Case by Gabrielle Jasmin MD, CNH PEM Fellow

8-year-old male with history of eczema presents with RLE weakness. Mom reports that the child was recently seen in an outside hospital’s emergency department 2 weeks prior to presentation for cough and cold symptoms along with right leg calf and hip pain. At that time, he was diagnosed with pneumonia on CXR and started on Amoxicillin 500mg BID. Patient’s cough and cold symptoms have since resolved, and mother states that right leg pain has improved but he is now experiencing right leg weakness. This weakness interferes with walking and he needs to use his arms to lift his leg while walking. Patient is ambulatory but walking with a limp. Patient is also holding on to things to move around the house. Patient was seen by PCP today and sent to the ED for further evaluation. Denies fever, leg/joint swelling, no point tenderness, no redness. No difficulty with stooling or with urinary stream. No known trauma. No known allergies.  Patient is currently not taking any medications.

T 36.9C P: 75bpm RR: 20br/min BP: 106/67 O2 Sat: 100%

General:  Alert.  appropriate for age.  interacting.  
Skin:  Warm.  no rash.  
Head:  Normocephalic.  atraumatic.  
Neck:  Supple.  no tenderness.  no lymphadenopathy.  
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.  no discharge.  vision grossly normal.  
Ears, nose, mouth and throat:  Tympanic membranes clear.  Oral mucosa moist.  No pharyngeal erythema or exudate.  
Cardiovascular:  Regular rate and rhythm
Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  
Gastrointestinal:  Soft, non tender, non distended
Back:  Nontender
Neurological:  Notable portions of the neurologic exam as described below. Motor exam notable for 5/5 strength in upper extremity bilaterally at both shoulder and elbow joint.  5/5 strength in left lower extremity at knee, ankle and hip joint.  5/5 strength in right lower extremity at knee and ankle.  1/5 strength in right lower extremity at hip joint. While sitting on bed: pt uses his R hand to move the R leg. Unable to extend hip when laying on side. However, with leg hanging off of bed, able to extend and flex knee against resistance. 1+ Patellar reflex on Right, 2+ Patellar reflex on Left. CN intact. No dysmetria or dysarthria.
MSK Exam: Full and painless ROM of R hip, knee and ankle. No visible swelling, redness or point tenderness of RLE. No muscular hypertrophy, or tenderness to palpation of areas of concern. No calf pain. No joint swelling.  Full range of motion at right knee and ankle joint.  Diminished active range of motion at right hip initially secondary to pain.  Passive range of motion at all joints intact on right lower extremity with no pain elicited.

Neurology evaluated bedside and PE significant for RLE weakness with R foot drop on exam with loss of reflexes. Vitals remain stable.

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