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 severe foot pain in a child  



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Author8 Posts
  #1

12 yo child

History:

appendicectomy ate age 10,
repeated sinusits and URT infections since age 1

The child stepped on a rusty and muddy nail 14 hours ago. Severe foot pain and swelling that began 4 hrs ago. Also moderate shortness of breath.

Physical

the foot is swolle and vey painful spontaneously. Severe tenderness on palpation of the injured area. Moderate green discharge from the wound.

BP = 100/60
HR = 180
RR = 32; laborious breathing
Temp: 40 C

Jaw stiffening

While you examine the child, he is developing a seizure.

Lab:

CXR - bilateral and diffuse lung infiltrates, normal heart, clear csotovertebral angles
ECG: sinusal tachycardia; no ST-T changes
AXR: no abnormalities
SaO2 = 89%
Gram stain: GN bug

The most immediate measure is :wink: :
The next logical investigation is :wink: :
The most probable dx is :!: (be very grateful)




  #2

Dx is tetanus and complication of foot infection

Immediate measure is to control seizures with diazepam. May need to intubate and ventilate if respr fail cuz he has laboured breathing. Then clean and debride wound followed by peni Abx and tetanus Ig.

Logical Ix would be detailed immunisation history. May need a booster or a full course if unimmunised.


  #3

dear sanz, you are close. That's good. But you've missed some very important aspects I mentioned about.

repeated sinusits and URT infections since age 1

that tells me this patient might have some sort of immune deficiency. In other words, his immune system is not reacting normally to infection. So, he is at increased risk of developing even more serious ones.

The child stepped on a rusty and muddy nail 14 hours ago. Severe foot pain and swelling that began 4 hrs ago. Also moderate shortness of breath.

rusty and muddy - think of tetanus

Physical

the foot is swolle and vey painful spontaneously. Severe tenderness on palpation of the injured area. Moderate green discharge from the wound.

gren discharge - probably Pseudomonas aeruginosa

BP = 100/60
HR = 180
RR = 32; laborious breathing
Temp: 40 C

fever, decreased BP, blood cultures - GN bug - clue to septicemia

Jaw stiffening

clue to tetanus

While you examine the child, he is developing a seizure.

probably febrile seizure, although tetanus itself or the bugs in blood can also cause that.

Lab:

CXR - bilateral and diffuse lung infiltrates, normal heart, clear csotovertebral angles
ECG: sinusal tachycardia; no ST-T changes
AXR: no abnormalities
SaO2 = 89%
Gram stain: GN bug

tachypnea, tachycardia, laborious breathing, septicemia and suggestive CXR - clue to ARDS

The most immediate measure is :
The next logical investigation is :
The most probable dx is (be very grateful)

So, let's sum up.

The pt. probably has tetanus and Pseudomonas aeruginosa sepsis. Both can be fatal. He has also suggestive S/S of ARDS, which can be caused by sepsis.

The pt's SaO2 is 89 %. Together with S/S of ARDS and seizure - Next: Give O2 supplement, intubate and mechanically ventilate; give Diazepam; then stabilize hemodynamically the pt. (iv line, fluids / blood, pressor drugs), in the hope that the pt. does not develop septic shock. After that, give "big gun" ABs (to cover Pseudomonas / Staph. aureus - also cover clostridium tetani) and tetanus immunization.

The next logical exam is to determine the ABGs - since there is severe hypoxemia and tha pt. is tachypneic - clue to metabolic acidosis. Correct eventual electrolyte disturbances and watch for S/S of other organ involvement.


Hope it helped.


  #4

Sure! Thanx for these cases... more please!


  #5

"miky" wrote:


While you examine the child, he is developing a seizure.

probably febrile seizure, although tetanus itself or the bugs in blood can also cause that.



miky,by definition, febrile seizures occur in children aged 3 months to 5 years.
this child is 12 yrs old.


  #6

Mash,

You are perfectly right. But this patient has bugs in his blood, severe hypoxemia and many others. So, according to some textbooks, fever can cause seizures in certain situations even in older children.


  #7

u r right miky dat he has bugs in his blood..
isnt it possible dat he has tetanic seizures.
moreover, after 5 yrs of age we call 'em 'seizures precipitated by fever' and not febrile seizures...


  #8

miky. one question if the child has immunodeficinec do we need to give him tetanus toxoid + Ig or just the Ig?





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