Download 小兒科報告2007.11

小兒科報告2007.11
報告者: 吳宜芳
Patient Information
 入院時間:2007/11/21 04:35
 Chart NO: 21101640
李X珊
 Age: 5-year-6-month-old (birth date: 2002/05/29)
 Gender: female
 BW: 16kg (3rd-10th percentile)
 Vital sign:
 TPR: 38.9/131/24
 BP: 117/75
Chief Complain
left ankle swelling since 3 days ago
Present Illness
 left ankle swelling with local pain since 3 days
ago
 mild fever up to 38.5 noted today
 Can not walk due to pain
 no trauma
 no rashes, no petechia
 no cough, no rhinorrhea
 No diarrhea, no abdominal pain
 poor appetite, and poor activity
Past History
Vaccination: as scheduled
Admission history： nil
Operation history: nil
No special diseases
No known drug allergies
Physical Examination
 Appearance: Well-looking
 Consciousness: alert ; GCS: E4V5M6
 HEENT:
conjunctiva not injected
ear drum not injected
throat: injected, tonsil: not enlarged, no oral ulcers
 NECK: no lymphadenopathy
 CHEST: BS: clear, no crackle , no wheezing
 Heart sound: RHB, no murmur
 ABDOMEN: soft and flat, normoactive bowel sound
no tenderness; no rebound pain; no muscle guarding
 SKIN: no rashes, no petechia, no ecchymosis
 EXTREMITIES: no deformity, no erythema
left ankle limited ROM with tenderness, and mild swelling
Review her charts~
left elbow pain since more then one month
ago, no trauma, no swelling, no fever
Visit orthopedics OPD for twice on 9/28
and 10/12
Left elbow pain subsided later under no
medications
11/21
Left ankle
AP+ Lat. view
11/21
Left elbow
Lat. view
11/21
Left elbow
AP view
Disposition
Etofenamate 5% gel bid topical use
Ibuprofen solution 8cc. QID
Acetaminophen syrup 8cc. Q6H
Discharge?
Table 57.1. Joint Pain—Differential Diagnosis
 Infection
Nongonococcal bacterial (septic)
Staphylococcus aureus
Haemophilus influenza
Group B streptococci
Escherichia coli
Gonococcal
Viral
Mycobacterial
Fungal
 Postinfectious
Viral: hepatitis B, parvovirus, EpsteinBarr virus, cytomegalovirus, varicellazoster, herpesvirus 6, enterovirus,
adenovirus
Bacterial: acute rheumatic fever, Lyme
disease, chlamydia (Reiter's syndrome),
mycloplasma, shigella, campylobacter
 Other
Toxic synovitis of the hip
Malignancy
Leukemia
Neuroblastoma
Bone tumor
Hemophilia
 Trauma/Overuse
Contusion
Hemarthrosis
Fracture
Ligamentous sprain
Bursitis
Tendonitis
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Osteochondritis dissecans
Chondromalacia patellae
Osgood-Schlatter disease
 Immune-mediated / Vasculitic
Chronic idiopathic arthritides of
childhood
Serum sickness
Kawasaki disease
Inflammatory bowel disease
Systemic lupus erythematosus
Henoch-Schönlein purpura
Joint pain in children
 Establishing a diagnosis for the child with joint pain is
challenging because the differential diagnosis is lengthy.
 Clinical and laboratory findings are rarely specific for a
particular disease, and disease patterns for many of the
etiologies are often highly variable among different
patients.
 An emphasis on historical points and physical
examination findings can serve to narrow the diagnostic
possibilities.
Joint pain-history in details!
 the specific joint or joints involved
 symptom onset time and duration
 history of trauma
 fever
 rash
 tick bites
 sexual risk factors
 intravenous drug use
 recent illnesses
Joint pain- trauma?
 A key initial point in the history is whether
trauma preceded the pain
 In the setting of acute trauma and in the
absence of fever, an effusion is indicative of a
hemarthrosis and is rarely a diagnostic or
therapeutic indication for performing an
arthrocentesis.
Joint pain- one joint?
 A child with acute onset of monoarthritis of the
hip or any other large joint, defined by the
presence of an effusion and marked by severely
restricted range of motion, with or without fever,
needs an arthrocentesis.
 A joint aspiration is rarely necessary to establish
a diagnosis for a child with polyarthritis and
fever or to rule out a septic process in this
setting.
Joint pain- septic arthritis
 In the absence of trauma, monoarthritis of the hip may
represent a true orthopedic emergency. Because the
most important prognostic factor is the length of delay
between the onset of infection and the institution of
therapy.
 septic arthritis involves only a single joint in more than
90% of affected children; 80% of these are hip, knee, or
ankle infections.
 Staphylococcus aureus is the most common infecting
agent for older children, whereas group B Streptococcus
and gram-negative enteric organisms must also be
considered in neonates.
Table 57.4. Distinguishing Clinical Features of Etiologies of
Polyarthritis Disease Clinical Characteristics
Gonococcal
Adolescent, tenosynovitis, rash
Lyme
Tick bite, erythema migrans migratory large joints
Acute rheumatic fever
Recent streptococcal infection, extreme pain,
carditis
Serum sickness
Urticaria, angioedema
Kawasaki
Prolonged fever, rash, conjunctivitis, mouth
changes, small interphalangeal joints and large
weight-bearing joints
Subacute bacterial
endocarditis
Congenital heart disease, fever, new murmur,
splinter hemorrhages
Systemic lupus
erythematosus
African-American female, skin or renal disease
Arthritis of small joints
Henoch-Schönlein
purpura
Purpura below the waist
Involves joints below the waist
Inflammatory bowel
disease
Abdominal pain, diarrhea
Joint pain- fever?
Table 57.5. Fever and Joint Pain
 Usually Febrile at Presentation
Nongonococcal bacterial (septic)
Gonococcal
Acute rheumatic fever
Chronic idiopathic arthritides of childhood (systemic onset)
Subacute bacterial endocarditis
Serum sickness
Kawasaki disease
 May or May Not Be Febrile at Presentation
Leukemia
Mycobacterial
Postinfectious (reactive)
Lyme disease
Systemic lupus erythematosus
Inflammatory bowel disease
Joint pain in children
 A complete blood count and erythrocyte
sedimentation rate is indicated for the febrile
child with signs of joint inflammation, especially
in the absence of trauma.
 A radiograph will detect fractures or a slipped
capital femoral epiphysis (SCFE)
 Radiographs aid in determining whether swelling
is caused by a joint effusion or is simply softtissue swelling outside the joint space, a
distinction that is often difficult to make on
physical examination alone.
Joint pain
no trauma
more than one joints
媽媽跑到門診直接找骨科醫師…
Orthopedics doctor suggest blood tests
Check CBC, D/C, BUN, CRP, B/C
Blood Tests Results
 檢驗項目
檢驗值
單位
H/L 參考值
============================================
 BUN (B)
5
mg/dL
5-20 (child)
 CRP
16.97
mg/L
H <5
Blood Tests Results
 檢驗項目
檢驗值
單位
H/L 參考值
=======================================================
 WBC
3.6
1000/uL L 6.0~10.4(4Y-6Y)
 RBC
2.61
million/uL L 4.28~5.05(6M-6Y)
 Hemoglobin
7.5
g/dL
L 11.6~13.7(3M-6Y)
 Hematocrit
22.0
%
L 34.2~39.8(6M-6Y)
 MCV
84.3
fL
74.9~ 84.6(6M-6Y)
 MCH
28.7
pg/Cell
25.2~29.1(6M-6Y)
 MCHC
34.1
g/dL
32.6~35.1(6M-6Y)
 RDW
17.8
%
H 11.5-14.5
 Platelets
40
1000/uL L 150-400
 Blast cell
9.0
%
H 0
 Myelocyte
1.0
%
H 0
 Meta-Myelocyte 1.0
%
H 0
 Segment
10.0
%
L 27.8~57.6(4Y-6Y)
 Band
1.0
%
0-3
 Lymphocyte
77.0
%
H 34.4~62.8(4Y-6Y)
 Monocyte
1.0
%
L 2.0~ 7.6(4Y-6Y)
11/21
CXR
Disposition
Acute leukemia, favor ALL
Admission (11/21)
Bone marrow aspiration (11/22)
Urinalysis
 檢驗項目
檢驗值
單位
H/L 參考值
===================================================
 Color
Pale yellow
Yellow
 Turbidity
Clear
Clear
 SP.Gravity
1.004
L
1.005-1.030
 pH
6.5
4.5 - 8.0
 Leukocyte
Negative
Negative
 Nitrite
Negative
Negative
 Protein
Negative
mg/dL
Negative
 Glucose
Negative
g/dL
Negative
 Ketone
Negative
Negative
 Urobilinogen 0.1
EU/dL
0.1 - 1.0 EU/dL
 Bilirubin
Negative
Negative
 Blood
Negative
Negative
 RBC
0
/uL
<20/uL
 WBC
0
/uL
<30/uL
 Epith-Cell
0
/uL
<30/uL
During admission
 檢驗項目
檢驗值
單位
H/L 參考值
==============================================
 Creatinine(B)
0.4
mg/dL
0.2-1.0 (infant-18Y)
 AST (GOT)
28
U/L
13- 40 (2-18Y)
 ALT/GPT
10
U/L
7-40 (1-18Y)
 Calcium
9.0
mg/dL
8.4-10.8 (2-18Y)
 Inorganic P
5.5
mg/dL
3.0-6.0 (1-12Y)
 Na
145
meq/L
133-146 (<18Y)
 K
4.2
meq/L
3.5-5.1 (<18Y)
 TP (B)
6.5
g/dL
5.5-8.0(6M-18Y)
 LDH
791.0
U/L
H 125-215
 ALB
4.0
g/dL
2.8~ 5.4(0-14Y)
 Uric Acid (B)
3.8
mg/dL
<8.0 (desirable)
Review her films
9/28
No
significant
abnormality
10/12
osteolytic change
with periosteal
reaction at
proximal radius
Review her films
9/28
10/12
osteolytic change
with periosteal
reaction at
proximal radius
11/21
Left elbow
AP view
Presence of
periosteal reaction
at proximal radius
Bone and joint pain in childhood cancer
 Bone and joint pain is a common symptom of
childhood cancer.
 Patients with bone tumors usually present with
pain at the site of involvement.
 Diffuse or multifocal bone pain is seen with
disseminated malignancy, especially acute
leukemia, and also in patients with bony
metastases from tumors such as neuroblastoma
and Ewing's sarcoma.
Bone/ joint pain in leukemias
 Bone pain is one of the cardinal manifestations
of childhood acute leukemias and is seen more
commonly in ALL than AML.
 Jonsson et al. report that 40% of newly
diagnosed children with ALL had
musculoskeletal symptoms at diagnosis, and in
almost half of them, they were the only
symptoms and were severe.
Bone/ joint pain in leukemias
 those with leukemia are more likely to have
worse pain at night, sometimes waking them
from sleep.
 Although the pain in leukemic children could be
severe, it also tended to shift in location and
involve bones as well as joints.
 leukemia or neuroblastoma can both present
with true joint swelling, as can bony tumors.
 Pallor, weight loss, as well as anemia or
cytopenias, would support this diagnosis.
Bone and joint pain in childhood cancer
 One useful clue that points to malignancy is
elevated sedimentation rate that is unassociated
with thrombocytosis because of marrow
infiltration.
 Another useful clue pointing to malignancy is
elevation of serum LDH that can be seen with
leukemia, NHL, Ewing's sarcoma, and
neuroblastoma.
 careful review of radiographs of the involved
bones may uncover findings suggestive of
leukemia or metastatic tumor.
Bone/ joint pain in leukemias
 We examined 50 children with acute
lymphoblastic leukemia with reference for
skeletal pain as well as the nature and the
degree of skeletal changes.
 The pain did not correlate with the
roentgenographic findings. Some children had
characteristic bone changes without bone pain.
 Roentgenographic findings were observed in 35
of the 50 children (70%).
Skeletal changes in children with acute lymphoblastic leukemia
Tijdschr Kindergeneeskd. 1981 Oct;49(5):153-9
Bone/ joint pain in leukemias
The major lesions observed were:
transverse metaphyseal lucent bands
osteolytic lesions
osteosclerotic lesions
periosteal reaction
osteoporosis
Skeletal changes in children with acute lymphoblastic leukemia
Tijdschr Kindergeneeskd. 1981 Oct;49(5):153-9
Bone/ joint pain in leukemias
 Skeletal radiographic changes that can occur in
a child with acute leukemia include
 diffuse osteopenia
 metaphyseal bands
 periosteal new bone formation
 geographic osteolysis
 osteosclerosis
 mixed osteolysis and sclerosis
 permeative destruction
Orthopedic manifestations of acute pediatric leukemia.
Orthop Clin North Am. 1996 Jul;27(3):635-44
Key Point
 the differential diagnosis of joint pain in children
is lengthy, but an emphasis on historical points
and physical examination findings can serve to
narrow the diagnostic possibilities.
 Bone and joint pain may be the only symptoms
of acute leukemia.
 careful review of radiographs of the involved
bones may uncover findings suggestive of
leukemia or metastatic tumor.