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M E G H A N E D M U N D S O N

Morning Report

Pain with a Limp

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H & P

HPI:

11Y 9M female with PMH of hypothyroidism presentsfor right upper leg pain and limp for 3 weeks and 2

days of fever.

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HPI Details

Pain is described as aching and burning radiating from thesuperior aspect of the right knee to the proximal femur.

Patient can bear weight on her leg and ambulate.

Pain is worse at the end of the day.

Pain wakes her up at night. Ibuprofen provides minimal relief.

No prior URI or GI symptoms but patient does developdiarrhea in the hospital.

Patient is obese. No weight loss, pallor, bruising or bleeding.

Aunt thought leg felt warm and brought her to ED.

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Additional Details

PMH: hypothyroidism on Synthroid

PSH: none

IUTD except for Flu

Medications: SynthroidNKDA

Normal diet

FH: Mom-hypothyroidism

MGGM-"bone marrow cancer"PGF-adult onset leukemia

SH: father passed away 3 weeks ago from unknown causes

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PE

T 38.4. HR 88. RR 20. BP 123/70. SaO2 95% on Room Air.WEIGHT - 71.1 Kg

GENERAL: alert, smiling and cooperative, well developed and nourished girl in no acute distressHEAD: normocephalic, atraumatic.EYES: normal pupillary reflexes bilaterally, extraocular movements intact, no conjunctivalinjection.EARS: normally placed

NOSE: no discharge or obstruction.OROPHARYNX: moist mucus membranes, tonsils 1+ without exudate, no pharyngeal erythema orlesions.NECK: supple without lymphadenopathy or tenderness to palpation.CARDIOVASCULAR: normal rate, rhythm, and S1/S2, without murmur or gallop. Pulsesappropriate. Capillary refill time

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LABS?IMAGING?

CONSULTS?

Now what?

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Labs

BMP- 143/3.8/103/26/11/0.64/83 AG- 14 Ca- 9.8

CBC with diff- 12.2/11.9/36.7/458 N- 60.4 L-24.1 M-14.0 E- 7B- 0.6

ESR- 60

CRP- 5.7

Blood cultures obtained

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Imaging

XR Knee- Normal radiographs of the right knee.

XR Hip- Normal radiographs of the right hip.

Asymmetric positioning of the patient precludescomparison of bilateral fat planes surrounding the hipjoint to assess for hip joint effusion. This should becorrelated with known clinical information.

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Differential Diagnosis?

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Differential Diagnosis

SCFE

Legg Calve Perthes

Septic Joint

Transient Synovitis Osteomyelitis

Osteosarcoma

Leukemia, Lymphoma

Psoas Abscess Post Infectious/Reactive Arthritis

Benign Bone Tumors

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Heme Onc Consult

Ortho for tissue biopsy

Chest Ct for pulm mets

Bilateral BM Aspirates

Surgical path report

Port placed

Follow up for outpatientchemo treatment

Cxs, prelim path-smallround blue cell tumor

Normal

No evidence of leukemia

or lymphoma Consistent with

PNET/Ewing Sarcoma

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Future Plan

Chemo before surgery: vincristine, doxorubicin,cyclophosphamide, ifosfamide, and etoposide

Resected tissue studied for necrosis

>90-95% indicated good response Post op chemo and radiotherapy

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Clues

Pain and swelling not responding to conservativetherapy

Deep bone pain

Nighttime awakening Palpable mass

X-ray showing a lesion

Ewings is more likely to be associated with systemicfindings

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