Diagnostic or therapeutic?

This is a new patient, 58 female who presents with acute on chronic left hip pain. She is slow to rise from the waiting room chair and limps to approach my room.  She describes two months of increasing left hip pain.

There are two components – a deep pain with a pointing sign to the groin crease and a pain that tracks down the lateral thigh. There was no recalled trauma or prior history.

On examination there was both tenderness over the greater trochanter, a positive Trendelenburg sign and positive impingement tests (FABER and flexed int/ext rotation).  Interestingly this patient had previous had a plain radiograph and CT at St Elsewhere which were reported as essentially normal.  However this was not in keeping with her symptoms and signs of significant left hip pain and disability.

I felt this was a combination of trochanteric bursitis/gluteal tendonosis and a internal hip derangement.  After a talk that I thought there were two problems, without prophesying about what was the chicken or egg, we decided to organise MRI and perform a diagnostic/therapeutic trochantric bursa injection.   lefthip

There was only slight benefit to the injection for the patient with a persistence of the deep and positional left hip ache.  MRI demonstrated significant chondral loss, fissuring and bone oedema, out of keeping with the radiograph and CT.  There was no identified labral injury.  Now I feel this is a right gluteal and tensor fasciae latae tendonosis as a sequelae to left hip chondral loss.

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The value of a normal test result

This week I had a infrequent patient in, last seen in 2014, generally fit and well, non-smoking 35year old male.  He presented with left sided sharp chest pain that had come on suddenly while walking on the beach 36hours prior.  He rated the pain as 5/10, worse with deep inspiration and cough, relieved by lying down. There were no fever, sweats, productive cough or other infection symptoms. On examination normal RR, HR, BP, SpO2 and chest clear to auscultation and percussion. He is a tall, skinny man and with the other normal findings and history, a spontaneous small pneumothorax is a differential. Previously I would have sent this man for an erect CXR but with ultrasound there in the room we can look directly.

alines
Normal A-Line Lung ultrasound profile between two anterior rib spaces, the Bat Wing sign. Normal pleural sliding on video “ants marching”

So reassured about an absence of pneumothorax there was reassurance, assumption this was chest wall/intercostal muscle pain and a safety net plan for follow up if needed.

I called the patient 48hours post their consultations and all symptoms had resolved.

By having US available in the room, the patient was saved a trip to the radiologist, Medicare saved the cost of a radiograph and I was saved time following up the result.  Ruling out of pneumothorax with POCUS is one of the uses that has the highest specificity with sensitivity 86–98% and specificity 97–99%.