History

History: Name:-Baby Inuki DimansaAge :- 11 monthsAddress :-Pallewela

Presenting complaint: Fever and difficulty in raising the left arm at the shoulder joint for 4 days duration

History of presenting complaintPresented with :

Continuous fever

Nausea

Difficult to raise left arm at the shoulder joint

Baby was crying when try to raise her hand

History of presenting complaint:Not vomitedNo history of trauma No coughNo symptoms suggestive of UTINo episodes of diarrhea No rashesNo other joint pain or swellingNo ear discharges

Past medical history : Has not been hospitalized beforeAntenatal Hx : UncomplicatedBirth Hx :By NVD Birth weight 2.800 kg Postnatal period was uncomplicatedImmunization up to-date including HibNo complications after birth

Development Hx : Appropriate with the ageDietary Hx : Exclusively breast fed up to 6 months Started complementary feeding at 6 months

EXAMINATIONGeneral examination:

Ill looking Not Pale LethargyLoss of interest in surroundingsFebrileNo bulging fontanelles No sunken eyes No redness or swelling of eyelids

Upon examination of the L shoulder: limited movements, swelling, non-erythematous and warm to touch.

EXAMINATION:THROAT & EAR EXAMINATION :- Normal

CRFT < 2 sec palms not swollen

no peeling off fingers & toes

no oedema

CVS examination :-

Pulse rate -> 120bpm, regular, good volume

Rest of the examination was unremarkable.

Respiratory system examination proper :-

RR -> 30/min Rest of the examination was unremarkable.

Abdominal examination :-

no hepatomegaly

no spleenomegaly

inguinal, femoral nodes were not palpable Rest of the examination was unremarkable CNS examination :- Features suggestive of meningitis such as:Conscious

Neck stiffness absent

Brudzinskis sign negative

Kernigs sign - negative THESE SIGNS ARE NOT RELIABLE IN A BABY WHO IS < 18 MONTHS

Cranial nerve examination was normal.

Tone & power normal in both upper & lower limbs except left shoulder joint

Management:Most likely diagnosis: osteomyelitis +/- septic arthritis

Investigations:Day 1:FBCCRPX-Ray of L shoulder-AP -LateralBlood culture (before commencing antibiotics)Hx-Pt was on Clarithromycin for 2 daysRx- IV Augmentin (Co-amoxyclav) 225mg 8hrly Paracetamol Syrup 5ml sosDay 2:Ix-ESRUFRUrine cultureUSS of L shoulder joint

Rx- Change antibiotic to:Cloxacillin 180mg 8hrlyGentamicin 20mg 8hrly IV

Day 3:Continue IV antibioticsRepeat CRPReferred to Orthopaedic Surgeon

INVESTIGATION FINDINGS

FBC:Upon admission:Hb 10.2g/dLWBC 14800/mm3-Neut-49/mm3-Lympho-48/mm3Platelets 290,000/mm3

Day 1:Hb-10.4g/dlWBC-13.01*10^9/L-Neut-40.5%-Lympho-47.6% Platelets 482*10^9/LESR :Upon admission:Day 01:47mm/1hr56mm/1hr

CRP: Day 01: Day 03:14.7 mg/L16.3 mg/L

Blood culture: No bacterial growth

UFR:Appearance:clearKB: positivePus cells: +(2-3)/hpfRed cells: NilEpithelial cells: +Casts: NilCrystals: + Calcium oxalate

Urine Culture: No bacterial growthX-Ray:

No abnormalities

USS L shoulder:

Small echoic effusion of 2.1mm with internal echoesNo other abnormalitiesAppearance could be due to septic arthritis of L shoulder jointSummary:A 11month old baby presented with fever for 4 days duration associated with decreased movements of the left shoulder for 3 days duration. There are no local signs such as swelling, redness and warmth around the L shoulder joint. The rest of the limb has good tone and power.