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Non-traumatic limp and fever in a school-age child.

Case Presentation

Jordan is a 10-year-old Caucasian male, presenting to the primary care clinic for a sick visit. His mother reports a chief complaint: "He has had a limp for three weeks." This is Jordan's second visit to the clinic in the past two weeks for limping. Jordan does not have any chronic health problems and no scheduled daily medications. His mother reports that she has given him ibuprofen for fever, with the last dose being "two days ago."

History of Present Illness

Jordan was seen two months ago for vomiting that was determined to be viral gastroenteritis. He was seen two weeks ago and diagnosed with an upper respiratory infection; however, he also complained of his "right leg hurting." His mother says that he has been limping "off and on" since his last office visit. During Jordan's visit two weeks ago, diagnostic studies, including a CBC, ESR, CMP, and a right leg X-ray, were negative. His mother reports that Jordan is still limping and waking up during the night complaining of pain. She also reports a two-day history of low-grade fever. The highest temperature his mother reported was 100.4[degrees] F (tympanic). Jordan has no known allergies. He states: "It hurts every time I go outside to play." His mother confirms his statement and includes that he complains of pain most often after playing outside.

Past Medical History

Jordan is an established patient at this clinic. His past medical history includes recurrent otitis media as a young child, bronchiolitis twice, several upper respiratory infections, and several episodes of viral gastroenteritis. Jordan was hospitalized twice for bronchiolitis (age five months and 18 months). At age 12 months, he had bilateral myringotomies with pressure equalizing tubes for the recurrent otitis media. His mother reports that Jordan has mild eczema but states: "He is, for the most part, healthy."

Development and Growth History

Jordan's mother had health supervision during pregnancy and reports no complications during pregnancy. Jordan was delivered at 38 weeks gestation via a cesarean delivery. He met all of his first-year developmental milestones within normal limits.

Family and Social History

Jordan's mother is 35 years old, and Jordan's father is 38 years old. His mother reports that they are married and both are in good health. Jordan has one older sister with juvenile rheumatoid arthritis. The paternal grandparents' history is unknown; however, the maternal grandmother has a history of asthma, and the maternal grandfather has high cholesterol. Jordon's mother reports that she is a stay-at-home mom and that their home is in a safe neighborhood.

Nutritional History

Jordan's mother reports that she breastfed for only a short period of time, then Jordan was on a milk-based formula. Jordan started on fruits around four months, and was on table foods and whole milk by age one year. He now eats "pretty well" per his mother's report. She says Jordan eats from all four food groups and drinks one to two cups of 2% milk daily.

Review of Systems

HEENT: Jordan has a history of recurrent otitis media as a young child. He began having problems with this at age three months. Jordan had ear tube surgery at age 12 months and has only had otitis media twice since that time. Mom denies discharge from eyes, nose, or ears. Denies oral sores. Denies complaints of ear or throat pain. Cardiovascular: There is no report of chest pain, cyanosis, syncope, tachycardia, night sweats, murmurs, or fatigue. Respiratory: Jordan has had recurrent upper respiratory infections. His most recent infection two-months ago was prolonged with bacterial rhinitis. His mother denies any current cough, rhinorrhea, wheezing, or congestion. GI: Jordan's mother denies emesis, constipation, polyuria, and diarrhea. GU: Jordan's mother denies dysuria, hematuria, polyuria, frequency, or urgency. Neurological: There is no report of nervousness, dizziness, tingling, convulsions, developmental delays, weakness, uncontrolled movements, or problems with tactile stimulation. Musculoskeletal: There is a twomonth history of right leg limp with intermittent pain. Jordan's mother denies joint pain, postural deformities, or exercise/physical intolerance. Jordan does not have a history of developmental dysplasia of the hip. His mother denies any recent history of trauma. Endocrine: There is no history of disturbances in growth, excessive fluid intake, polyphagia, goiter, thyroid disease, or periods of weight gain or weight loss. Skin: Jordan has a history of eczema treated with over-the-counter hydrocortisone cream.

Physical Assessment Findings

General Appearance: Jordan presents awake and alert. He appears well-hydrated and well-developed, and responds age-appropriately throughout the examinbation. Jordan is walking with an intermittent right-sided limp.

Vital Signs: Temp: 98.2 (temporal), Height: 56.5in, Weight: 66 lbs, HR: 88, RR: 24. Pain reported as 2/5 on the FACES pain scale.

HEENT: Head round, normocephalic, without masses or lesions. PERRLA and bilateral red reflex noted. TMs noted clear bilaterally. Nose: nares patent. Trachea: noted midline. Neck: full ROM without resistance, no tenderness to touch. There are no lumps or masses. Carotid pules are normal (3+) with no bruits upon auscultation. Mouth: moist mucosa membranes without lesions noted. Tongue intact without edema. Uvula midline and mobile.

Integumentary: Warm and dry to touch. No inflammation, no redness, no pus drainage, no tenderness, and no lesions noted. Color pink and well perfused. No bruising noted. No dry patches or excoriations noted.

Respiratory: Respirations even and unlabored. Lungs clear to auscultation bilaterally. No dyspnea noted.

Cardiovascular: Regular, rate, and rhythm noted. No murmurs, rub, or gallop noted. Less than three-second cap refill noted. No cyanosis, clubbing, or edema noted.

Abdomen: Abdomen soft and non-distended. No tenderness to touch noted. Abdominal reflex present. Umbilicus is midline and inverted. Peristalsis is not visible. Bowel sounds are normoactive in all four quadrants. No hepatomegaly or splenomegaly noted.

Neurological: CN II-XII noted intact. Jordan is able to state his name, age, and birth date.

Musculoskeletal: Full ROM and symmetrical muscle strength noted in all extremities. No edema, no tenderness, no erythema noted over joints. Hips and shoulders are level when standing. Spinous processes are straight and none tender. Jordan has a slight right intermittent limp when walking. He says that his right leg hurts at the knee when he walks, but he does not show any signs of pain with passive ROM of the legs and hips. Point tenderness is noted over the right knee with palpation. No point tenderness noted at any other sites.

Genitalia: Omitted.

Anus: Omitted.

Summary

Jordan is a 10-year-old male, well nourished, being evaluated for a right leg limp. He is awake, alert, and animated throughout the examination. The examination revealed point tenderness, no edema, and no obvious deformity.

Differentials

Osteomyelitis-An infection that typically starts in the bone. The infection often spreads from another infected area; however, it can occur as the result of a penetrating wound. Symptoms include tenderness and pain around the knee, increased temperature, refusal to bear weight on the affected side, and elevated white blood count (WBC) (Hay, Levin, Deterding, Abzug, & Sondheimer, 2016). School-age children are commonly affected due to their growing bones. Jordan presented with a limp and history of a low-grade fever, and point tenderness only over the knee. He did not have any signs of infection.

Transient Synovitis-An inflammatory reaction in the hip that often follows a viral upper respiratory infection. A sudden onset of limping is a common complaint, along with a history of a recent infection, fever, and hip pain. The most common age of diagnosis is between three and nine years (Zorc et al., 2013). Patients with this diagnosis can typically move their hip through some range of motion with limited pain and have normal inflammatory laboratory studies. Jordan had a limp, and a recent history of a viral infection and minimum complaints of pain.

Juvenile Rheumatoid Arthritis-An autoimmune disorder characterized by chronic inflammation of joints. Symptoms present at diagnosis often include limp, joint pain and swelling, cyclical fevers, rash, and muscle weakness (Jones & Higgins, 2010). Completing a history and physical is imperative for diagnosis. It is rare for a child with musculoskeletal pain and/or a limp with no other symptoms to have a diagnosis of arthritis. Jordan had a limp and a two-day history of fever; however, there were no complaints of swelling, muscle weakness, or unexplained rashes.

Legg-Calve-Perthes Disease--A disease process characterized by an interruption of blood supply to the hip. This interruption of the blood supply leads to poor bone healing, and eventually, bone death. Symptoms include being a school-age male, limping only on the affected side, limited ROM, and pain in the hip, groin, or knee (Zorc et al., 2013). Damage occurs over months, so a bone scan is often needed to confirm diagnosis. Laboratory studies are typically not helpful in making the diagnosis. The diagnosis is confirmed typically after other disorders are ruled out. Jordan has a limp, and his pain is exaggerated during activity.

The Management Plan

This particular case study seems to be following the expected course for Legg-Calve-Perthes' Disease (LCPD). The presenting symptoms of intermittent leg pain and limping are consistent with expected symptoms in LCPD. Jordan complains of hip and knee pain on awakening and after playing, and this is to be expected. He was referred to an orthopedist for further evaluation, and three weeks later, a diagnosis of LCPD was confirmed. The CBC and ESR were both normal. Xray of the pelvis revealed that the "pelvis and sacrum are intact; femoral epiphysis and growth plate are intact; tibia and fibula are intact." A hip ultrasound revealed an effusion. The orthopedist recommended decreased physical activities (i.e., all sports), physical therapy twice a week for six weeks, and to follow up in two months.

References

Hay, W.W., Levin, M.J., Deterding, R.R., Azburg, M.J., & Sondheimer, J.M. (2016). Current diagnosis & treatment: Pediatrics (23rd ed.). New York, NY: McGraw-Hills Companies.

Jones, K.B., & Higgins, G.C. (2010). Juvenile rheumatoid arthritis. In PJ. Allen & J.A. Vessey (Eds.), Primary care of the child with a chronic condition (5th ed., pp. 587-606). St. Louis, MO: Mosby.

Zorc, J.J., Aplern, E.R., Brown, L.W., Loomes, K.M, Marino, B.S., Mollen, C.J., & Raffini, L.J. (Eds.). (2013). Schwartz's clinical handbook of pediatrics (5th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Tedra S. Smith, DNP, CPNP-PC, CNE, is an Assistant Professor and Specialty Track Coordinator Pediatric Nurse Practitioner Primary Care, Family, Community & Health Systems, The University of Alabama at Birmingham, Birmingham, AL.
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Title Annotation:Critical Thinking Case Studies
Author:Smith, Tedra S.
Publication:Pediatric Nursing
Article Type:Clinical report
Date:Mar 1, 2017
Words:1725
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