Edited Sample Report
Diagnoses: Maxillary sinusitis; Cerebral Abscess
I was asked to accompany this 6½ -year-old girl in transport
from * * * * * to * * * * * General Hospital after she recently underwent
investigation and therapy for a fever, headache, and nausea and vomiting
that followed an upper respiratory tract infection.
Initially, this patient was found to have a right maxillary sinusitis
and was treated with oral antibiotics. However, she became more ill
and was admitted to * * * * * Hospital where a CT scan of the head revealed
a left frontal cerebral abscess with epidural abscess. The patient underwent
craniotomy for drainage of epidural abscess by the neurosurgeon and
drainage of her right maxillary sinus by the otolaryngologist.
She received a prolonged course of intravenous and broad-spectrum antibiotics
postoperatively.
Edited Sample Report
Diagnoses: Cervical Central Spinal Cord Syndrome and Epidural hematoma;
Child Abuse
I was paged in order to assess, stabilize, and prepare this 23-month-old
boy for transport to the Intensive Care Unit at * * * * *.
This patient was brought to the Emergency Department in * * * * * General
Hospital on ***** after an unwitnessed fall of a low height onto a carpeted
floor at home. The mother brought the child to the Emergency Department
for suspected injury of his right arm.
When examined by the Emergency physician, the patient was noted to
have an abnormal pattern of bruising on his head and trunk and there
was some suspicion of non-accidental trauma. A skeletal survey was undertaken,
but no fractures were identified and the child was referred to the pediatrician
on-call. The child was ultimately discharged home from the Emergency
Department after a period of observation and recovery of normal arm
function.
The patient was brought back to hospital the next afternoon after the
mother reported a progressive weakness involving the arms and subsequently
the legs over the next day. The child initially was unable to lift a
bottle to his mouth without assistance and later was noted to have a
wobbly gait after his nap.
Re-evaluation by the pediatrician revealed a flaccid and areflexic
paralysis of the upper limbs and motor activity was restricted to a
minimal flexion of the fingers. Although power of the lower limbs was
reduced, the child was still able to kick. Deep tendon reflexes were
difficult to elicit.
A number of laboratory investigations were undertaken and the only
abnormality was a leukocytosis on the CBC accompanied by a thrombocytosis.
A computed tomography scan of the head was also normal.
Treatment with high-dose intravenous glucocorticoids was undertaken
for suspected spinal cord injury according to the spinal cord protocol
at * * * * * Hospital.
A complete physical examination, as well as review of all available
laboratory investigations and x-rays was performed by myself when I
arrived in the Intensive Care Unit in the * * * * * General Hospital.The
major findings were those of an extremely irritable and pale boy who
had multiple ecchymosis on his head and neck at different stages of
resolution. The child was able to rotate his neck, but not flex or extend
there. He also could not shrug his shoulders. The only motor activity
in the upper limbs was restricted to the distal interphalangeal joints
of the hands. Power in the legs was diminished, but the child was able
to kick.
My concern was that this child may have developed either a transverse
myelitis, epidural hematoma, central cord syndrome or epidural abscess.
The child was transferred via aircraft to * * * * * and then via ambulance
to * * * * * where he underwent urgent Magnetic Resonance Imaging of
his spine, spinal cord and neurosurgical consultation.
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