AM
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Shill
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From: Madison WI USA
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It wasnt really cheating. Its like when you were in school, and had an exam where the teacher forgot to erase the answers from the chalkboard. Who is not going to sneak a peak?
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RE: Case - July 19, 2007 12:19:46 PM
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Dr.Wagner
Posts: 1239
Joined: January 24, 2003
From: Indianapolis
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Come on...why else would you check the attachments? Really, I don't care, I am glad you are participating! Now that I can post films, expect MANY MANY more.
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RE: Case - July 19, 2007 12:41:20 PM
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Shill
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Joined: February 13, 2003
From: Madison WI USA
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I know you dont care that I "cheated". I know you arent that uptight! I clicked on the attachment as I thought it might be a different view. This was a great case, and thanks very much for doing them. I have on my schedule from time to time, a gentleman whom I have seen for multiple things in the past who has dermatomyositis, but he does not have any significant issues directly related to it, nor does he have the horrible appearing films such as these.
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RE: Case - July 19, 2007 2:44:33 PM
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orthotherapist
Posts: 206
Joined: February 6, 2007
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Shill,
UW must have taught us how to be inquisitive (I also opened the attachement thinking it may be a different view). I was about to post something about dermatomyositis and then I read your post - of course I would not have let on where I came up with the diagnosis like you did.
Thanks for posting these wags
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