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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 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
