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M9) Progressive chronic hip pain
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with joint pain.
- Review the DDx considerations in a patient with joint pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with joint pain.
History
A 76-year-old female comes into the clinic with worsening pain in her right hip when bearing weight on her right side over the last two years. It is worst at night (8/10) and improves with rest. She denies any prior history of trauma. She now cannot tie her shoelaces or put on her socks without help.
Physical Exam
BP: 125/90, HR 80, RR 15, Temp 99.0%, O2 saturation 100%. BMI: 35. General: The patient walks with a limp due to pain. Her gait has a prolonged swing phase. MSK: Decreased range of motion at the right hip due to pain.
Provisional Diagnosis
Select the Dx you believe is most appropriate
This patient with risk factors of older age and obesity presenting with decreased range of motion of the right hip, pain with increased weight bearing, and antalgic most likely has osteoarthritis. A hip fracture or dislocation is less likely considering the lack of history of trauma, gradual onset of symptoms, and ability to bear weight.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
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The patient requires routine workup.
First Imaging Study
What is the first imaging study you will order?
X-ray is the best initial evaluation for bony or joint space abnormalities.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
X-ray
There is a right hip fracture.
There are no fracture lines to suggest a fracture in the right femur or acetabulum.
There are abnormalities in the subchondral bone in the right hip.
There is increased density of the subchondral bone of the right femoral head and acetabulum due to inflammation of the right hip, representing subchondral sclerosis. There are also subchondral cysts in the subchondral bone, which are fluid filled spaces occurring secondary cystic degeneration.
There is joint space narrowing in the right hip.
There is severe joint space narrowing in the right hip.
There are osteophytes in the right hip.
There are osteophytes arising from the right femoral head and acetabulum, representing reactive bone in an attempt to repair articular damage.
The left hip is normal.
There is mild osteoarthritis of the left hip.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
The findings are confirmed with the X-ray.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient’s clinical presentation and findings are consistent with a diagnosis of osteoarthritis.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires routine workup and management as their condition is not immediately life or limb threatening.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is presenting with severe osteoarthritis of the right hip. They will be referred to a physical therapist and prescribed NSAIDs. The patient should also undergo dietary and exercise counseling for weight loss. If they fail a trial of conservative therapy, they will be referred to an orthopedic surgeon who specializes in joint replacement.
Lessons Learned:
- Risk factors for osteoarthritis include older age, obesity, and previous joint injury.
- Patients usually present with progressive pain that worsens with increased weight bearing throughout the day.
- The disease is progressive and gets worse over time and cannot be reversed. However, different treatments options can be utilized to try to slow the progression.
- Radiographs are a good initial imaging modality.
- Findings on radiographs include joint space narrowing, subchondral sclerosis, subchondral cyst formation, and osteophytosis.
Socioeconomic Factors: Even after adjusting for risk factors, those who are with lower education and in nonprofessional lines of work have been found to have increased prevalence of and morbidity from osteoarthritis.
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