CONFIRMING DIAGNOSIS Identifying the causative organism in a Gram stain or culture of synovial fluid or a biopsy of synovial membrane confirms septic arthritis. When synovial fluid culture is negative, positive blood culture may confirm the diagnosis.
Joint fluid analysis shows gross pus or watery, cloudy fluid of decreased viscosity, usually with 50,000/µl or more white cells, primarily neutrophils. Synovial fluid glucose is usually more than 40 mg/dl. (See Other types of arthritis, page 584.)
Other diagnostic measures include the following:
❑ X-rays can show typical changes as early as 1 week after initial infection — distention of joint capsules, for example, followed by narrowing of joint space (indicating cartilage damage) and erosions of bone (joint destruction).
❑ White blood cell count may be elevated, with many polymorphonuclear cells; erythrocyte sedimentation rate is increased.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Scrotal swelling:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Arthralgia:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Demographics. The patient’s age is sometimes helpful in determining the cause of arthralgia. Systemic lupus erythematosus (SLE) commonly presents between the second and fourth decades of life. Rheumatoid arthritis (RA) is more common between the fourth and sixth decades; osteoarthritis (OA) peaks in the seventh and eighth decades. Infectious causes, as well as trauma, have no particular age association. Younger, female patients are more likely to have RA or SLE, whereas postmenopausal women are affected by gout and OA of the knee and hand. Male patients more likely have gout, ankylosing spondylitis, and OA of the hip. Race is helpful in some disorders: SLE is more common in African-Americans.
B. Affected joints. The new onset of monarticular symptoms can be seen in trauma, infection, crystal-induced disease, periarticular problems, and degenerative and inflammatory arthritic processes. Early OA can present in one joint, most commonly the knee, or in any joint damaged by antecedent trauma. Recurrent pain in one joint can indicate OA flare, gout or pseudogout attack, SLE, sarcoidosis, or a periarticular problem. Gout presents in the first metatarsal phalangeal joint in 50% of cases (Chapter 12.6).
Multiple joint involvement, especially with other associated symptoms, is characteristic of a systemic process. Symmetric involvement of the metacarpal-phalangeal, proximal interphalangeal joints (PIPs), wrist, and feet is more common in RA; involvement of the knees or hips is unusual (1). OA favors the PIPs, distal interphalangeal, carpal-metacarpal joint of the thumb, hips, knees, ankles, feet, and spinal column (1), but involvement is not necessarily symmetric. Erosive OA can affect multiple joints of the hands. SLE often affects the hand and wrists.
C. Pain characteristics. Additional history includes the exact location of the pain (around vs. inside the joint), the time course (episodic or intermittent vs. constant pain), and the presence and onset of joint swelling or warmth. Joints that are stiff in the morning and hurt at rest are seen in RA. RA pain waxes and wanes throughout the day and night, and is unrelated to activity. OA pain is associated with use and improves with rest.
D. Family history. RA, SLE, gout, ankylosing spondylitis, and OA of the fingers all have a familial component. SLE is also found in families with other autoimmune diseases.
E. Lifestyle factors. Dietary history is important in gout, as a diet high in purine foods (liver, sweetbreads, kidneys, red meat, sardines, and anchovies) can precipitate an attack in susceptible individuals. Certain underlying diseases, sexual practices, alcoholism, and intravenous drug use are risk factors for septic arthritis.
F. Associated symptoms. Other complaints are often helpful in narrowing the differential diagnosis. Fatigue that does not improve with rest can be seen in RA, SLE, and infectious arthralgia. Rash can be seen in arthralgia resulting from a variety of infectious and inflammatory causes. Urticaria is common in the acute serum sickness syndrome. A history of a tick bite or targetlike rash may indicate arthritis from Lyme disease. Vaginal discharge, pelvic pain, or urethritis symptoms or discharge should raise the possibility of an infectious cause or Reiter’s disease. Fever is likely with infectious, and some inflammatory, causes of arthralgia.
G. Past medical history. Other known medical illnesses are also important as they may be associated with inflammatory or degenerative causes of arthralgia (Table 12.1). Childhood joint disease predisposes to early onset degenerative disease.
New medications, including diuretics, chemotherapeutic agents, antituberculosis drugs, and low-dose aspirin, can precipitate gout. Other medications and vaccination reactions can cause polyarticular arthralgias.
Physical examination
A. Joint examination. Inspect the joint for evidence of trauma, breaks in the skin, swelling, erythema, deformity (e.g., bony changes, tophi), and asymmetry with contralateral joints. Palpate the joint and surrounding tissues for warmth, tenderness, effusion, edema, and crepitus. Perform joint range of motion (ROM). Pain with active, but not passive ROM is more consistent with a periarticular problem.
B. Examination of other systems. Conjunctivitis, oral lesions, urethritis, genital or extremity ulcers, rash, tophi, and nail pitting can indicate a more systemic problem. Rheumatic disease can affect other organs (e.g., pleural effusion, splenomegaly, Raynaud’s phenomenon).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Monarticular Joint Pain:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Timing of the pain. What is the onset and duration of the pain? Was there a specific inciting incident or trauma? When does the pain occur? Pain wakening the patient from sleep may suggest a malignancy. Is pain present at rest? Does movement or weightbearing exacerbate the symptom? Any associated joint stiffness?
B. Location of the pain. Localization to the joint is typical in osteoarthritis (OA). Exceptions are hip OA, where pain can localize to the groin or thigh, and OA of the spine, where pain can localize to the buttocks. Radiation of the pain may suggest periarticular or neuropathic problems.
C. Associated symptoms. Fever, night sweats, or weight loss may suggest an infectious cause or an underlying systemic illness. Rash can occur with infectious or inflammatory arthritides.
D. Medical history. Many medical problems can be associated with an inflammatory or a degenerative arthritis (Table 12.7). Knowledge of prior joint surgery or prosthesis placement is important. A history of childhood joint disease (e.g., slipped capital epiphysis) or bone disease (e.g., osteochondritis dissecans) can predispose to early onset degenerative joint disease.
E. Social history. The patient’s support system is especially important if severe functional impairment is present. The employment or recreational history may indicate a risk of repetitive joint trauma. Sexual risk factors and a history of alcohol or intravenous (IV) drug abuse are important.
F. Medications. What medication or treatment has been used and what was the response? A history of systemic steroid use can lead to osteonecrosis of the femoral head.
Physical examination
Is discomfort apparent? Is fever present? Assess the patient’s gait and note if a mobility aide is used. Inspect the joint for surgical or traumatic scars, muscle atrophy, deformity, joint swelling, and erythema. Palpate for warmth, tenderness, and effusion. Evaluate joint range of motion (ROM). If active ROM is full and normal, evaluation of passive ROM is unnecessary. Pain with active, but not passive ROM suggests a periarticular process. Depending on the joint involved, palpate the relevant periarticular structures and perform the appropriate provocative maneuvers. Examine for rash.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Acute Monoarticular Arthritis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Injury
❑ Gout
❑ Osteoarthritis
❑ Lyme disease
❑ Gonococcal arthritis
❑ Seronegative spondyloarthropathy
❑ Septic arthritis
❑ Pseudogout
❑ Septic bursitis
❑ Avascular necrosis
Diagnostic Approach
Ascertain that arthritis (joint inflammation) is present by eliciting pain on joint motion. A hot, swollen joint with constitutional symptoms such as fever, weight loss, and malaise suggests infection. The skin may hold clues to psoriasis, systemic lupus, viral exanthems, Lyme disease, and others. Erythema nodosum occurs with sarcoidosis or inflammatory bowel disease. Urethritis suggests gonorrhea or Reiter syndrome. A monoarticular presentation of a polyarticular disease may be rarely seen in rheumatoid arthritis, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, and sarcoidosis.
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Source: Field Guide to Bedside Diagnosis, 2007
Arthritis/Dermatitis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑Lyme disease
❑Erythema nodosum
❑Rheumatoid arthritis
❑Systemic lupus erythematosus
❑Psoriatic arthritis
❑Disseminated gonococcemia
❑Sarcoidosis
❑Scleroderma
❑Dermatomyositis
❑Reiter syndrome
❑Rheumatic fever
❑Behçet syndrome
❑Still disease
❑Hypersensitivity vasculitis
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Source: Field Guide to Bedside Diagnosis, 2007
Polyarticular Arthritis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Osteoarthritis
❑ Rheumatoid arthritis
❑ Lyme arthritis
❑ Systemic lupus erythematosus
❑ Psoriatic arthritis
❑ Polyarticular gout
❑ Viral arthritis
❑ Scleroderma
❑ Reiter syndrome
❑ Inflammatory bowel disease
❑ Gonococcal arthritis
❑ Ankylosing spondylitis
❑ Systemic vasculitis
❑ Sarcoidosis
❑ Pseudogout (CPPD)
❑ Acute rheumatic fever
❑ Still disease
Diagnostic Approach
Ascertain that the pain is articular; that is, it is exacerbated by the function of the joint. Detecting synovitis limits the differential to inflammatory arthridites and systemic rheumatic diseases. Findings of synovitis include palpable soft tissue bogginess around a joint, warmth over a joint, or effusion. Involvement of the wrists, elbows, or metacarpophalangeal joints implies inflammatory disease rather than osteoarthritis. Morning stiffness persisting for as long as 1 to 2 hours, relieved by NSAIDs, is typical for inflammatory arthritis, as is a history of a red joint.
Differentiating features include the following: Erythema nodosum: sarcoidosis, inflammatory bowel disease-related arthritis, or Behçet disease. Rash: lupus, Still disease, vasculitis, dermatomyositis, endocarditis, disseminated gonorrhea, or Behçet disease. Fever greater than 40˚C: Still disease, bacterial arthritis, or lupus. Fever preceding arthritis: viral arthritis, Lyme, reactive arthritis, Still
desease, or bacterial endocarditis. Spiking fever: bacterial infection or Still
disease. Splenomegaly: rheumatoid arthritis and lupus. Raynaud: scleroderma, mixed connective tissue disease, or lupus. Oral ulcers: lupus, Behçet disease, or viral arthritis. Dry eyes and mouth: Sjögren syndrome, mixed connective tissue
disease, or lupus. Ocular findings: lupus, Behçet disease, sarcoidosis, or reactive arthritis. Migratory arthritis: gonococcemia, rheumatic fever, meningococcemia, viral arthritis, lupus, acute leukemia, or Whipple disease. Episodic recurrences: Lyme, crystal-induced arthritis, inflammatory bowel disease, Still disease, or lupus. Morning stiffness: rheumatoid arthritis, polymyalgia rheumatica, Still
disease, or viral arthritis. Symmetric small-joint synovitis: rheumatoid arthritis, lupus, or viral arthritis.
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Source: Field Guide to Bedside Diagnosis, 2007
Scrotal Pain/Swelling:
Differential Overview
(Field Guide to Bedside Diagnosis)
Pain Predominant
❑ Epididymitis
❑ Testicular torsion
❑ Prostatitis
❑ Referred pain
❑ Trauma
❑ Orchitis
❑ Torsion of the appendix testis
❑ Inguinal hernia/incarcerated
Swelling Predominant
❑ Varicocele
❑ Inguinal hernia
❑ Hydrocele
❑ Spermatocele
❑ Sebaceous cyst
❑ Testicular cancer
Diagnostic Approach
Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.
Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.
Referred pain can be differentiated from scrotal pathology by a normal testicular examination.
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Source: Field Guide to Bedside Diagnosis, 2007
Rheumatoid arthritis:
Diagnosis
(Handbook of Diseases)
Typical signs and symptoms suggest RA, with a firm diagnosis supported by laboratory and other test results:
❑ X-raysin early stages show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.
❑ RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.
❑ Synovial fluid analysisshows increased volume and turbidity but decreased viscosity and elevated white blood cell counts (often greater than 10,000/µl).
❑ Serum protein electrophoresis may show elevated serum globulin levels.
❑ Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation typically parallels disease activity).
❑ Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.
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Source: Handbook of Diseases, 2003
Neurogenic arthropathy:
Diagnosis
(Handbook of Diseases)
A patient history of painless joint deformity and underlying primary disease suggests neurogenic arthropathy. The physical examination may reveal bone fragmentation in advanced disease. X-rays help confirm the diagnosis and help assess the severity of joint damage.
In the early stage of the disease, soft-tissue swelling or effusion may be the only overt effect; in the advanced stage, articular fracture, subluxation, erosion of articular cartilage, periosteal new bone formation, and excessive growth of marginal loose bodies (osteophytosis) or resorption may be seen.
Other diagnostic measures include:
❑ vertebral examination:narrowing of disk spaces, deterioration of vertebrae, and osteophyte formation, leading to ankylosis and deforming kyphoscoliosis
❑ synovial biopsy: bony fragments and bits of calcified cartilage.
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Source: Handbook of Diseases, 2003
Juvenile rheumatoid arthritis:
Diagnosis
(Handbook of Diseases)
Persistent joint pain, rash, and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA and for monitoring disease activity and response to therapy.
❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.
❑ Erythrocyte sedimentation rate, complement (C)-reactive protein, haptoglobin, immunoglobulin, and C3 levels may be elevated.
❑ Test results may be positive for ANAs in patients who have pauciarticular JRA with chronic iridocyclitis.
❑ RF is present in 15% of patients with JRA, as compared with 85% of patients with RA.
❑ Positive HLA-B27 test may forecast later development of ankylosing spondylitis.
❑ Early X-ray changes include soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.
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Source: Handbook of Diseases, 2003
Psoriatic arthritis:
Diagnosis
(Handbook of Diseases)
Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis. X-rays confirm joint involvement and show:
❑ marginal erosion at interphalangeal joints with areas of thin, “fluffy” new bone formation
❑ “whittling” of the distal end of the terminal phalanges
❑ “pencil-in-cup” deformity of the distal interphalangeal joints
❑ relative absence of osteoporosis
❑ sacroiliitis
❑ atypical spondylitis with syndesmophyte formation, resulting in hyperostosis and paravertebral ossification, which may lead to vertebral fusion.
Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.
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Source: Handbook of Diseases, 2003
Scrotal swelling:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the patient isn’t in distress, obtain his medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is he sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does the patient have a history of prostate surgery or prolonged catheterization? Is the swelling affected by changing his body position or level of activity?
Physical examination
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Scrotal swelling:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient isn’t in distress, proceed with the medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
CULTURAL CUE:Patients of certain cultural backgrounds, such as Mexican-Americans, may need to establish a trusting relationship before discussing matters of a personal nature.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Scrotal swelling:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient's vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in a supine position and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles'position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can't be transilluminated.)
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Source: Nursing: Interpreting Signs and Symptoms, 2007
JOINT PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of joint pain includes a careful history
and examination for other signs such as swelling, redness, and hyperthermia
of the joints. If the joint pain is worse in the morning, consider RA. If
multiple joints are involved, look for RA, lupus, and osteoarthritis. Single
joint involvement suggests gonorrhea, septic arthritis, tuberculosis, or
gout, among other things. Small joints are involved more frequently in RA,
Reiter syndrome, and lupus, although the large joints are more frequently
involved in osteoarthritis, gonorrhea, tuberculosis, and other infections.
Remember, however, that both osteoarthritis and gonorrhea may involve the
small joints of the hands and feet. Rheumatic fever presents a migratory
arthritis; this is a helpful differential point. When the knee joint is
involved, the astute clinician will always examine for a torn or subluxated
meniscus and loose cruciate or collateral ligaments. MRI or arthroscopy will
pin down this diagnosis. Listed below are the most valuable diagnostic
tests. Synovial fluid analysis for uric acid and calcium pyrophosphate, the
character of the mucin clot, a white cell count, and culture can be done in
the office and may make the diagnosis almost immediately. This may eliminate
the need for hospitalization.
A therapeutic trial of aspirin or colchicine is useful in diagnosing
rheumatic fever and gout, respectively. If the joint fluid examination is
nonspecific and no systemic signs of infection are evident, the injection of
steroids into the joint is reasonable while the physician waits for the
results of more sophisticated diagnostic tests.
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Source: Differential Diagnosis in Primary Care, 2007
JOINT SWELLING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will often help identify the cause of the joint
swelling. If there is fever and migratory arthritis, one suspects rheumatic
fever or Lyme disease. Fever with involvement of several joints would
suggest RA, lupus erythematosus, or gonorrhea.
Fever and involvement of one joint primarily is found in septic arthritis
and tuberculosis but may be found in gonorrhea. No fever and large joint
involvement may be found in osteoarthritis, gout, and pseudogout.
Osteoarthritis customarily affects the distal phalangeal joints, whereas RA
affects the metacarpophalangeal joints. Psoriatic arthritis also affects the
distal phalangeal joints primarily. Charcot joints are usually large.
The initial workup of joint swelling includes a CBC, sedimentation rate,
urinalysis, chemistry panel, and x-rays of the involved joints. If a large
joint is involved, joint fluid can be aspirated and analyzed. A culture
should also be done.
If gonococcal arthritis is suspected, urethral or cervical smears and
cultures will be helpful, but culture of the fluid on special medium is most
important. If gout or pseudogout is suspected, it is important to examine
the joint fluid for crystals under polarized light. If RA is suspected, an
RA titer will often be positive. Lupus erythematosus can be confirmed by a
positive ANA and anti–double-stranded DNA antibodies. Rheumatic fever can
be confirmed by a positive ASO titer or streptozyme test. If the synovial
fluid has a high white count, hospitalization and initiation of parenteral
antibiotics are indicated without delay.
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Source: Differential Diagnosis in Primary Care, 2007
Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 2-year-old boy presented to the emergency department for evaluation of back
pain. Three days before admission, he began to complain of abdominal pain,
refused to eat lunch that day, and spent most of the afternoon watching
television rather than playing outside with his siblings. At that time, he was
taken to a nearby hospital for evaluation. On examination, he had mild, diffuse
abdominal tenderness but no rebound tenderness or involuntary guarding.
Abdominal radiographs showed significant stool in the rectum and distal colon.
He was diagnosed with constipation, was given a glycerin suppository, and was
discharged home after producing a moderate amount of stool.
On the day of admission, he returned to the hospital with persistent abdominal
pain and new complaints of low back pain. His oral intake had been poor over
the past few days. There had been minimal response to a glycerin suppository
earlier that day. He also seemed particularly uncomfortable while his diaper
was being changed. There was no fever, cough, hematemesis, hematochezia,
dysuria, or urinary frequency. There were no ill contacts and no known trauma.
The only pet was an elderly dog that had been euthanized earlier in the week.
II. Past Medical History
Tympanostomy tubes had been placed at 15 months of age for recurrent otitis
media. He had only one episode of otitis media after the tubes were placed. He
did not have a previous history of constipation. He does not take any
medications. The family history was remarkable for a paternal uncle who had a
myocardial infarction at 55 years of age.
III. Physical Examination
T, 38.9°C; RR, 36/min; HR, 130 bpm; BP, 115/55 mm Hg; SpO2, 99% in room air
Weight, 18.0 kg (greater than the 95th percentile)
The child appeared uncomfortable and refused to stand. The eyes, nose, and
oropharynx were clear. The neck was supple. The abdomen was mildly distended
and diffusely tender, particularly in the right lower quadrant. However, there
was no rebound tenderness or involuntary guarding. There was no costovertebral
angle tenderness. There was discomfort with passive flexion of the right hip.
There was mild edema and tenderness to percussion along the right paraspinous
muscle at the level of the L1 vertebra. There was no kyphosis, scoliosis, or
abnormal lordosis. There were no apparent sensory or motor neurologic deficits,
although the degree of back and abdominal pain made assessment of muscle
strength in the lower extremities difficult. There was no muscle atrophy.
Rectal tone was normal. The deep tendon reflexes were symmetric and
appropriately brisk. The remainder of the examination was normal.
IV. Diagnostic Studies
Complete blood count revealed the following: 19,700 white blood cells (WBCs)/mm3, with 67% segmented neutrophils, 29% lymphocytes, and 3% monocytes; hemoglobin,
11.4 g/dL; and platelets, 390,000/mm
3. Serum electrolytes were remarkable for a bicarbonate level of 19 mEq/L, a
blood urea nitrogen level of 7 mg/dL, and a creatinine level of 0.3 mg/dL.
Urinanalysis revealed a specific gravity of 1.020 and 3+ ketones but the
microscopic examination was normal. Serum albumin and transaminases were
normal. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR)
were elevated at 7.9 mg/dL and 65 mm/hour, respectively. Abdominal obstruction
series revealed scattered air
–fluid levels and a small amount of stool in the rectum.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-2: 2-Year-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 2-year-old boy presented with a 2-week history of difficulty walking. The
parents had noticed that he would no longer run while playing with his
siblings. Over the past week, he had begun walking with a limp and refusing to
climb stairs. His pediatrician detected splenomegaly and tenderness over the
right hip. There was no fever, cough, rhinorrhea, throat pain, diarrhea, or
trauma. There had been no ill contacts. A pet dog was acquired 1 week earlier.
Hip radiographs and several laboratory studies were obtained, after which the
patient was immediately referred to the emergency department.
II. Past Medical History
The patient was born at term without complications. He had been hospitalized
with wheezing at 4 months of age and required oral antibiotics at 12 months of
age for outpatient treatment of pneumonia. He was not receiving any medications
and had no allergies. Family history was remarkable for a maternal aunt with
rheumatic heart disease.
III. Physical Examination
T, 37.3°C; RR, 34/min; HR, 104 bpm; BP, 98/43 mm Hg
Height and weight, both 25th percentile for age
On examination, the child was pale and tired-appearing. His sclerae were
anicteric. The heart and lung sounds were normal. The spleen tip was palpable
just below the left costal margin. The liver edge was palpable 3 cm below the
right costal margin. There was mild discomfort with passive flexion of the
right hip, but the range of motion was normal. There was no overlying erythema
or warmth. Examination of the left hip was unremarkable. The testes were in
normal position and were not enlarged, swollen, or tender. Numerous petechial
lesions were scattered on his lower extremities bilaterally. Small lymph nodes
were palpable in the anterior cervical and inguinal regions.
IV. Diagnostic Studies
The complete blood count revealed 4,300 WBCs/mm3, with 3% band forms, 8% segmented neutrophils, and 85% lymphocytes, giving an
absolute neutrophil count of 473/mm
3. The hemoglobin was 8.0 g/dL, with a reticulocyte count of 1.3%. The platelet
count was 31,000/mm
3. CRP and ESR were 2.6 mg/dL and 60 mm/hour, respectively. Serum lactate
dehydrogenase (LDH), uric acid, transaminases, and electrolytes were normal.
The hip radiographs performed earlier were reviewed (Fig. 5-2A).
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-3: 14-Year-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 14-year-old boy presented to the emergency department complaining of left knee
pain. Three days before this visit, he noted left knee pain after playing
basketball and began to limp. This knee pain improved over the next few days.
While walking across a wooden floor on the evening of his emergency department
presentation, he slipped and fell. As soon as he stood up, he noted pain in his
left knee again that occasionally radiated to the left hip. He did not strike
his head. There was no other bone pain. There was no headache, blurry vision,
or loss of consciousness. There was no fever, weight loss, myalgias, or
malaise.
II. Past Medical History
The patient had required hospitalization at 8 years of age for disorientation
after a car accident; his symptoms resolved, and he was discharged the next
day. At 10 years of age, he developed poststreptococcal glomerulonephritis. He
had been treated with a short course of corticosteroids but had not required
specific therapy since that time. He did not report taking any medications.
There was no family history of endocrine or autoimmune disorders.
III. Physical Examination
T, 37.1°C; RR, 24/min; HR, 105 bpm; BP, 125/80 mm Hg
Weight, 101 kg
Physical examination revealed an obese boy without visible evidence of head
trauma. He was alert and cooperative. Heart and lung sounds were normal. The
abdomen was soft without organomegaly. There was no deformity of either lower
extremity. Passive flexion of the left hip accompanied by internal and external
rotation significantly worsened the left knee pain. Internal rotation of the
left hip was limited compared with that of the right hip. There was no
tenderness, swelling, or erythema of the left knee. There was full range of
motion of the left knee without discomfort when this joint was tested in
isolation. There was no sign of knee ligament instability. The right lower
extremity was normal. He was able to ambulate but clearly preferred not to
place too much weight on the left leg.
IV. Diagnostic Studies
The complete blood count revealed the following: 8,600 WBCs/mm3 (65% segmented neutrophils, 30% lymphocytes, and 5% monocytes); hemoglobin,
13.1 g/dL; and 204,000 platelets/mm
3. The CRP concentration was 0.7 mg/dL, and the ESR was 12 mm/hour. Serum
electrolytes and calcium were normal.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-4: 16-Year-Old Girl:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 16-year-old girl was admitted with joint pain and a 35-pound weight loss over
the preceding 7 months. After completion of her gymnastics season 7 months
before admission, she had noticed decreased energy and stiff, slightly swollen
peripheral joints bilaterally, including elbows, wrists, knees, and ankles. She
was diagnosed with juvenile rheumatoid arthritis and treated with naproxen, a
nonsteroidal antiinflammatory drug (NSAID). Her pain improved slightly. Shortly
after starting naproxen, she began having daily episodes of epistaxis that
required four to five facial tissues to control the bleeding. Five months
before admission, she changed from naproxen to ibuprofen without significant
change in the degree of joint pain.
Three months before admission, she noticed a change in her bowel habits, from
two to three stools per week to daily stools that were frequently mixed with
blood. One month before admission, she developed intermittent cramping
abdominal pain. She continued to have episodes of epistaxis and was treated
with fluticasone nasal spray and an oral antihistamine for presumed allergic
rhinosinusitis. Her weight decreased from 148 pounds to 113 pounds. She
complained of decreased appetite and decreased activity level over the
preceding few months. There were no fevers, flank tenderness, dysuria, urgency,
or frequency. There was no change in mood or intentional weight loss. There was
no change in her menstrual cycle. She had not traveled recently.
II. Past Medical History
She had not previously required hospitalization. Menarche occurred at 11 years
of age. Her periods were regular. There were no other medical problems. Her
only medications were ibuprofen, fluticasone nasal spray, and oral
antihistamines as previously mentioned. There was a family history of
hypertension in older relatives.
III. Physical Examination
T, 35.8°C; RR, 18/min; HR, 93 bpm; BP, 123/66 mm Hg
Weight, 40 kg; Height, 162 cm (50th percentile); weight-for-height ratio, less
than 5th percentile
Physical examination revealed a thin girl. Her palpebral conjunctivae were
slightly pale. There were several superficial but actively bleeding erosions on
the left medial nasal septum. There were no oral ulcers. Heart and lung sounds
were normal. The abdomen was soft with mild right lower-quadrant tenderness to
palpation. There were no peritoneal signs. Bright red blood mixed with stool
was detected on rectal examination. There was a small left knee effusion and
bilateral ankle effusions. All joints had a normal range of motion.
IV. Diagnostic Studies
Complete blood count revealed 8,900 WBCs/mm3; hemoglobin, 9.6 mg/dL; and 463,000 platelets/mm3. MCV was 70 fL. The reticulocyte count was 1.5%. ESR was 89 mm/hour.
Prothrombin time, partial thromboplastin time, and serum transaminases were
normal. Serum albumin was 3.0 mg/dL. Urine pregnancy test was negative. There
were no red blood cells (RBCs) or WBCs on urinanalysis. Stool was sent for
bacterial culture, ova and parasite examination, and
Clostridium difficile toxin detection. Abdominal radiography revealed stool in the rectal vault.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-5: 13-Year-Old Boy:
I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)
A 13-year-old African-American boy without significant past medical history
presented to the emergency department with a 2-day history of worsening back
pain. The pain was located in his upper and lower back, and, although he was
uncomfortable in any position, standing upright made his back pain
significantly worse. His pain was not relieved with cyclobenzaprine, a muscle
relaxant. The patient had no history of trauma and denied weakness, sensory
loss, and bowel or bladder dysfunction as well as recent fevers, upper
respiratory symptoms, cough, nausea, vomiting, weight loss, and night sweats.
II. Past Medical History
His past medical history was remarkable for one previous episode of back pain 2
years earlier that required use of a wheelchair for 2 weeks. He had received
iron supplements for treatment of anemia at that time. Additional details of
that episode were not available. He had never been hospitalized and had no
surgical problems. He was not sexually active and had no history of cigarette
or drug use. Family history was significant for a sister with sickle cell
trait.
III. Physical Examination
T 37.7°C; RR 24/min; HR 110 bpm; BP 105/70 mm Hg; Weight 35kg.
The patient was a well-developed, well-nourished male crying in pain. Head,
eyes, ears, nose, and throat were normal. There was no lymphadenopathy. There
was no thoracic wall tenderness. The heart and lung sounds were normal. His
abdomen was soft and nontender without hepatomegaly or splenomegaly. He had no
point tenderness of his back; however, he complained of
“inside pain” over his sacrum. The rectal examination revealed normal sphincter tone and no
palpable masses. His extremities were warm with good peripheral pulses, and he
had full range of motion of all four extremities.
IV. Diagnostic Studies
Complete blood count revealed 8,400 WBCs/mm3 (81% segmented neutrophils, 17% lymphocytes, 2% basophils, 1% eosinophils, and
no bands); hemoglobin, 10.4 g/dL; MCV, 72fL; mean corpuscular hemoglobin
content (MCHC), 23.4 g/dL; red cell distribution width (RDW), 15.1; platelets
241,000/mm
3; and a reticulocyte count of 3%. Blood smear showed anisocytosis,
poikilocytosis, and polychromasia. Electrolytes, blood urea nitrogen,
creatinine, and glucose were normal. ESR was 20 mm/hour. Urinalysis revealed
small amounts of urobilinogen.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-6: 9-Year-Old Boy:
II. Past Medical History
(Pediatric Complaints and Diagnostic Dilemmas)
The patient had received all required immunizations, and, aside from a broken
nose sustained from a batted softball 3 years earlier, he had no significant
past medical history. He did not require any regularly scheduled medications.
He had no known medication allergies.
His family history was significant for a mother and maternal grandmother with
migraine headaches and trisomy 21 in his youngest brother. There is no family
history of arthritis or malignancy. His recent travel had consisted of 2 weeks
at the New Jersey shore over the summer and 1 month of
“sleep-away” camp in northeastern Pennsylvania.
III. Physical Examination
T, 38.6°C; RR, 18/min; HR, 112 bpm; BP, 112/60 mm Hg
Weight, 60th percentile (down 3 kg from his preparticipation physical
examination 4 months earlier); height, 75th percentile (up by 1.0 cm from the
earlier measurements)
The patient was a cooperative boy in no acute distress. He was slender, and his
clothes hung loosely from his frame. Eyes, nose, ears, and oropharynx were not
inflamed. His tonsils were 3+ and symmetric without erythema or exudates. His
neck was supple with only shotty anterior cervical adenopathy. His thyroid was
not enlarged. His lungs were clear with good aeration. His heart had a regular
rhythm but was tachycardic, with a soft systolic murmur at the apex that was
audible throughout systole. His abdomen was soft, nontender, nondistended, and
without hepatosplenomegaly. The left ankle demonstrated a small effusion with
increased warmth and mild erythema. There was exquisite pain with active and
passive range of motion and with gentle palpation of the joint. All other
joints were normal on examination.
IV. Diagnostic Studies
A complete blood count revealed 12,200 WBCs/mm3 (74% neutrophils, 20% lymphocytes, 5% monocytes, and 1% eosinophils);
hemoglobin, 9.5 g/dL; and a platelet count of 556,000/mm
3. A basic metabolic panel was normal, but inflammatory markers were elevated,
with an ESR of 120 mm/hour and a CRP concentration of 8.3 mg/dL. A rapid
streptococcal test and culture of his throat were both negative. Radiographs of
both ankles were obtained and were normal.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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