Telephonic consultation(orthopedic cases)

TELEPHONIC CONVERSATION WITH PATIENTS IN ORTHOPEDICS

“Listen to the patient, he is telling you the diagnosis.” Though in the field of medicine, telephonic consultation is avoided; but what if the patient trust us and calls to tell his problem; being physicians we should be ready for whatever case comes to us in which ever form. This article is based on how the physician has to ask the patient so as to reach to a conclusion for his diagnosis in orthopedics.

CASE – 1 

A 78-year old female, who probably slipped and had on the floor on the hips; presently suffers from severe pain in abdomen and the back region. She has been helped by her son to get up and walked till the bed. Now her son calls the doctor and asks his help.

Did u support her fully or she managed to walk on her own to bed?	No, she managed on her own, only initially we supported her.
Now when she is lying on bed, can she turn or having difficulty to get up?	She is crying on turning doctor. She’s experiencing excruciating pain.
Ok! Where’s the pain?	Severe on sides of lower portion of the back and a bit in thighs.
Check if her both feet look similar or one foot	Yes, they are looking similar.
Could you ask her to lift her legs on her own; one leg at a time.	She’s able do it.

This is a case of Osteoporotic Wedge Compression Fracture, involving the dorso-lumbar junction (its extremely common and mostly missed) because the patient can walk, can do things on her own. Sometimes the patient can come & say that he was going to pilgrimage (since morning till night) & by night complaints of pain which becomes excruciating by next day. The patient can also come to us with a history that he had a jerk while sitting on the chair when he thought that the chair is higher but it was lower.

Later on when the patient comes the physician should check for tenderness, not at lumbo-sacral junction but at dorso-lumbar junction or little lower in dorsal area because of appearance of ‘gibbus’ over there. But the important thing is that they are able to raise their leg actively and they were able to walk from bathroom till the bed, which is a differentiating feature to the fracture around the hip.

CASE – 2

A 40-years old male patient complaints about excruciating pain in left hand. He becomes restless. What can be done?

Since when the pain started?	Doctor, since 2-3 days & since yesterday night the pain became excruciating and even if he’s moving a bit, he’s having difficulty.
Are you experiencing the pain at the site where it began or it shifted to some other place? Does it is present in shoulder, neck or arm?	Little bit in left arm & in left chest also (max. pain in left arm).
Is there any difference in your pain if you look up or down with your neck movement?	Oh! I can’t look up at all doctor. If I move my neck to look up I feel severe pain.
Are you able to lift your arm in which you have(left in this case)?	No, I can do it on my own.
Rest your affected hand on your head. Is there any change in your pain when you do it?	Little bit pain is reduced. I can’t sleep at night and rather I prefer to sit. But if I try to make my hand as my pillow then I’m able to sleep.

This is a case of Cervico-Discogenic Radiculopathy. It occurs very often and may be missed to be an Anginal pain. Main point to note is when the patient says, “I can’t sleep at night rather prefer to sit.” Because the moment he lays his head for sleeping, his neck goes to extension.

Also the patient can’t look up as it increases his pain; this shows the radicular component of pain worsening on extending, flexing or rotating the neck is classically for Discogenic component.

If the patient says,“The pain is excruciating going down the arm” it shows the radicular component, because it can extend to pectoral or peri-scapular area. When the patient keeps his hand on his head, it partially reduces the intensity of pain, which again is a feature of Disco-genic Radiculopathy.

CASE – 3

A 35-years old female complaints throbbing pain in right shoulder since past 2 days. Initially it was moderate but now can’t even move the hand. What could be done?

Did you fall 2-3 days before or got a jerk?	No, nothing happened. No jerk, no injury.
Now that you have pain, do you have pain somewhere in the neck region?	No, nowhere else, only shoulder.
Are you able to lift your hand on your own?	No, not on my own. Wait I’ll try with my another hand…. Ya, I can lift little but pain is still there.
Ok! Did anyone told you about increased uric acid level?	No, last year I got my health check up, nothing came.

This is a case of Rotator-Cuff Calcific Tendinitis. Mostly, it has acute onset. The patient complaints about excruciating throbbing pain & it is usually localized to the shoulder. Rarely, pain would radiate to  peri-scapular or arm region (but it may radiate). The point to consider is active range is excruciating painful & difficult, which we can ask & passively some movement is possible but off-course not the full range. Also the neck movements don’t alter the quality of pain.

The physician asks about the level of uric acid, because in Rotator-cuff-tendinitis, we’re talking about ‘calcific’ which is more common & can also be crystal induced Rotator-cuff-tendinitis in people who are hyper-uremic, can come to the physician with similar complaint like Rotator-cuff-calcific-tendinitis, but in this case it would be because of the presence of crystals. We can also get double crystals, where the patient can come to us with increased uremic and X-ray shows calcification. However, treatment for both is the same.

CASE – 4

A 30-year old male comes with pain in right wrist which started suddenly. What can be done?

Since when it started?	Suddenly since yesterday night around 2 it started, out of the blue.
Did you fall or you lifted something heavy?	No, absolutely nothing.
Did you go to some party in last few days and drank alcohol?	Yes, just yesterday I had few glasses of wine.
Anytime did your health reports showed increase uric acid?	No.
Can you check your wrist & tell if there’s any swelling or redness?	Yes, the place where we tie the wrist-watch, there’s swelling, redness & pain also when I touch over there.
After making a fist, any problem in moving it up or down?	Only while I’m trying to pick-up something (flexion).

This is a case where there’s Crystal Deposits in the dorsum of the Carpals. Now these crystals could be of – Calcium oxalate, Calcium phosphate, Uric acid crystals. History of alcohol intake may be helpful to think about Uric acid crystal (but its not always uric acid). Small asymmetrical redness should not be missed. Confirmatory thing would be examining & looking for tenderness, erythema & usually movements in reverse direction could be restricted.

Try to talk to the patient and not to the relative while having telephonic consultation. Though it is controversial but still sometimes it’s very important to help the patient to stabilize their condition by the time they come to visit the physician.