A case of painful elbow: What's your diagnosis?

Answer to Clinical Vistas: A case of painful elbow

The Diagnosis: After considering the patient's primary occupation (Fig. 2), both examining clinicians (on separate occasions) diagnosed olecranon bursitis and prescribed cephalexin 500 mg QID and celecoxib 200 mg OD. Despite the certainty of these 2 physicians of their diagnosis, the patient sought the opinions of a rheumatologist, a rheumatology fellow, a nephrology fellow, a cardiology fellow, 3 endocrinologists, 3 internal medicine residents, a clinical clerk, a ward aide, and anyone else he ran into that day. After at least 14 concurring opinions, the patient accepted the diagnosis.

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Fig. 2: The patient (D.H.S.) studying for his Royal College exams.

Over the next 48 hours, the patient's symptoms increased, and he began to show signs of a delusional state, babbling on about necrotizing fascitis devouring his left arm. He entered a panicky state, describing visions of trying to hold Harrison's or demonstrating physical examination techniques with one arm.

After 48 hours, the swelling began to stabilize and regress; and as the physical symptoms resolved, the patient's delusional state returned to normal. After receiving careful instruction not to lean on his elbows, the patient recovered sufficiently to continue his studying, although whining behaviour persisted for some weeks.

This case represents an underreported hazard of residency training. Much publicity has surrounded the effect of long hours on residents' health,1^,2^,3 but the hazards of academic and licensing examinations have received little media attention. Although associated with increased stress, insomnia, weight gain and loss of social skills, studying for exams (sometimes called “cramming”) has never before been reported as a cause of infectious complications. We, the authors, believe more attention should be given to this important area, as it may prevent future incidents and unnecessary clinical and spousal stress. Future Royal College prep sessions should include warnings about the dangers of Royal College bursitis, and the prophylactic possibilities of elbow pads.