Case
#50 "Oh, By The Way, Can You Also Check
Out…."
by Charlene Babcock Irvin, MD
An
18 month old baby presents with a chief
complaint of fever. Dad brought the baby in
on Monday. He noted that mom had dropped the
baby off on Friday night, but on Saturday,
the baby’s grandma noted she began running a
high fever. The dad notes that baby’s
grandma did take the temperature, but didn’t
tell him what it was exactly. She only said
it was ‘high’. The fever persisted on
Sunday, with the last documented history of
fever at midnight (Dad did not know how high
the fever was, and didn’t know how it was
taken; just that he was told it was ‘high’).
Grandma gave the baby some Tylenol at that
time (midnight), and that’s why Dad brought
the baby in this am (arrived at 6:30AM).
PMH: Full term baby, went home with mom. Dad
thinks she may have had 2 or 3 ear
infections in the past, but not sure
exactly. No hospitalizations. He thinks
shots are up to date.
SH: Mom and Dad not married. Mom takes care
of the baby, except on some weekends when
Dad takes care of her. No smokers in Dad’s
home.
ROS: Baby has had a runny nose with green
mucus. No vomiting. No rashes. She has had a
decreased appetite for food, but will drink
liquids normally. She has had the normal
amount of wet diapers, and the urine doesn’t
smell strong or abnormal. She has not had
any diarrhea. Dad does note an occasional
cough.
While starting the physical exam, Dad also
asks to have her arm checked out. He noticed
she is not using it like she normally does.
He thinks this started on Saturday night.
There is no history of trauma. Dad is not
sure if anyone pulled on the arm or swung
the baby by the arms.
PE: P=115, RR= 25, Temp=98.8F rectally,
BP=95/70
Interactive with Dad, good eye contact,
sitting on Dad’s lap in no acute distress,
holding right arm to her belly (flexed and
pronated)
HEENT: Neck Supple, skull atramatic. TM
(After wax removal) normal. Oropharynx
normal. No lymphadenopathy. Dried
yellow/green mucus in nares.
Heart: RRR, no abnormalities
Lungs: Normal
Abd: Scaphoid, normal, non-tender. No hernia
GU: No rashes or gross abnormalities
Ext: No rashes. She is holding her right arm
flexed with her palm close to her belly. She
tolerates palpation without problems, but when you attempt to supinate the wrist, she begins to wimper.
Increased warmth is not
appreciated. An effusion is not clearly
appreciated.
1. What is a nursemaid’s elbow?
2. Can you attempt reduction without
x-rays?
3. What are the techniques for
reduction of a nursemaid’s elbow?
4. If
you do decide to get x-rays, what are the
lines to identify in pediatric elbows?
5. Any other concerns in this case?
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