Case of the Month #10, Presentation

The Case:

A 49 year old man without any past medical history presents with R hip pain for 2 months. The pain is nonradiating, worse with flexion of the R hip, walking, or bending forward. Over the past month, he reports occasional night sweats, increased fatigue, 10lbs of unintentional weight loss, and decreased appetite.

His work involves a lot of stairs, heavy lifting, and standing on his feet. He denies any recent injuries and has been living in Brooklyn for the past 20 years.

ROS: Negative for fevers, chills, vomiting, skin changes, extremity/joint pain or swelling, hematuria, dysuria, back pain, numbness, weakness, change in bowels, recent sick contacts, hematemesis, melana, BRBPR, cough, hemoptysis.

Soc Hx: Occasional etoh, +cigarette smoking daily, occasional crack use, denies IVDA

VS 146/82, T 100 orally, HR 100, SaO2 99%, FS 92, RR 17

Gen: well developed, no apparent distress

HEENT: PERRLA, EOEMI, moist mucus membranes, no scleral icterus or palor

Pulm: CTAB without w/r/r, no resp distress

CV: s1s2 appreciated, no murmur, rubs, or gallops

Skin: no acute lesions

Back: no CVAT/midline bony tenderness

Abd: soft, nondistended, bs+, minimal RLQ tenderness with deep palpation. No rebound or guarding

Ext: Significant pain with active flexion of R hip. No pain with passive ROM of R hip, internal/external rotation, or active extension of R hip. Otherwise, NV intact, no edema, ecchymosis or tenderness to palpation x 4 extremities. Full and painless ROM of b/l upper extremities and L lower extremity.

1. What are your top three differential diagnoses? You leading diagnosis?

2. What is the next step in working up this patient?

Mostly by Dr Andrew Kopping

Also by Dr. Andrew Grock