Peds 17 Flashcards
Emily is a 4-year-old previously healthy female who presents with acute right leg pain, refusal to walk, low-grade fever in the setting of URI symptoms a couple of days ago, and a recent minor fall. The only musculoskeletal finding on exam is limited internal rotation of the right hip, and she is otherwise well appearing. WBC 11.4k, CRP <0.8, ESR 14.
What’s the leading dx?
Transient synovitis
S/s: refusal to bear weight on one leg and fever. Lab results come back with elevated ESR (>40), CRP (>2), and WBC count (>12,000). What’s the leading dx?
Septic arthritis
What’s the immediate management plan for septic arthritis?
When septic arthritis is suspected, aspiration of the joint should be performed as soon as possible to confirm the diagnosis and facilitate initiation of treatment.
Broad spectrum abx –> narrow course after causative specimen identified
How do you treat transient synovitis?
Rest and ibuprofen
A 12-year-old male with obesity comes to the clinic with a chief concern of right knee pain. On exam the right knee is neither swollen nor erythematous but he is noted to have limited ROM of the right hip. In addition, when he lifts his right leg, it externally rotates. The patient did not have a URI or any trauma preceding the onset of pain. The vital signs are normal at the time of the visit and he is well appearing and afebrile. What is/are the best next step(s) in management?
A. AP and lateral x-ray of the hip B. Aspiration of the knee C. MRI of the knee D. Observation and weight reduction counseling E. Ultrasound of the right hip joint
A. AP and lateral x-ray of the hip
A 6-year-old female comes to the clinic because of worsening right knee pain over the past month. On exam, you note generalized lymphadenopathy and splenomegaly. She coughs intermittently throughout the visit, and her mother explains that she is just getting over a cold. You note absence of tenderness, erythema, effusion or warmth over the hip, knee, and ankle joints. Her vitals are unremarkable except for a low-grade fever (100.8 F). Reviewing her chart, you note that she has lost 5 lbs since her visit 2 months ago. She sits with her right leg externally rotated but appears to be in pain despite trying several different positions, refusing to bear weight on that side. What is the most likely diagnosis?
A. Leukemia B. Osteomyelitis C. Reactive arthritis D. Septic arthritis E. Transient synovitis
A. Leukemia
A 3-year-old female comes to the clinic with a limp and a slightly externally rotated right hip. Which of the following signs/symptoms would you expect in the history or exam if a diagnosis of transient synovitis were made?
A. ESR of 110 mm/hr B. High-grade fever C. History of a recent upper respiratory tract infection D. Iridocyclitis E. Knee pain
C. History of a recent upper respiratory tract infection
A 3-year-old female is at the pediatrician’s office for continued right knee pain after a ground-level fall six weeks ago. The patient is UTD on all immunizations, has no significant PMH, and no recent illnesses. The patient’s mother reports the patient complains of pain mostly in the morning when going to daycare but doesn’t seem to be bothered by it while playing outside in the afternoon. On exam, the patient’s vitals are all within normal limits. Her physical exam reveals a well-appearing toddler who walks stiffly and avoids bending her right knee. The knee has a mild effusion but no obvious erythema. There is pain with passive flexion and extension of the right knee. During the exam she tells you her left ankle also hurts, which her mother had forgotten about but says started hurting the same time as the right knee. Her CBC is normal, while her ESR and CRP are mildly elevated. Which of the following is the most likely cause of this child’s condition?
A. Bacterial osteomyelitis B. Juvenile idiopathic arthritis C. Leukemia D. Septic arthritis E. Transient synovitis of the hip
B. Juvenile idiopathic arthritis
Oligoarticular juvenile arthritis is the most common type of JIA (60% of JIA) and causes pain in four or fewer joints for six or more weeks. This patient is generally well even after six weeks of pain, which would be unlikely if this patient had septic arthritis. Her pain improves with activity, and the ESR/CRP are only mildly elevated. On exam, she has a mild effusion but no obvious erythema. In cases of systemic JIA, patients may have a rash which lasts only a few hours (evanescent) that is also macular and salmon-colored, and high-spiking and appears periodically (once or twice a day); however, this form of JIA is not consistent with this patient’s history.
A 4-year-old child is refusing to walk over the course of a week. Her mother recalls that she fell off her bike yesterday. On exam, she is afebrile, but has decreased range of motion of her hip. You review her file and note that she is up-to-date on her immunizations and she was last seen three weeks ago for a self-limited episode of diarrhea that she developed while visiting family in rural Mexico. Aspiration of her affected hip joint reveals slight increase in inflammatory cells but normal chemistries and a negative gram stain. Culture is pending. Which of the following is the most likely diagnosis?
A. Osteomyelitis B. Reactive arthritis C. Septic arthritis D. Transient synovitis E. Trauma
B. Reactive arthritis
The patient likely had a recent case of mild to moderate gastroenteritis in Mexico, which may have been secondary to a bacterial enteritis such as shigella, or campylobacter. In reactive arthritis, joint inflammation occurs a few weeks later because antibodies made during the illness are attacking the joint. While several inflammatory cells would be seen in the aspirate, importantly, the cultures will turn out to be negative.
