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The patient describes very sharp pain in lower left leg and knee on extension of the leg.

He reported 10/10 pain in lower left leg on mobilization. Unable to weight-bear on left leg due to pain. Upon standing up, the patient felt sudden sharp pain in the lower left leg and had to sit back down.

No radiation to the pain.

Pain and tenderness reported on palpation of rash on lower left leg.

Pain and tenderness reported on palpation of fluid-filled blisters on feet bilaterally.

Ordered Acetaminophen PO PRN

Ordered morphine PO PRN

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The patient presented with a new onset rash with tender lesions over the lower limbs over the last few days.

Non-blanchable, palpable petechial rash over chest, upper back, thigh and groin area.

Blanchable, nontender erythematous red patches overlying the chest.

10 cm by 6 cm red swollen patch on left lower leg, non-blanching, located on the lateral aspect of the left tibia. Warm and tender on palpation. The patient reported that this area was painful and made it difficult to weight-bear on the left leg.

Red swollen patch on heel of the left foot. Warm and tender on palpation.

3 fluid-filled blisters located on the heel and side of right foot, also warm and tender to touch.

The MRP asked that this rash be monitored closely because invasive Group A streptococcal (GAS) can progress to a serious condition called necrotizing fasciitis in serious cases. Necrotizing fasciitis is an aggressive skin and soft tissue infection that causes muscle fascia and subcutaneous tissue necrosis (Wallace & Perera, 2023). The infection can spread rapidly, so it is important to monitor for necrotizing fasciitis if the patient appears to be in intense pain (Wallace & Perara, 2023).

References:

Wallace, H., Perera, T. (Feb 21, 2023). Necrotizing Fasciitis. National Library of Medicine. Publishied January, 2025. https://pubmed.ncbi.nlm.nih.gov/28613507/

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Necrotizing fasciitis is a subset of aggressive skin and soft tissue infections that cause muscle fascia and subcutaneous tissue necrosis. This infection typically travels along the fascial plane, which has a poor blood supply, leaving the overlying tissues initially unaffected, potentially delaying …

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The patient reported new onset of pain in lower extremities over the last 2 days. Rash also observed overlaying the lower limbs.

The patient reported significant sharp pain with extension of his left knee.

No obvious swelling around the knee joint.

No pain on palpation of the knee.

No pain on dorsiflexion or plantar flexion of left ankle.

The patient reported sharp pain in the lower left leg upon standing up to go to the bathroom.

The pain made it difficult to weightbear on the left leg.

Patient required assistance to transfer from the bed to the toilet. He was a 1PA using a 4WW due to the pain in his left knee and leg.

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Wyatt L.

15 year old M

Bacterial pneumonia with cavitation of the right upper lobe, new onset rash and painful lower limbs

Droplet precautions

NKDA

59.8kg

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Admission report states that the patient has had a 3 week history of chest congestion, runny nose, sore throat, and productive cough with some hemoptysis.

The patient's chest x-ray revealed consolidation with central cavitation and suspected lung abcsess in the right upper lobe, indicative of pneumonia with complications. Throat and blood cultures were positive for Group A streptococcus bacteria.

This 15-year-old male has a diagnosis of Streptococcus A pneumonia with cavitation. Cavitation is a rare complication of pneumonia that occurs when a pus-containing lesion of the lung parenchyma gives rise to a cavity (Tyerman et al., 2022). The cavity is formed by necrosis (tissue death) of the lung tissue (Tyermann et al., 2022).

On assessment, patient had a mild congested cough, non-productive with no hemoptysis noted.

Patient had a tuberculosis skin test done but the results showed no exposure to tuberculosis infection.

Work of breathing normal with no observable signs of respiratory distress such as accessory muscle use, nasal flaring, or tracheal tug. Patient denied any shortness of breath.

On auscultation of the lungs, the patient had decreased air entry to bases bilaterally. Almost no breath sounds heard over the right upper lobe (area of cavitation).

No adventitious sounds noted.

Symmetrical chest expansion.

Respirations easy and regular.

RR 18 breaths/minute.

O2 saturation good, 98-100% on RA

PRAM Score = 3 (Mild)

Patient's CRP elevated at 212.2 (H).

White Blood Cells elevated at 24.5 (H).

References:

Tyermann, J., Cobbett, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., Reinisch, C. (April 22, 2022). Conditions of Oxygenation and Ventilation. Lewis's Medical-Surgical Nursing in Canada, Fifth edition.

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On assessment, the patient's abdomen was flat and soft. Bowel sounds present in all 4 quadrants.

No change in bowel movements reported by the patient.

No nausea or vomiting.

The patient has had decreased appetite over the last few weeks as per him and his mother.

The patient does not like the hospital food and has not been eating provided meals. His mom has been bringing him food daily.

Adequate food intake. Observed the patient eating and snacking in the room often throughout shift.

The patient is running D5NS at 20 ml/hour.

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Heart rate 66 bpm, regular rhythm.

Blood pressure 118/62, MAP 77

Capillary refill less than 3 seconds.

CWMS intact to lower limbs bilaterally.

+2 non-pitting edema present from the left foot up to the knee.

+1 non-pitting edema present to the left foot up to the ankle.

Radial pulses normal and easily palpable bilaterally.

Post tibial pulses normal and easily palpable bilaterally.

Dorsalis pedis pulses normal and easily palpable bilaterally.

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The patient's mom is present at the bedside.

The patient lives with his mom. He has a good relationship with his mom.

His parents seperated within the last few months and his dad moved out of the house.

Dad has been on an extended trip to Thailand.

Mom has a boyfriend but the he is not currently living with them. The patient gets along with his mom's boyfriend.

The patient's older brother passed away about a year ago. He was 17 years older than the patient.

Mom has been supportive. She has been at the bedside most of the time and spent all nights in the hospital with Wyatt since his admission. She has been bringing him meals and beverages from outside the hospital daily.

Mom's boyfriend was also present at the bedside. He relieved the mom and stayed at the patient's bedside for some time until she came back. He was supportive of the patient and they appeared to get along well.

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The patient has a 20g peripheral IV to the right hand. IV site dry and intact. IV patent, no signs of phlebitis or infiltration. No patient complaints.

Patient is ordered 900 mg clindamycin IV once daily to treat his bacterial pneumonia.

Patient is ordered IV maintenance fluids. Running D5NS at 20 mL/hour.

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The patient has had adequate urine output. Urine is yellow and clear. No odour present.

No changes in regular voiding frequency as per patient.

The patient has been using urinals to void due to pain in left lower leg when weight-bearing.

Urine test showed trace amounts of ketones, a small amount of protein, and leukoesterase. Ketones and protein are usually normal in trace amounts. Leukoesterase indicates the presence of white blood cells, suggesting inflammation or infection within the urinary tract.

The patient's fluid intake has been adequate. Observed the patient drinking often throughout shift. He has water bottles and Perrier that his mom brought for him in the fridge in his room.

He is running D5NS at 20 mL/hour.

Mild hyponatremia with sodium of 131 (L). All other electrolytes within normal limits.

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The patient is alert and oriented to person, place, time, and situation. Able to correctly give name, birthdate, time, and place when asked.

Calm and cooperative with care. Able to answer all questions appropriately.

Mood is appropriate to age and situation.

Sensation intact to all extremities.

Handgrip strength strong and equal bilaterally

Plantar flexion strong and equal bilaterally.

No abnormalities noted in coordination or gait, although patient having difficulty weightbearing on left leg due to pain.

The patient reported 10/10 sharp, non-radiating pain in the left knee and lower leg with movement.

Patient also reported pain and tenderness in left knee and lower leg on palpation.

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The patient is in the adolescent stage of childhood. He is a 15-year-old male. At this age, the child is maturing, although remains self-centered. The child begins gaining independance from their family, questioning moral values, understanding the rights of others, and valuing affirmation from peers. Physically, adolescents at this age will experience puberty, hormonal changes, and dramatic growth as they reach maturity.

Wyatt has been independant with his care. He showers and maintains hygiene without being prompted. He required some assistance with toileting due to pain in left leg, but is otherwise independant with mobilization and movement.

Upon psychosocial assessment, Wyatt spoke about the importance of his social life. He likes going to highschool for the social aspect of it. He also has a girlfriend that is the same age and grade as him. He denied being sexually active, although he notes that they attempted intercourse once but did not follow through.

According to Piaget, Wyatt is in the 'Formal Operations' stage of child development. This means he can:

Understand abstract concepts and hypotheticals such as behaviour, ideals, and morality.

Use deductive reasoning.

Can plan life events.

According to Erikson, Wyatt is in the 'Identity vs. Role Confusion' stage of child development. This means he is:

Learning about different roles.

Peers and role models are big influences in his life.

Exploring and finding his identity.

Pushing to conform to certain views may create role confusion and feeling lost.

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The patient is able to communicate his needs effectively.

Calm and cooperative with care.

Answers all questions appropriately when asked.

Reports and describes pain using the 0 - 10 pain scale.

Family is supportive, mom at bedside and involved in care.

Appears to be coping well in the hospital. Observed the patient watching a movie and smiling and laughing. Able to distract himself with T.V and his phone.

He has a good social life and has a lot of friends at school.

Is getting mostly A's in all of his classes. He is currently in grade 9.

Plays rugby, football, and is a high-ranking player in a video game.

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Chest X-ray

Patient's chest XR showed consolidation with centeral cavitation of the right upper lobe, suspected abscess. No osseus abnormality. No pleural effusion. Cadiac silouhette normal.

MRI of the Left Leg

A non-contrast MRI was performed on the patient's left lower leg, within anterior compartment of the left lower leg.

There is 29 cm long intramuscular fluid collection in axial dimensions. Fluid collection runs immediatly anterior to the course of the extensor digitorum longus tendon, and posterior to the tibialis. Only small amount of surrounding tissue component.

Differential considerations: Intramuscular fluid collection within anterior compartment of the lower left leg.

Tenosynovitis of the extensor tendon.

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HR: 66 bpm

RR: 16 breaths/min

O2 Saturation: 99% on RA

Blood Pressure: 118/62

Temperature: 36.7

All vital signs within normal and stable range.

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Connection Between Body Systems and Clinical Manifestations

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Connection Between Body Systems and Clinical Manifestations

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In this patient's case, his primary diagnosis was a Group A streptococcal bacterial pneumonia, initially manifesting as respiratory symptoms and cavitation of the right lung. The patient then had a sudden onset of integumentary symptoms, including a painful rash, lesions and blisters on his lower limbs. This bacterial infection also affected the musculoskeletal system. The rash and blisters were accompanied by significant MSK pain on movement. The MRI revealed intramuscular fluid collection in the lower left leg. The patient was unable to weightbear on his left leg, as well as reported pain on extension of the left knee. This invasive infection has also impacted the cardiovascular system. The patient's blood culture was positive for GAS. The patient had observable edema in his lower limbs.

The respiratory system would be my priority assessment in this patient's care because the body's ability to maintain adequate oxygen supply is essential to maintaining bodily function. Although the patient's condition and oxygenation was stable, pediatric patients with respiratory infections can rapidly deteriorate. I would want to do consistent respiratory assessments, monitor O2 saturation and RR, encourage deep breathing and coughing, and encourage fluid intake (resp, fluid & electrolytes). The patient reports significant pain to the lower left leg. I would treat this pain with his PRN Tylenol and Morphine. As he is getting morphine for the pain, I would closely monitor his RR, level of consciousness, and O2 saturation (resp, MSK, and neuro). I would also closely monitor the patient's skin and rash symptoms, reassessing frequently for any spreading or significant changes such as swelling/edema (integumentary, cardiovascular, fluid balance).

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Invasive Group A Strepptococcus Infections

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Invasive Group A Strepptococcus Infections

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Most commonly, Group A streptococcal bacterial infections lead to mild illnesses such as step throat. However, sometimes the bacteria invade the lungs, blood, or spread along the layers of tissue that surround muscle (BC Center for Disease Control, 2022). These are called invasive group A streptococcal infections (iGAS) and are very serious, potentially life-threatening conditions (BC Center for Disease Control, 2022).

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The patient is ordered Clyndamycin 900 mg IV once daily. Clindamycin is a broad-spectrum antibiotic used to treat severe bacterial infections and lung abscesses.

The patient is ordered PRN Acetaminophen. Acetaminophen is a non-opioid analgesic with antipyretic properties, used to treat mild - moderate pain and fevers.

The patient is ordered PRN Morphine. Morphine is an opioid analgesic used to treat moderate - severe pain. This drug can cause respiratory depression, decreased LOC and decreased RR. Pediatric patients given this drug should have regular sedation and respiration monitoring.