Hot Seat #157: 10 day old with elbow swellingPosted on: September 19, 2020, by : Mary Beth Howard
CC: 10 day old girl with elbow swelling
HPI: 10 day old ex FT girl presenting with left elbow swelling and decreased movement of left arm. Parents report that in the middle of the night, they noticed she was not moving her left arm the same way she was her right. Waking every 1-3 hours to feed, wet and dirty diapers qfeed. 3 days ago, temp was 99 on temporal thermometer, 100.1 rectally, checked 3 minutes later and 99.3 without acetaminophen. No known trauma, however, mother notes that she fell asleep on her side while nursing 2 days ago.
PMH: Born 40 weeks NSVD. Labor 26 hours. No birth traumas. Discharged home with mother. Received vitamin K.
Meds: vitamin D
FHx: No family history of epilepsy, seizures, bleeding/clotting disorders, recurrent infections.
SHx: Lives with mother and father. No sick contacts. No other caretakers.
Gen: No fevers. Diapers : normal amount Oral intake: breastfeeding well
Skin: No rash, no bruising
Eye: No redness, no discharge
ENT: No nasal congestion
Respiratory: No increased work of breathing, no stridor, no apnea
CV: no nursing cyanosis, no nursing diaphoresis
GI: no vomiting, no diarrhea
GU: no hematuria
Neuro: no seizures, no altered level of consciousness
T 37.7 HR 150 RR 32 BP 81/56 SpO2 97%
Gen: Alert, appropriate for age
Skin: warm, dry, pink, no rash.
Head: AFOF, NC/AT
Eye: PERRLA, normal conjunctiva, moving eyes spontaneously
ENT: Oral mucosa moist
CV: RRR, no murmurs, WWP, distal pulses 2+
Respiratory: lungs clear bilaterally, no increased WOB
GI: Soft, NT/ND, normoactive bowel sounds
MSK: moving legs bilaterally with 5/5 strength, right UE with normal range of motion, normal strength. Reduced movement of left arm, holds left arm extended posture, able to abduct arm at shoulder spontaneously, does not spontaneously move left hand/wrist/elbow. No overlying skin changes including erythema or bruising.
Neurologic: opens eyes to mother. Asymmetric Moro reflex: does not flex left arm. Reduced grasp present in left hand, reduced tone in left arm, fussing with flexion/extension at left elbow joint. Normal axial tone. Normal tone in right arm, bilaterally lower extremities.
CBC WBC 13 H/H14.2/40.7 Plt 745
ESR 55, CRP 3.61
Chem: Na 138, 4.5, Cl 101, CO2 26, BUN 10, Cr 0.21, Glucose 87
Left UE x-ray is normal
HUS showed small R choroidal cyst, otherwise unremarkable.
US: complex left elbow joint effusion (likely hemarthrosis) without evidence of radio-capitellar subluxation-dislocation. Normal shoulder joint. No subperiosteal fluid.
Orthopedics is consulted given joint effusion and requests repeating the ultrasound while they are present to tap the joint.
Orthopedics taps the elbow effusion under ultrasound guidance, obtains 4cc of cloudy, bloody fluid.
WBC 260,000 with 92% neutrophils
LP Obtained: CSF: RBC 3000 WBC 10 glucose 63, protein 54
ID was consulted, recommended who recommended starting patient on Oxacillin/Gentamicin
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