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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.