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Daniel Tawfik, MD/PGY-3
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3 days of right anteromedial thigh pain
Sudden onset
Alternating between sharp and aching
Slightly better with Tylenol
Worse when moving the leg after sitting or lying down
Also with fever, headache, and decreased energy 3 days
ago (now resolved)
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PMH: previously healthy
Meds: none
Allergies: NKDA
FHx: neg SHx: lives with parents and younger brother in. No
known
sick contacts, no unusual exposures, no recent travel
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VS: T 37.6, P 108, RR 18, BP 96/56, SpO2 98% RA
Gen: Well-appearing, pleasant, interactive
HEENT: 2+ tonsillar enlargement without exudate
CV: RRR, no murmurs or gallops RESP: clear, good aeration,
unlabored breathing
ABD: soft, NT/ND, NABS, no masses. Liver at RCM.
NEURO: CN intact, 2+ reflexes throughout
MSK: antalgic gait, mild tenderness over rightanteromedial
thigh. No mass, fluctuance, redness,
swelling, or effusion.
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VS: T 39, P 124, RR 18, BP 106/58, SpO2 97% RA
Gen: In obvious pain, crying
HEENT: 2+ tonsillar enlargement without exudate
CV: Tachycardic, regular rhythm, no murmurs or gallops RESP:
clear, good aeration, unlabored breathing
ABD: soft, NT/ND, NABS, no masses. Liver at RCM.
NEURO: CN intact, 2+ reflexes throughout
MSK: severe tenderness over right anteromedial thigh.No mass,
fluctuance, redness, swelling, or effusion.
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Infectious Disease Septic arthritis of hip or knee
Pyomyositis
Cellulitis
Zoster
Osteomyelitis
Psoas abscess
Rheumatology Reactive arthritis
Pauciarticular JIA Rheumatic fever
Polymyalgia rheumatica
Heme/Onc Leukemia
Osteosarcoma
Ewings sarcoma
Sickle cell crisis
Hemophilia/hemarthrosis
MSK/traumatic Hematoma
Tendonitis
Muscle sprain SCFE
Legg-Calve-Perthes
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Bacterial infection of striated muscle
Typically with abscess formation
First described in 1885 as a tropical disease
Increasing recognition in temperate climates
Now 1 out of every 1000-2000 pediatric admissions and rising
Often in setting of immunodeficiency
HIV/AIDS (more in adults), diabetes, CVID, SCID, CGD, etc.
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Requires bacteremia + trauma
Following URI, meningitis, etc
Known trauma history in only 15-50% of cases
Locations: Thigh, calf, buttock, arm
Organisms
Staphylococcus aureus (80-90%)
Streptococcus pyogenes
May occur following primary varicella infection
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Early stage Mild cramping
Pain
Tenderness
Low-grade fever
Intermediate stage Increased tenderness
Fever
Chills
Anorexia
Erythema
Underlying abscess
Late stage Septic shock
Compartment syndrome
Osteonecrosis
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Started on Nafcillin and Clindamycin
Clindamycin discontinued when blood culture showed
GAS
Switched to Augmentin after 2 days Completed 21 days of
antibiotics
No further sequelae
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