Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.
A 45-year-old woman presents for a sick visit. She has a chief complaint of a 2-to-3-day history of sudden onset of right elbow pain and swelling, stating, quote, “I've never had pain like this before. It looks like I have a swollen ball hanging from my elbow.” Close quote. She denies recent or remote trauma to the area, fever, pain and other joints or skin lesions, but does report spending an extensive amount of time on her computer recently due to a major work project. Physical exam reveals an area of painful sack-like swelling below the right elbow that's slightly warm without evidence of redness or trauma. Range of motion of the joint elicits discomfort, but is largely intact. This clinical presentation is most consist with:
A. Rheumatoid arthritis.
B. Tendinitis.
C. Olecranon bursitis.
D. Septic arthritis.
The correct answer here is C, olecranon bursitis. Where do we start? First, determine what kind of question this is. Given that we're asked to choose from a variety of clinical conditions and to pick one of those, this is a diagnosis question. Let's take a look at the background information. Within the body's joints are hundred of bursae or bursa small sacs that act like shock absorbers. Bursitis develops when the synovial tissue that lines the sac becomes thickened and produces excessive fluid, leading to swelling and resulting pain. That's that quote sac hanging off of her elbow. The most commonly affected bursa are the sub deltoid, olecranon, ischial, trochanter, and pre patellar bursa.
Risk factors for acute bursitis include joint overuse trauma to the affected area or infection. Typically, the person with bursitis will report a history of select activity that contributed to its diagnosis. For example, in this patient scenario, she's been working on a project where she spent a good deal of time on her computer. Further questioning would likely reveal that she's been leaning on her right elbow for a protracted period of time. Indeed, a colloquial name for olecranon bursitis is drafters elbow, so-named from being seen in workers who are drafting documents such as building plans and would likely spend long hours leaning on the elbow. By the way, it's a fairly outdated way of referring to this calling it drafters elbow because it literally refers back to a time when drafters would spend hours drawing lines on building plans and things like that. Most of that's now computer-generated.
Wherever in the body bursitis is located, the patient history will typically be of sudden onset of pain in the joint, with swelling in the region. Joint range of motion is usually intact, but the range of motion of the joint elicits discomfort.
Now let's take a look at the options as to the answers for this question. To repeat the question 45-year-old woman presents for a sick visit with the chief complaint of a 2-to-3-day history of sudden onset right elbow swelling with pain, stating, “I've never had pain like this. It looks like I have a swollen ball hanging from my elbow.” She denies recent or remote injury to the area, fever, pain in other joints or skin lesions and does report recently spending an extensive amount of time on her computer due to a major work project. Physical exam reveals an area of painful sack like swelling behind the right elbow, slightly warm without redness or evidence of trauma. Joint range of motion elicits discomfort, but is largely intact.
This clinical presentation is most consistent with A, rheumatoid arthritis. This is incorrect. Well, having this disease actually increases the risk for bursitis development, rheumatoid arthritis often abbreviated RA. Rheumatoid arthritis typically presents with a gradual onset of discomfort, redness and swelling in multiple small joints, especially the hands, feet, and wrists. Please keep that in mind. The typical presentation of R.A. is generally poly joint and smaller joints when it starts off. Unexplained fatigue and involuntary weight loss is often reported in the clinical presentation of rheumatoid arthritis. Bursitis is more common in patients with osteoarthritis, but we have been given no history of R.A. or O.A. in this patient scenario.
B, elbow fracture. In the absence of significant history of elbow trauma, which is what we're told in this scenario, the likelihood of fracture is quite remote. In addition, she's a woman of reproductive age. She's in her forties. And this is not a time where osteoporosis is common. Bone mineralization is usually robust, fracture due to minor trauma that might not have been noticed is virtually never seen in a woman of this age.
C, olecranon bursitis. This is, of course, the correct answer. One of the classic findings in olecranon bursitis is this quote, ball of fluid hanging from the elbow. The underlying mechanism is, of course, the inflammation of the bursal sac, a structure that usually flat and located between the olecranon in the skin, but it's now filled with fluid. This is typically a clinical diagnosis, meaning no special tests are needed. The disease is diagnosed by history and physical exam. First line therapies are conservative, meaning you want to advise her to avoid the triggering behavior, rest the joint, ice, compression, and NSAIDs, and chances are she's going to be significantly better in a few days.
Now, the last option we were given was D, septic arthritis. Obviously this is incorrect since option C is the correct answer. Septic arthritis is an infectious disease of one or many joints most commonly caused by bacterial infection. Typically, the infection starts elsewhere in the body and then settles into a given joint. As an alternative, the joint can be severely injured, particularly with a skin break and infection enters the joint through that mechanism. The person with septic arthritis could report relatively sudden onset of joint pain and swelling. As we heard with this patient, but would also be quite systemically ill with fever and body aches. The major risk factors for septic arthritis include age older than 80 years. Again, she doesn't have that. Presence of diabetes. It's not mentioned in the question. Therefore, assume she doesn't have diabetes. Rheumatoid arthritis. Ditto. It doesn't say that she has it. We're going to assume she does not, because on board questions you will be given all the information you're needed to answer the question correctly. Recent joint surgery, hip or knee prosthesis, skin infection, the use of immunosuppressive meds there. None of those are reported in this question. Those are all the major risk factor for septic arthritis. Therefore, if not reported, we assume these are not present in this case scenario. What's the key takeaway here? The differential diagnosis of joint pain is complex. While the physical exam can be quite focused as it was in this scenario, taking into account the history of present illness, including the presence or absence of fever or trauma can be quite helpful.
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