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Case presentation Mr C
Paula Harding, 2013
Triage: Neck pain
GP referral – “sudden sharp neck pain radiation
to left shoulder 3/7 ago, sharp pain with
breathing, swelling, limited shoulder abduction…
?torticollis, shoulder impingement”
19 yr ♂ presents to ED with neck
pain
 Presents with mother
 3/7 ago sitting down at night sudden L sided neck pain – no trauma or
incident
 Trouble since sleeping at night
 6/10 rest, 9/10 pain with activity – no analgesia
 Intermittent tingling R 5th finger
 Aggs:
 all shoulder and neck movements, DB&C
 Denies p&n, weakness, N&V, OS travel, recent infections, IVDU (no track
marks), SOB, weight loss, lethargy, able to swallow
 Throbbing head when getting up or sudden movement, accompanied with
dizziness
 Night sweats
 R handed, carpet layer, keen skier, non smoker, social ETOH, lives with
mother
 NKA, nil medical history, nil medications
Differential diagnosis?
 ? Wry neck
 ?vasculitis/aneurysm/carotid/TOS
 ?pneumothorax
 ?discitis with referral
 ?malignancy, Hodgkins lymphoma
 ?non musculoskeletal signs
O/E
 Tall thin pale looking boy
 Left shoulder resting in elevation
 L supraclavicular region – swelling and fullness, small
area of erythema, tender to touch and sensitive++, skin
intact
 AROM Cx – all ltd & painful, sh P1 90° flex/abd
 PROM Cx – ↓ pain
 ° TOP Cx, AC, GH joint, clavicle
 Neuro : sensation NAD, full distal power
 Strong radial pulse, normal perfusion/colour of hand
 Obs: Febrile 37.5°
 BP 115/70, HR 80, 98% RA
 Unable to do Addison’s test
 Ausc: chest clear
Differential diagnosis
 Non musculoskeletal
 Infection
 Cellulitis?
 Bite?
 Supraclavicular mass/abscess?
 Malignancy/Hodgkins lymphoma
 Glandular
Needs medical review – bloods & blood culture,
CXR,US, →ESSU, official handover – out of scope
Bloods
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Glucose 7.8 (3.8-7.7)
ALT 8 (12-52)
CRP 147 (0-5),
ESR 24 (1-10)
WBC 13.9 (3.9-12.70),
neutrophils 11.80 (1.90-8.00)
Platelets 146 (150-396)
 Blood culture - -ve
Interpretation of bloods - Glucose: 7.8
(3.8-7.7)
 Possible causes of hyperglycaemia = high blood glucose
 Diabetes
 Acromegaly
 Acute stress (response to trauma, heart attack, and stroke for instance)
 Long-term kidney disease
 Cushing's syndrome
 Drugs, including: corticosteroids, tricyclic antidepressants, diuretics,
adrenaline, oestrogens (birth control pills and hormone replacement therapy
[HRT]), lithium, phenytoin (Dilantin), aspirin
 Excessive food intake
 Hyperthyroidism
 Pancreatic cancer
 Pancreatitis
In patients with fasting plasma glucose levels between 5.5-6.9 mmol/L
or random plasma glucose levels between 7.8-11.0 mmol/L, an oral
GTT should be performed if the patient is at high risk for diabetes.
ALT – Alanine aminotransferase 8
(12-52) – test for liver function

ALT is an enzyme found mostly in the liver; smaller amounts are also
found in the kidneys, heart and muscles. Under normal conditions, ALT
levels in the blood are low. When the liver is damaged, ALT is released
into the blood stream, usually before more obvious symptoms of liver
damage occur, such as jaundice (yellowing of the eyes and skin).

Other liver function tests AST , ALP, CGT

Application: Detection and monitoring of liver cell damage.

Interpretation: Increased ALT levels are associated with hepatocellular
damage.

ALT is more specific for hepatocellular damage than is AST or LD and
remains elevated for longer, due to its longer half-life.

ALT may be slightly elevated in skeletal muscle disease but the degree of
elevation is much less than for AST and CK

Very high levels of ALT (more than 10 times the highest normal level)
are usually due to acute (short-term) hepatitis, often due to a virus
infection. In acute hepatitis, ALT levels usually stay high for about 1–2
months, but can take as long as 3–6 months to return to normal.
CRP: c-reactive protein 147 (0-5)
 Marker of inflammation – raised in autoimmune disorders,
bacterial infections, neoplastic disorders
 Produced in the liver by the same process as causes pyrexia
and released into the blood
 CRP is a more sensitive early indicator of an acute phase
response than is the ESR. It also returns towards normal
more rapidly with improvement or resolution of the disease
process. The test is less sensitive than the ESR for some
disorders eg, ulcerative colitis, SLE.
 Another test to monitor inflammation ESR. Both tests give
similar information about the presence of inflammation.
However, CRP appears and then disappears sooner than
changes in the ESR. Thus, your CRP level may fall to normal
if you have been treated successfully, such as for a flare-up
of arthritis, but your ESR may still be abnormal for a while
longer
WBC 13.90 (3.90-12.70)
 White blood cells are made in the bone marrow and protect
the body against infection and aid in the immune response.
If an infection develops, white blood cells attack and
destroy the bacteria causing the infection.
 Increased numbers maybe due to: viruses, infections, RA,
cancer, post surgical, leukaemia
 Conditions or drugs that weaken the immune system, such
as HIV infection or chemotherapy, cause a decrease in white
blood cells. The WBC count detects dangerously low
numbers of these cells
 An elevated number of white blood cells is called
leukocytosis. This can result from bacterial infections,
inflammation, leukaemia, trauma or stress. A WBC count of
11.0 – 17.0 x 109/L cells would be considered mild to
moderate leukocytosis
Platelets 146 (150-396)
 Found in bone marrow and form a clot or thrombus
when aggregated together with the help of fibrin
 Low platelets: drugs- antibiotics, quinine sulphonamides
is called thrombocytopenia
 High platelets: present in some infections, autoimmune
disorders is thrombocytosis
 thrombocytopenia
 http://rcpamanual.edu.au/index.php?option=com_clinica
l&task=show_clinical&id=739&Itemid=27
Neutrophils 11.80 (1.90-8.00)
 Normally 40-75% of WBCC
 High numbers associated with bacterial infections, but
also auto-immune disorders, physiological stress
ESR: Erythrocyte sedimentation
rate 24 (1-10)

A thin column of blood settles under influence of gravity, RBC separate
from plasma – recorded as fall in RBC

Increased EST – cancer, anaemia, inflammation, RA, multiple myeloma,
TB, myocardial infarction

Non specific markers –abnormal result could reflect a variety of different
pathologies

A very high ESR usually has an obvious cause, such as an infection. The
doctor will use other follow-up tests, such as cultures, depending on the
patient’s symptoms.

Moderately elevated ESR occurs with inflammation, but also with
anaemia, infection, pregnancy and old age

The ESR is helpful in diagnosing two specific inflammatory diseases,
temporal arteritis and polymyalgia rheumatica
ESSU – ID review
 Bloods: indicative of
infection/inflammation
 US: left chest wall cellulitis, °collection,
reactive cervical lymph node, veins patent
 CXR: NAD
 38 ° overnight
 Admit under ID
ID diagnosis
 Cervical Adenitis
 Ddx : Epstein–Barr virus infection
(glandular fever)
 Rx: IV antibiotics flucoxacillin, analgesia,
repeat bloods
 Bloods 2/7 later: CRP 46*, platelets 163,
WBC 5.60, Neutrophils 3.85,
 Dx 3/7 later HITH IV cephazolin CRP 24*
Cervical adenitis
 A localized bacterial infection in one of a series of lymph nodes found
running along the sides of the neck
 Adenitis is a general term for an inflammation of a gland or lymph node
 Common in children, associated with a sore throat
 3 types
 Acute bilateral cervical lymphadenitis – URTI, EBV
 Acute unilateral pyogenic lymphadenitis – S aureaus and group A strep
in 80% cases
 Chronic cervical lymphadenopathy – infection/HIV/cat scratch
Consider causes:
 peridontal disease, exposure to insects/animals/ cat scratches/skin
lesions/virus- measles, rubella/TB – OS travel
Requires assessment of liver, spleen, lymph nodes, throat, skin, neck
Peters & Edwards (2000) Cervical Lymphadenopathy and Adenitis, Paediatrics in Review 21(12):399-405
Reflections
 Consider throat/glands/lymph as source of
neck pain
 Consider exposure to animals/insects
 Distracted by diagnosis & didn’t organise
analgesia until later
 Use of diagram to illustrate skin changes
/fullness/lump/enlarged lymph
http://rcpamanual.edu.au/
http://www.labtestsonline.org.au/
Blann A, Routine Blood Results Explained