CC: 9mo male with fever and toe redness

HPI: 9mo otherwise healthy boy presents with acute onset fever and great toe redness. Per mother, great toe was noted to be red and swollen at daycare about 2 hrs prior to presentation. She did not notice it in the morning when getting him dressed. When mother arrive to pick him up at daycare, he felt warm, but she did not take his temperature. No rashes or redness elsewhere. Patient pulls to stand but not ambulatory.

ROS: + tactile temperature, +fussiness. Normal PO intake and UOP. No rashes or lesions elsewhere. No cough/congestion. No vomiting or diarrhea.

PMHx: No PMH. No history of skin infections

PSHx: No past surgical history

FHx: No family history of skin or soft tissue infections

Social History: lives at home with mother, father, and sibling. In day care

Exam:

T: 39.6, HR 162 BP 105/69 RR 25 SpO2 100%

General: Crying, calms in mother’s arms.

Skin: Warm, mottling of hands and feet bilaterally

Head: Normocephalic. Atraumatic.

Neck: supple

Eyes: PERRLA, EOMI, conjunctiva clear

Cardiovascular: Tachycardic, regular. No murmur. CR 2-3s

Respiratory: Lungs CTAB

GI: Soft, nondistended, normoactive bowel sounds

MSK: erythema of right great toe with circumferential erythema, swelling extending to base of the first metatarsal. Patient withdraws when toe is palpated. No induration, fluctuance, or fluid drainage. Plantar aspect of DIP joint with 0.5cm linear excoriation/abrasion. Nail bed wnl. No obvious hair tourniquet. Moving foot spontaneously. Cries with attempted weight bearing.

Neurologic: Alert, developmentally appropriate. No focal neurologic deficit observed

A blood culture, CBC, and inflammatory makers are obtained:

WBC 13.69 H/H 11/32 plts 404

ESR 17

CRP 1.67

A bedside US demonstrates no fluid collection, no foreign body, no cobblestoning

X-ray with no radiopaque foreign body or radiographic evidence of osteomyelitis in the left foot and left great toe

On reassessment, the patient has defervesced and is well appearing with normal vital signs, the erythema of the toe has receded slightly.

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