Fussiness and fever

[pootcarr]

lets say patient is a 9 month old female. Non toxic. Non septic. eating, urinating, stooling appropriately.

Case 1: patient has fever of 103 and only symptom is "maybe some nasal drainage". Even at this temperature the patient is smiling and interactive with you and feeding from the bottle. Her temperature is 100.3 after tx with motrin in the ED. Physical exam normal. How hard do you push for the parents to have a UA / other studies?

Case 2: Completely normal history and exam. Temp 98. Brought in for 1 week of fussiness and crying if put down wanting to be held. Besides doing a complete exam including looking for anal fissures, hair tourniquets etc, do you look for corneal abrasions or add any other studies to your work up? What do you do to provide reassurance to the parents?

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[Arcan57]

Case 1: Assuming not crazy duration (>5 days) of fever, I think UA can be skipped if patient has good outpt f/u.

Case 2: I make sure there isn't any caregiver drama or concern for NAT. Corneal abrasions shouldn't cause a week's worth of fussiness. I don't order labs or xrays on a fishing expedition without concern for some specific diagnosis. I tell the parents that I'm not finding the big, bad things were I think they need to be in the hospital but there are a lot of things that can make a baby fussy that I don't have tests for in the ED. I give them standard return precautions and send them back to the pediatrician to close the loop.

 

[GeneralVeers]

Both cases as described: Reassurance, no studies and discharge home.

 

[pootcarr]

as a brand new attending I find myself with always a nagging thought of should i be doing more for these patient's that I am very certain do not have anything emergent. I am confident during the exam and discharge, but then i get home at night and think about them. Is this normal? I'm assuming it will pass.

 

[Arcan57]

as a brand new attending I find myself with always a nagging thought of should i be doing more for these patient's that I am very certain do not have anything emergent. I am confident during the exam and discharge, but then i get home at night and think about them. Is this normal? I'm assuming it will pass.

When you're running them through your head later are their missed history or physical exam findings or alternative diagnoses that are coming to mind? If not then you're probably ok. It's pretty common to come out of residency without a very accurately calibrated "sick kid" meter, especially if you don't have kids of your own to use as your controls. Add-on the incredibly non-specific early presentations of severe disease in infants and it's a recipe tailor made for doubt.

 

[bougiecric]

Both cases as described: Reassurance, no studies and discharge home.

Completely agree.

At least for me, this became much easier after I had kids. It made me realize that the vast, vast, vast, vast majority of infants/toddlers with fevers never show up at your ER. My kids seemingly have fever every month; viruses are so common at this age. Never once have I brought them to the ER, let alone a pediatrician. (Err, I mean, of course they go to a pediatrician for vaccinations, and for issues other than uncomplicated fever.)

Testing for UTI is so overblown. I'm much more cognizant of this now that I have my own kids. It'd kill me to subject my kid to a urinary catheter, seriously, so I'm much more selective of when I order UAs in these patients.

Has one of my kids had a UTI during a fever, and I missed it? Maybe, but who cares. Her immune system took care of it. There is no epidemic of pyelo / urosepsis / renal scarring / CKD from missing UTIs. Check out this Smart EM podcast on the subject:

http://www.smartem.org/podcasts/pediatric-uti-its-about-future

All that said, kids can obviously get sick. If they look ill, work them up. If you're going to let them go, spend some time having a detailed conversation with parents regarding return precautions.

 

[Birdstrike]

Age 3 months to 3 years is largely based on the clinical picture. You might do anywhere from a full septic workup to nothing, depending on the history and exam. My advice is to have kids. I can say my kids were case 1 and/or case 2 dozens of times between age 3 months and 3 years and I never ran one test on them. Having kids improved my ability to spot sick vs not-sick infinitely, in kids. I know, it sounds dumb, but it's true. My comfort as a doctor of children increased immensely when I had kids.

 

[emergentmd]

I think starting in EM, kids are difficult b/c you have not seen enough and patients can't tell you what is going on. If an adult came in with fever of 103 and otherwise looked fine, you would call it a viral syndrome and not even sweat it.

Kids can't talk so you start to think of everything under the sun. I see my colleagues do blood tests often on 2+ yr olds with fever while they are running around eating chips. I am not sure what these tests will prove other than making the doc feel better.

Having kids definitely help. It makes you more at ease and gives you experience with what kids go through on a daily basis.

I almost Never draw blood on kids and if I do, I tend to admit them b/c they are sick.

Both kids can go home, no need to recheck the temp. The only time I do anything on a well looking kid with a fever is a girl with no other source. If they have a runny nose, there is your source.

 

[Arcan57]

Completely agree with the having kids thing. It also is a huge trump card to be able to say to the parents that your 2 yr old did the same thing at that age. The other thing I figured out over time on the well appearing kids is that MIL is responsible for a disproportionate number of visits among febrile kids in the ED. Everyone in the room knows the kid is fine except for the MIL that hasn't dealt with an infant/toddler in 20+ years and is sure that the brain-dead harlot who tricked her perfect angel into marriage is a crappy mom. When three generations show up, you've got to address the older person in the room or they'll be right back tomorrow night.

 

[WilcoWorld]

edit…same as above

 

[pootcarr]

great tips and advice. Here is another patient I saw multiple times during my shift tonight

"The well appearing early twenty y/o male who comes with chest pain and numbness in his hands and some nausea and maybe vomiting and oh yeah he has stress at work but its not that much worse then usual but maybe it is??? and he gets a ringing in his ear every 4 months but it might be worse tonight. Also his hands are numb did he mention that?"

Residency: maybe do a cardiac work up depending on how much they harp on the chest pain. all negative. your fine dude go home
Post residency:.............what if hes not fine??

 

[The Buff]

In my admittedly short experience bilateral hand numbness in an otherwise well person is almost always due to stress.

 

[dotcb]

Optional EKG, H & P, if normal - reassurance and DC home with return precautions.

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"The well appearing early twenty y/o male who comes with chest pain and numbness in his hands and some nausea and maybe vomiting and oh yeah he has stress at work but its not that much worse then usual but maybe it is??? and he gets a ringing in his ear every 4 months but it might be worse tonight. Also his hands are numb did he mention that?"

 

[Birdstrike]

Optional EKG, H & P, if normal - reassurance and DC home with return precautions.

???

 

[Arcan57]

If someone (regardless of age) complains of chest pain, you're proper f%&$ed if something bad happens to them and you didn't get an EKG.

 

[link2swim06]

If someone (regardless of age) complains of chest pain, you're proper f%&$ed if something bad happens to them and you didn't get an EKG.

Someone just lost a huge malpractice case because an early 20 something came for chest pain and was d/c without an EKG. Then died that night from myocarditis.

Attorney convinced the jury (aka lied) that the EKG would have shown myocarditis and he would of lived.

 

[Old_Mil]

Someone just lost a huge malpractice case because an early 20 something came for chest pain and was d/c without an EKG. Then died that night from myocarditis.

Attorney convinced the jury (aka lied) that the EKG would have shown myocarditis and he would of lived.

You're 20 with chest pain. You're fine. Except when it is myocarditis. Then you're not fine.


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[Old_Mil]

If someone (regardless of age) complains of chest pain, you're proper f%&$ed if something bad happens to them and you didn't get an EKG.

Basically. Chest pain - unless there is a clear history of similar anxiety symptoms, no history of drug use, etc, is almost always going to get an EKG/CXR.

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[Stitch]

Completely agree with the having kids thing. It also is a huge trump card to be able to say to the parents that your 2 yr old did the same thing at that age. The other thing I figured out over time on the well appearing kids is that MIL is responsible for a disproportionate number of visits among febrile kids in the ED. Everyone in the room knows the kid is fine except for the MIL that hasn't dealt with an infant/toddler in 20+ years and is sure that the brain-dead harlot who tricked her perfect angel into marriage is a crappy mom. When three generations show up, you've got to address the older person in the room or they'll be right back tomorrow night.

There was a study on this a while ago basically showing that grandmas drive up non emergent ED use: http://www.ncbi.nlm.nih.gov/pubmed/8532567

 

[Arcan57]

There was a study on this a while ago basically showing that grandmas drive up non emergent ED use: http://www.ncbi.nlm.nih.gov/pubmed/8532567

Awesome. It's always nice to have observations validated.

 

[DeadCactus]

Why you wouldn't get an EKG on chest pain? Cheap, quick, non-invasive. It's like not getting a blood pressure. Highly unlikely to demonstrate any pathology but good luck defending the decision if anything bad happens...

 

[killerleaf]

9 months old, fever plus fussy equals teething.

 

[Birdstrike]

Why you wouldn't get an EKG on chest pain? Cheap, quick, non-invasive. It's like not getting a blood pressure. Highly unlikely to demonstrate any pathology but good luck defending the decision if anything bad happens...

I must have missed the part where we went from "9 month old fussy," to the med mal implications of ekg's and chest pain.

 

[DeadCactus]

I must have missed the part where we went from "9 month old fussy," to the med mal implications of ekg's and chest pain.

great tips and advice. Here is another patient I saw multiple times during my shift tonight

"The well appearing early twenty y/o male who comes with chest pain and numbness in his hands and some nausea and maybe vomiting and oh yeah he has stress at work but its not that much worse then usual but maybe it is??? and he gets a ringing in his ear every 4 months but it might be worse tonight. Also his hands are numb did he mention that?"

Residency: maybe do a cardiac work up depending on how much they harp on the chest pain. all negative. your fine dude go home
Post residency:.............what if hes not fine??

 

[Arcan57]

Fussiness + fever in a 9 mo old is not teething. It's most likely a virus. When I tell the parents this, I've started using Ebola as an example since most people seem to get that antibiotics don't work against it.

 

[Birdstrike]

Fussiness + fever in a 9 mo old is not teething. It's most likely a virus. When I tell the parents this, I've started using Ebola as an example since most people seem to get that antibiotics don't work against it.

On RateYourDoctor.com right now:

"Our Doctor... I think his name was Dr Arcan...or Doctor Heinz 57 or something like that, told us little Suzie's fever and fussiness was from frickin' Ebola, and that nothing was wrong; that it would go away on it's own. Can't you believe that crock of sh--?? Man, we walked right out of that crap place and went right over to Happy Valley Hospital and got some antibiotics to knock this flu right out. I'm never going back to that place. Happy Valley's the best. Hell, they CT 'd all our heads just to make sure we got 'checked out' and refilled grandpa's dillies with a 3 day work note for all of us, too. That's a real hospital. Frickin' awesome."

 

[styphon]

On RateYourDoctor.com right now:

"Our Doctor... I think his name was Dr Arcan...or Doctor Heinz 57 or something like that, told us little Suzie's fever and fussiness was from frickin' Ebola, and that nothing was wrong; that it would go away on it's own. Can't you believe that crock of sh--?? Man, we walked right out of that crap place and went right over to Happy Valley Hospital and got some antibiotics to knock this flu right out. I'm never going back to that place. Halley Valley's the best. Hell, they CT 'd all our heads just to make sure we got 'checked out' and refilled grandpa's dillies with a 3 day work note for all of us, too. That's a real hospital. Frickin' awesome."

5/5 review
5/5 medical skills
5/5 "would recommend again"