Module 37, General Medical Level

1,2

A 9 month old male with history of normal pregnancy, delivery and growth presented to the emergency room. The mother reported 2 days of fever of unknown origin with vague abdominal pain and diarrhea. Initial work-up revealed: temperature of 40.1, WBC 16,800 with left shift, X-rays of Chest Abdomen, Pelvis, and Hips were normal. A bone scan was negative, spinal tap was normal. The child was admitted with a diagnosis of viral infection vs. mycoplasma pneumonia. He was started on erythromycin. On hospital Day 2 the Right hip was noted to be flexed and the child appeared to have pain with any movement of the hip.

Question 37A

An ultrasound of the hip is the next step in the work up.

Question 37B

Acute appendicitis should be considered highly on the differential diagnosis of this baby on day two.

Question 37C

An aspiration of the hip is done which yields purulent fluid. The hip now needs to be aspirated every twelve hours until the child is afebrile.

Question 37D

This child's general illness makes it very unlikely that the process is localized to the hip joint.

Question 37E

In the emergency room the child should have had a CBC, ESR, and blood cultures as a minimum of a work up. These are the only significant tests which would help the acute management.