Intern Report Case 1.6

intern-report

Presented by Kyle Perry, MD

Chief Complaint: “He’s limping.”

History of Present Illness:
A 13 year-old male presents to the emergency department with his parents who say that he has been limping over the past few months and it is progressively getting worse.  He says he limps because he is having pain in his left hip and knee.  He describes it as a dull pain, 7/10, radiates towards his knee at times, exacerbated by standing for extended periods of time and relieved somewhat by rest. The pain is never completely alleviated.  He denies any traumatic injury, weakness, numbness, paresthesias, fever, or recent illness.  He occasionally will take Tylenol or Motrin with some relief.  It has progressively worsened and over the last several days he has been unable to be as active as usual.

Past Medical History: Asthma
Past Surgical History: None
Medications:
Albuterol as needed
Allergies: NKDA
Immunizations: Up to date
Social History: He denies alcohol, tobacco, or drug use.  He is in 7th grade.  He denies sexual activity.  They have smoke detectors in the house.  No pets.
Family History: His brother has asthma.  Grandmother has diabetes and hypertension.

Physical Exam:
Vital Signs: T 36.7, BP 112/72, P 76, R 18, SpO2 100%RA  Wt. 70 kg, Ht. 130 cm
General: Pt appears his stated age.  He lying on the stretcher comfortably
HEENT: Normocephalic, atraumatic.  PERRL, EOMI, MMM
Cardiovascular: Regular rate and rhythm, +S1, S2, no murmurs, rubs or gallops, pulses are palpable in all 4 extremities and symmetrical
Respiratory: Clear to auscultation bilaterally.  No wheezes
Abdomen: Soft, non-tender, non-distended, obese, + bowel sounds.
Neurological: A&O x3 speaking in full, coherent sentences.  Sensation is intact throughout.  Strength is 5/5 in both upper extremities and right lower extremity, and 4/5 in left lower extremity secondary to pain.
Skin: Warm, dry and intact.  No rashes, no erythema or signs of cellulitis.
Extremities: He has a noticeable limp and is favoring his left hip.  He has moderate tenderness over the left hip with palpation over the greater trochanter area. Limited ROM secondary to pain with passive and active flexion and abduction.  He is laying with his hip somewhat abducted and externally rotation for a position of maximal comfort.   He is only able to flex his hip to approximately 60 degrees.  He has slight tenderness over his left knee that is not localizable.  No warmth, erythema, or swelling of either the hip or knee.

Radiographic Studies:

12

Questions:

1.)    What is the most likely diagnosis?
a.    Slipped Capital Femoral Epiphysis
b.    Legg-Calve’ Perthes Disease
c.    Juvenile Rheumatoid Arthritis
d.    Osgood schlatter Disease
e.    Infectious mono-arthritis

2.)    What classification of Salter Harris fracture is this?
a.    I
b.    II
c.    III
d.    IV
e.    V

3.)    What is the treatment for this condition?
a.    Hip replacement
b.    Physical therapy with weight bearing as tolerated
c.    Rest, application of ice to the affected knee for 20 minutes every 2-4 hours, NSAIDs for pain relief, and gradually increasing activity with a brace
d.    Urgent operative repair with internal fixation of the hip with consideration of treating the contralateral side
e.    One time dose of 15,000 mcg of vitamin D, or 125-250 mcg given daily for 2-3 months until healing is well established

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

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