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Tyson Jones, MD, PGY2
2/19/14
Morning Report
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HPI T.H. is a 2 year old previously
healthy male
Fever to 103, NB/NB emesis x2, and limp x 1 day.
Diarrhea x 3 days, approx 2
weeks ago. Complaining of pain with lifting
legs up for diaper changes.
Taken to PCP the next day withfever of 104F despite motrin
and tylenol alternating Q3hr. Admitted to OSH x 4 days,
then transferred to PCH.
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PAST MEDICAL HISTORY: Term birth, no complicationsat birth. No chronic medical conditions. Has had 2 earinfections treated with antibiotics, but none in the past 4
months. Otherwise healthy. PAST SURGICAL HISTORY: No surgeries
IMMUNIZATIONS: Up to date including the flu shot.
MEDICATIONS: None regularly. Has been taking tylenoland motrin alternating Q3hr with this illness.
ALLERGIES: none
DIET: normal for age
FAMILY HISTORY: PGF with T2DM, otherwise negativefor cancer, recurrent infection, arthritis or immunologic
diseases. SOCIAL HISTORY: Lives with parents and older sisters
ages 9, 7, and 5y. No pets in the home, no recent travel,no exposures to farm or exotic animals.
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REVIEW OF SYSTEMS +fever +complaints of pain in genital region vs hip
+vomiting
+??Limp
+diarrhea 2 weeks ago
- coryza/rhinorrhea
- rash
- cough - swelling/erythema
- no known trauma
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PHYSICAL EXAM
T 38.6. HR 140. BP 113/55. RR 34. SaO2 98% on Room Air.
WEIGHT - 11.5 Kg, (8th%ile) HEIGHT - 86.5 cm, (10th%ile)GENERAL: Very irritable with exam during exam, minimallycooperativeHEAD: normocephalic, atraumatic.EYES: normal red reflex and pupillary reflexes bilaterally,
extraocular movements intact, conjugate gaze, no conjunctivalinjection.EARS: Normal tympanic membranes, no erythema.NOSE: no discharge or obstruction.OROPHARYNX: moist mucus membranes, no exudate, nopharyngeal erythema.
NECK: supple without lymphadenopathy or tenderness topalpation. Normal ROM.
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PHYSICAL EXAM continuedCARDIOVASCULAR: tachycardic, normal rhythm, normal S1/S2, nomurmur, no gallop, normal pulses.
LUNGS: clear to auscultation bilaterally, no retractions.
ABDOMEN: non-tender, Difficult exam due to upset patient.
EXTREMITIES: all extremities warm and well perfused. No cyanosis, or
edema including no joint effusion noted.
BACK: no abnormalities noted, though difficult to assessGENITOURINARY: normal Male external genitalia.
NEUROLOGIC: Fussy with exam, consolable with mom, moves all
extremities equally in the bed without gross deficit, patellar tendon reflexes
normal.
SKIN: no rash
MUSCULOSKELTAL: passive ROM intact, though he does exhibit slight
guarding of left knee and hip, no erythema surrounding hip, knee, or
ankle joints. No joint effusion noted. Normal muscle strength. On fourth
exam of the day: Walks with stiff left leg and slightly inturned left foot.
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DDx
2 yo M with vomiting, diarrhea, fever, and limp x 4days
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Bone Conditions:
Benign neoplasm
Osteoblastoma
Osteoid OsteomaCongenital condition
Club foot
DDH
Developmental Condition
Legg-Calve-Perthes
diseaseSCFE
Infection
Osteomyelitis
Limb length discrepancy
Malignant Neoplasm
Ewing Sarcoma
LeukemiaOsteosarcoma
Osteonecrosis
Sickle Cell Disease
Overuse injury
Stress Fracture
Trauma
Toddlers Fracture
Intra-abdominal Conditions
Appendicitis
Neuroblastoma
Psoas-Abscess
Intra-Articular Conditions
Congenital conditions
Discoid lateral meniscus
Hemarthrosis
HemophiliaTrauma
Infection
Gonorrhea
Lyme Disease
Septic Arthritis
Inflammation
Acute rheumatic feverJuvenile Rheumatoid
Arthritis
Reactive Arthritis
SLE
Transient Synovitis
Neuromuscular conditions
Cerebral Palsy
Meningitis
Muscular DystrophyMyelomeningocele
Soft-Tissue conditions
Infection
CellulitisPyomyositis or viral
myositis
Soft tissue abscess
Chondromalacia patellae
Jumpers knee
Osgood-Schlatter disease
Sever disease
Spinal Conditions
Diskitis
Spinal Cord Tumors
Vertebral Osteomyelitis
BROAD DIFFERENTIAL FOR CHILD WITH A LIMP:
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Labs:Pertinent OSH Labs:
CBC: WBC 18.2 (Band 5, Seg 52, Lymph 35), Hgb 11.6, Hct 35.4, Plts281
BMP: Normal
Blood culture: NG
VRP: Coronavirus OC43+
PCH labs:
WBC: 24.0->14.0->13.8->18.2-
>10.5
CRP: 4.08->2.72->9.18->4.4
ESR: 11->17.0
UA: SG 1.020, pH 6, cloudy, trace
protein, neg nitrite, neg LE
Urine micro (clean catch): few
bacteria
Repeat UA: normal
D dimer 377
Ferritin 141
CK 52
CMP: normal
ASO
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Imaging
OSH: Pelvic Xraynormal OSH: Pelvic and Knee USnormal
Bone Scan: Normal bone scan. No evidence of osteomyelitis.SPECT: Normal bone scan SPECT of the pelvis and femurs. Noevidence of osteomyelitis
CT abdomen and pelvis : Normal CT of the abdomen andpelvis. Normal appendix.
MRI Pelvis: No sign of joint effusion/synovitis, osteomyelitis, orpyomyositis.
MRI L Leg: Very small area of abnormal signal andenhancement in the lateral anterior thigh musculature. No otherabnormality.
Renal US: Right: Normal. Left: Normal.
Abdominal US: No ileocolic intussusception. Small amount ofright lower quadrant free fluid.
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DIAGNOSIS: Reactive Arthritis
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REACTIVE ARTHRITIS
A form of non-septic
arthritis developing after
an extra-articular infection
Arthritogenic bacteria: GI: Salmonella, Shigella,
Yersinia, Campylobacter
GU: Chlamydia,
Ureaplasma
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Clinical Manifestations Several stages involved:
Clinical infection precedes the appearance of arthritisand/or enthesitis by 1 to 4 weeks
Active period of weeks to months Sustained remission or recurrent episodes which may
evolve to enthesistis related arthritis, especially inpatients that are positive for HLA B27Acute arthritis and/or enthesitis usually seen (may see
tenosynovitis, bursitis, dactylitis) Patients may continue to have fever, weight loss, fatigue
and muscle weakness Painless, shallow mucosal ulcers are common Urethritis and cervicitis are rare Conjuctivitis occurs in about two thirds of children at
onset
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Laboratory Studies
Mild decrease in hemoglobin and leukocytosiswith neutrophilia
Elevated inflammatory markers (platelets,
immunoglobulins, ESR and CRP)
Autoantibodies (RF and ANA) are usually absent
but reactive arthritis most frequently occurs in
HLA-B27 positive individuals
Synovial fluid is sterile Cultures (blood, urine, stool) obtained at the time
of infection may be positive
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Treatment:
NSAIDs Meloxicam 2.25mg PO qday x 1-2 months.
No clear evidence that antibiotics during the
inflammatory phase alter the course of the
disease
Rarely, corticosteroids (oral or intra-articular) may
be required
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References
1. Carter JD, Hudson AP. Reactive arthritis: clinicalaspects and medical management. Rheum Dis
Clin North Am 2009; 35(1):21-44.
2. Rihl M, Klos A, Khler L, et al. Infection and
musculoskeletal conditions: Reactive arthritis.Best Pract Res Clin Rheumatol 2006;
20(6):1119-37.
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