#FOAMped

Dr. Pilcher covers two difficult cases in this month’s medical malpractice insights.

A 15-year-old female with no reported past medical history presents with lower abdominal pain and possible STI symptoms. She reports living with a “friend” but cannot provide an address, does not attend school regularly, and is accompanied by an adult male who claims he’s “just a family friend” but refuses to leave her side and answers all questions for her. She is alert and oriented but appears fatigued, with mildly matted hair. She avoids eye contact with the clinician and nurse, and her story has changed multiple times since arrival. What are you concerned about outside of the abdominal pain?

A 43-year-old male presents with swelling to the right armpit. He also endorses a small wound to his right forearm, fatigue, mild muscle aches, and low-grade fever. On exam he has right axillary lymphadenopathy and a small, non-tender, slightly raised erythematous lesion to the right forearm with no overt evidence of extensive cellulitis. The patient states that he was playing with the neighborhood cat a little over a week ago. He believes the cat bit him on the arm before running off. What is the diagnosis?

A 2-year-old female with a past medical history of failure to thrive presents for evaluation of right arm pain. The mother states that the patient was recently started on mupirocin for a spot on her right forearm the day prior. Since then, the mother states she has noticed a “hard spot” on the patient’s right clavicle. Mother denies any recent trauma or falls and also reports a temperature at home of 37.8° C. Per chart review, the patient was recently discharged a week prior after a 6-day admission for failure to thrive. Vital signs include temperature 37.0° C, HR 136 bpm, RR 32 breaths/minute, and blood pressure of 99/57 mmHg. The head is atraumatic and normocephalic. Auscultation of the heart reveals a regular rate and rhythm, and lungs are clear to auscultation bilaterally.  Physical exam is notable for guarding of the right upper extremity with induration overlying the proximal right clavicle with minimal surrounding erythema. There are no step-offs or bruising throughout the bilateral upper extremities. The patient has 2+ bilateral radial pulses. There is decreased active range of motion of the right shoulder which appears to be secondary to pain. She has full range of motion of all other joints.

This post from Kriti Gupta and Nessy Dahan covers pediatric oncologic emergencies.