pediatric in pain

[Ewok Jerky]

arrived to find 6 y/o Haitian boy at home with dad. Hx of sickle cell dz. Today he stayed home from school because of chest pain. He is dressed in pajamas, laying on the couch under a blanket watching cartoons. He is awake and responds apporiatly when prompted, but has a flat affect. He has Hx of pain in his knees in the morning, sometimes takes motrin. He has never been hospitalized for sickle cell, and has not been under routine care.

Vitals- BP: 108/60, HR: 110, RR: 18, 94% room air

what next?

 

[OnceAnEMT]

Is the C/C the CP? I'd ask OPQRST on it to see if you can't isolate the differentials a bit, and most definitely do a full head to toe. Pertinent question would be if he has done anything physically strenuous recently, especially at an abnormally high level. As well, I'd ask about fluid intakes. Enough water? Too much soda? Etc. Both of those things are primarily causes for exacerbation of sickle cell trait and anemia.

That's coming from my athletic training student side. Definitely, definitely needs to see a PD MD if he is starting to get involved with sports, or anything other than walking around the house.

 

[Ewok Jerky]

Is the C/C the CP? I'd ask OPQRST on it to see if you can't isolate the differentials a bit, and most definitely do a full head to toe. Pertinent question would be if he has done anything physically strenuous recently, especially at an abnormally high level. As well, I'd ask about fluid intakes. Enough water? Too much soda? Etc. Both of those things are primarily causes for exacerbation of sickle cell trait and anemia.

That's coming from my athletic training student side. Definitely, definitely needs to see a PD MD if he is starting to get involved with sports, or anything other than walking around the house.

CC is indeed chest pain. sudden onset this AM with waking. Unable to charecterize due to limited vocabulary, but able to localize to mid-sternum, increased with respiration, and severe with palpation. Does not radiate. No releaving factors.

No recent strenuous activity, per dad he goes to school and acts like a normal 6 y/o old. Fluid intake is adequate, decreased appetite over the last 24 hours.

any more info you want? any thoughts on DDx?

 

[OnceAnEMT]

Any discoloration or swelling anywhere? Not sure if that would occur, just would be interesting if it did.

1. Partial blockage somewhere due to sickle cell, but not cardiac, yet. But I don't know why that would be aggravated by palpation.

2. Impact to chest while being a normal 6 y/o resulted in bruise or even structural damage (aggravated by palp)

Those two kind of cover what you've given. Just because he has sickle cell doesn't mean its involved. Knee pain, all kiddos have history of joint pain. Not sure of anything else. Whatcha got?

Actually, all that said, what are the lung sounds? Any cough since pain started? Ask to cough, any production?

 

[Ewok Jerky]

Any discoloration or swelling anywhere? Not sure if that would occur, just would be interesting if it did.

1. Partial blockage somewhere due to sickle cell, but not cardiac, yet. But I don't know why that would be aggravated by palpation.

2. Impact to chest while being a normal 6 y/o resulted in bruise or even structural damage (aggravated by palp)

Those two kind of cover what you've given. Just because he has sickle cell doesn't mean its involved. Knee pain, all kiddos have history of joint pain. Not sure of anything else. Whatcha got?

Actually, all that said, what are the lung sounds? Any cough since pain started? Ask to cough, any production?

No discoloration or swelling or signs of trauma. Lung sounds reveal rales in RUL, reports a productive cough x2 days.

I can tell you more but I will wait and see if anyone else chimes in.

 

[OnceAnEMT]

Going to put my Dx in the spoiler.

Redacted, forum doesnt support BB Coded spoiler. Will pm to you later.

 

[FLdoc2011]

Fever? Rash? Sick contacts?

 

[Ewok Jerky]

Fever? Rash? Sick contacts?

Good questions. T = 100.1, no rash, no sick contacts at home but he goes to elementary school.

 

[teedubbyaw]

Does he have that febrile gaze? Boogers, noisy breathing?

4 lead? BGL? Cap?

Judging by the picture you gave, he doesn't seem to be in severe pain. Maybe some more info on TICLS (pat) if that's not the case.

Definitely get him on O2.

 

[mycrofft]

Pain with palpation in the absence of chest auscultation raises the index favoring blunt trauma or some other sort of stern-costal inflammation. MAYBE high esophageal or mediastinal issue? Was it firm palpation, sternal or lateral palpation, etc?

 

[Angel]

id want to know about sputum production...in my head im leaning toward him being sick. chest pain all the time or only when he coughs?

o2 for sure, ecg


is he behaving normally according to dad? you mentioned flat affect; is he lethargic at all?

 

[mycrofft]

CC is indeed chest pain. sudden onset this AM with waking. Unable to charecterize due to limited vocabulary, but able to localize to mid-sternum, increased with respiration, and severe with palpation. Does not radiate. No releaving factors.

No recent strenuous activity, per dad he goes to school and acts like a normal 6 y/o old. Fluid intake is adequate, decreased appetite over the last 24 hours.

any more info you want? any thoughts on DDx?

This is more tenderness with residual discomfort (aka "pain"). Coughing would be agonizing.

Hm. Too low if midline to be foreign object. We're talking the neighborhood of the mediastium and esophagus and heart.

 

[KellyBracket]

Great discussion so far. I'm not going to leap in with my DDx yet, but I will say that I'm glad no one has suggested that this patient could follow up with their PMD for this.

Clue to my DDx: One of the pediatrics professors in med school would say that you only need to ask the parent in this situation (sickle & CP, fever) one question - Does he/she have any allergies?

 

[Ewok Jerky]

Great questions and great thinking guys. I posted this for 2 reasons, first to teach something I just learned and second to see how you guys would work up this kid. You all covered the basics great, just one last question before I give you the diagnosis (err, diagnosis we worked with)

Should you 12-lead him?

 

[teedubbyaw]

Should you 12-lead him?

Sure. He could be having a vaso-occlusive crisis.

 

[mycrofft]

OP come back!:sad:

 

[teedubbyaw]

OP come back!:sad:

They just posted...

 

[Ewok Jerky]

OP come back!:sad:

sorry guys, been finishing up my peeds rotation and had to put together a lecture, + its been pretty busy during the days.

anyways. this kid came into our community hospital ED with CP, Hx of sickle cell dz. has not been under routine care, never been hospitalized for pain although he usually experiences pain in his knees and sometimes arms. we admitied him and gave morphine in escelating doses to control his pain. we were unsuccessful overnight and the next day. we called the city childrens hosp for consult and found out that sickle cell kids arent even managed by the heme-onc fellow, they are managed by sickle cell specialist. althought th ekid showed no obvious signs of infection, there was concern for Acute Chest Syndrome (wich I had never heard of).

Acute chest syndrome is caused by an infection (typically PNA) which leads to hypoxia which leads to increased sickling which leads to vaso-occlusion and eventually death. I changed a few deets of this case to make it look more like acute chest.

I was thinking about how this might present in the field. Although there is not much you can treat for pre-hospital, this might be something to stow in the back of your brain if you ever run into a sicke cell kid. Great differentials also!

*and yes, run a 12-lead*

 

[mycrofft]

Wikipedia's article, with citations:

http://en.wikipedia.org/wiki/Acute_chest_syndrome

Vaso-occlusive

 

[FLdoc2011]

Did the initial admitting hospital not recognize acute chest syndrome in a kid with sickle cell?