Post by jmfkmd on Jul 30, 2014 16:59:44 GMT -5
Saw a 10 year old boy the other day in the East Zone (Peds was overflowing) who's CC on the board was: "Fell from Bike - Injured Left Leg."
What do I see when I walk in the room:?
Pleasant, smiling 10 yo boy who's smiling and throwing his stuffed Angry Bird up and down into the air. He politely answers all your questions and at bedside is his mom who wreaks of cigarette smoke, is emaciatingly skinny, and super skittish with my questioning and talking over the patient to answer my questions.
HPI:
Patient was playing with a neighbor yesterday when he turned his handlebars to the right fell to the side and somehow his left shin hit the handlebars. He often plays with this neighbor and mom at bedside states that the neighbor's mom is always present. Patient states his leg only hurts to palpation but he can still bear weight. Mom is concerned because the bruising is getting really big and his dad had a hx of compartment syndrome before.
PE (only pertinent points):
Vitals: AF, VSS
Skin: Bruising in different stages of healing on his posterior right chest wall in the shape of a perfectly round coin - on his right knee and right thigh, on his left leg with what appears to be a deformity and significant swelling over his left shin - bilateral forearms, and marks that looks like hematomas on his lips, chin, and forehead. He also has widespread non-blanchable red spots that look like tiny hemangiomas over bilateral lower extremities that resemble petechiae.
MSK: TTP over the left shin where the bruising and swelling is most significant. No left ankle or knee TTP. No TTP over any of the other bruises. No TTP over the petechiae. left lower leg is not firm or tense and +2 distal PMI.
Abd: Normal exam with percussion. No signs of organomegaly.
Reassessment:
Left Tib/Fib X-ray negative for any signs of fractures.
When I asked the mom about the petechiae, she stated that she's never seen that before. She thought they were either bug bites from the patient playing in the trees or a rash because she thinks he's allergic to some grasses. She states that the petechiae was not there yesterday and only noticed it earlier today when the patient was taking a bath.
I spoke with the mother alone and the child alone, and determined that there was no abuse going on, although I was suspicious of this since the bruises were in weird spots, looked like they resembled weird objects like household items, and some of them were in different stages of healing.
Well, the left tib/fib was negative for fracture, so call it a lower leg contusion and hematoma, and send home with follow up with patient's pediatrician right?
Since I'm asking that's obviously not what I did... but what would you do now?
A) Trauma Consult for possible domestic abuse
B) D/C with close follow up with PCP
C) Ortho Consult for r/o compartment syndrome
D) CBC with manual diff and Coags
E) I don't know, just admit them...
What do I see when I walk in the room:?
Pleasant, smiling 10 yo boy who's smiling and throwing his stuffed Angry Bird up and down into the air. He politely answers all your questions and at bedside is his mom who wreaks of cigarette smoke, is emaciatingly skinny, and super skittish with my questioning and talking over the patient to answer my questions.
HPI:
Patient was playing with a neighbor yesterday when he turned his handlebars to the right fell to the side and somehow his left shin hit the handlebars. He often plays with this neighbor and mom at bedside states that the neighbor's mom is always present. Patient states his leg only hurts to palpation but he can still bear weight. Mom is concerned because the bruising is getting really big and his dad had a hx of compartment syndrome before.
PE (only pertinent points):
Vitals: AF, VSS
Skin: Bruising in different stages of healing on his posterior right chest wall in the shape of a perfectly round coin - on his right knee and right thigh, on his left leg with what appears to be a deformity and significant swelling over his left shin - bilateral forearms, and marks that looks like hematomas on his lips, chin, and forehead. He also has widespread non-blanchable red spots that look like tiny hemangiomas over bilateral lower extremities that resemble petechiae.
MSK: TTP over the left shin where the bruising and swelling is most significant. No left ankle or knee TTP. No TTP over any of the other bruises. No TTP over the petechiae. left lower leg is not firm or tense and +2 distal PMI.
Abd: Normal exam with percussion. No signs of organomegaly.
Reassessment:
Left Tib/Fib X-ray negative for any signs of fractures.
When I asked the mom about the petechiae, she stated that she's never seen that before. She thought they were either bug bites from the patient playing in the trees or a rash because she thinks he's allergic to some grasses. She states that the petechiae was not there yesterday and only noticed it earlier today when the patient was taking a bath.
I spoke with the mother alone and the child alone, and determined that there was no abuse going on, although I was suspicious of this since the bruises were in weird spots, looked like they resembled weird objects like household items, and some of them were in different stages of healing.
Well, the left tib/fib was negative for fracture, so call it a lower leg contusion and hematoma, and send home with follow up with patient's pediatrician right?
Since I'm asking that's obviously not what I did... but what would you do now?
A) Trauma Consult for possible domestic abuse
B) D/C with close follow up with PCP
C) Ortho Consult for r/o compartment syndrome
D) CBC with manual diff and Coags
E) I don't know, just admit them...
