Age: 1.25
Sex: F
Vaccine: DTAP, HIBV
Symptoms: Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin decreased, Blood calcium increased, Blood chloride normal
Clinical narrative: On 9/22/18 mom called triage line to report patient limping on left leg, not wanting to bend left leg. There is no swelling on the leg. She doesn't appear to be tender per mom. Mother denies fever. No recent trauma to the leg that mom is aware of other than the shots she received 2 days ago. She also fell while on daycare yesterday but only scratched her face. Mother asked her babysitter if she had noticed something yesterday and she said no. Patient continues to have good PO intake and UOP. Infant is on eye antibiotic for blocked tear duct. Positive for limping and decrease range of motion with pain. Advised mother to take care to urgent care to be evaluated. Mother V/U. Had received vaccines 2 days prior. Triage MD advised patient be seen in ED or urgent care. Urgent care note: Date of Service: 9/22/2018. Patient is a 15 MO female. Subjective: History of Present Illness: Here today with complaint of leg pain. Mom noticed this morning that she was not bending her knee when she was walking. She does not have any injury that mom is aware of. She does go to daycare but did not have any injury there that mom is aware of. She got shots 2 days ago in that leg but pain does not seem to be around the shots. She does not have fever. She has not had a cold or any other symptoms. She is otherwise usually healthy. Review of Systems: All other systems reviewed and are negative. Objective: POLYTRIM 0.1 - 10,000%-unit/mL ophthalmic solution. Apply one drop to left eye as directed every 6 hour. Vitals: 09/22/18 1055, Temp: 36.7°C (98 °F), TempSrc: Tympanic, Weight: 10.3 kg (22 lb 9.6 oz), Body mass index is 18.62 kg/m². Physical Exam Constitutional: She appears well-developed and well-nourished. She is active. HENT: Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Nose: Nose normal. Mouth/Throat: Mucous membranes are moist. Dentition is normal. No tonsillar exudate. Oropharynx is clear. Pharynx is normal. Neck: Normal range of motion. Cardiovascular: Regular rhythm and S1 normal. Pulmonary/Chest: Effort normal and breath sounds normal. Musculoskeletal: Child is refusing to move the left knee. She will not bend it nor will she allow it to be bent. She will allow manipulation at both the ankle and the hip. The knee is not warm and does not appear swollen. Puncture sites from her shots are visible. There is no warmth or swelling around these. Neurological: She is alert. Skin: Skin is warm. Capillary refill takes less than 2 seconds. Nursing note and vitals reviewed. Assessment and Plan: Pain KNEE 3 VIEWS LEFT. Patient Instructions. Patient's X ray did not show a fracture. Please go to the ER for further evaluation as I am concerned she could have an infection in her joint. Electronically signed by MD at 09/22/18 1250. Office Visit on 9/22/2018. ED visit 9/22/18: Chief Complaint Patient presents with Wound Check Left leg. Had shots 2 days ago. Parents noticed she would not bend leg today. Sent here from urgent care for concern of septic joint. Questionable Leg Pain. History of Present Illness: Patient is a 15 MO otherwise healthy female who presents to the emergency department for leg stiffness. Pt received immunizations 2 days ago, parents now note left knee will not bend, denies injury or fall. Pt was referred to this ED from urgent care following x-ray this afternoon d/t concerns for septic joint. Denies fever, changes in appetite or wet/dirty diapers. No recent illness, injury or falls. Patient was given MOTRIN today at 1130. Pt is currently on ABx eye drops regimen. Parents deny any medical Hx or hospital admittance. History provided by: Mother and father. Language interpreter used: No. Review of Systems: Review of Systems. Constitutional: Negative for appetite change and fever. HENT: Negative. Negative for drooling and rhinorrhea. Eyes: Negative. Negative for redness. Respiratory: Negative for wheezing and stridor. Cardiovascular: Negative. Gastrointestinal: Negative. Negative for diarrhea, nausea and vomiting. Genitourinary: Negative. Negative for decreased urine volume and difficulty urinating. Musculoskeletal: Positive for gait problem. Skin: Negative. Negative for rash. Allergic/Immunologic: Negative for food allergies. Neurological: Negative for seizures and syncope. Hematological: Does not bruise/bleed easily. Psychiatric/Behavioral: Negative. All other systems reviewed and are negative. Allergies: Patient has no known allergies. Past Medical History: Past Medical History: Diagnosis. Date: Acute suppurative otitis media of both ears without spontaneous rupture of tympanic membranes 3/28/2018. Past Surgical History: History reviewed. No pertinent surgical history. Pertinent medical/surgical history reviewed. Past Medical History: Diagnosis. Date: Acute suppurative otitis media of both ears without spontaneous rupture of tympanic membranes 3/28/2018. History reviewed. No pertinent surgical history. Social History: Social History. Substance Use Topics: Smoking status: Never Smoker. Smokeless tobacco: Never Used. Alcohol use: 2.4 oz/week, 2 Glasses of wine, 2 Cans of beer per week. Comment: occasions. History Drug use: Unknown. Family History: Family History. Problem. Relation. Age of Onset. Depression, Father, None Reported, Maternal Grandmother, None Reported, Maternal Grandfather, None Reported, Paternal Grandmother, Depression, Paternal Grandfather, None Reported, Mother. Vitals: ED Vitals. Date and Time. T, BP, P, RR, SPO2P, SPO2. User 09/22/18 1710: 24 PER MINUTE, (!) 138, 98 % CW. 09/22/18, 1252, 36.6 °C (97.9 °F), 22 PER MINUTE, (!) 135, 95% DM. Physical Exam: Physical Exam. Constitutional: She appears well-developed and well-nourished. She is active. No distress. Well-appearing, playing in exam room. HENT: Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Mouth/Throat: Mucous membranes are moist. Eyes: Pupils are equal, round, and reactive to light. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: Effort normal. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no tenderness. Musculoskeletal: She exhibits no deformity or signs of injury. Decreased range of motion left knee, erythema or warmth, full range of motion bilateral hips and right knee, neurovascularly intact. Neurological: She is alert. Skin: Skin is warm. Capillary refill takes 2 to 3 seconds. No rash noted. No jaundice. Nursing note and vitals reviewed.