American Muggle. (Like: American Gangster)

[RustedFox]

The Worst Patients in the World

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

www.theatlantic.com

I approach articles like this with a shaker of salt, but maaaaan....

I don't want to color the discussion any more.

[Go.]

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[Birdstrike]

THE PATIENT

Clearly whoever wrote America has the worst patients in the world, has no idea what they are taking about. If they did, they’d know The Patient is always right. He must be agreed with and “satisfied,” always. If you succeed at satisfying The Patient, you are a “good doctor” as a result (and the hospital makes a massive amount of money). If you don’t “satisfy” The Patient, you did everything wrong (and the hospital makes a slightly less massive amount of money than they could have otherwise, which is ever, ever okay).

That’s 99% of what you need to know about Medicine in 2019.

 

[RustedFox]

"The American Lifestyle" needs to be reformed.

/Godwins Law in 10 posts or less.

 

[RustedFox]

When I say things like: "This is why its okay to hate the muggles."

This article summarizes a large part of that.

 

[Interpolfanclub]

Great article, God forbid in America that we say or do anything that might offend the patient. I've been out of residency 10 years and I feel like just in that short period of time patients have gotten even more demanding and difficult to please. Luckily I work in a hospital that is still run by a doctor who "gets it."

I agree with the article that much of our testing in America is driven by fear of malpractice and trying to satisfy patients. I could probably eliminate 50% of my testing if I didn't have to worry about malpractice or making people happy ordering useless tests. We could discharge most people from the lobby without seeing them. We are a country with ridiculous expectations of our physicians and health care system in general. Don't order too much, but don't waste resources. Don't order too little or you'll miss things and upset patients.

I have a discussion with our admin (I'm the ED director) when it comes to sepsis and stroke metrics etc. It's basically, "We can over order (holds hands wide) in order to diagnose this much illness (holds hands closer together.) Or we can be more cautious and we're going to miss a few things that present atypically but won't waste a bunch of resources." Which one do you think they tell me to do?

 

[thegenius]

The Worst Patients in the World

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

www.theatlantic.com

I approach articles like this with a shaker of salt, but maaaaan....

I don't want to color the discussion any more.

[Go.]

I read this a few days ago and thought of you! I considered posting it on the most recent muggle post "I hate you, muggles." LOL

It would be like throwing a dried out, dead evergreen tree onto a fire.

POOF!!!

 

[thegenius]

I agree with the article that much of our testing in America is driven by fear of malpractice and trying to satisfy patients. I could probably eliminate 50% of my testing if I didn't have to worry about malpractice or making people happy ordering useless tests. We could discharge most people from the lobby without seeing them. We are a country with ridiculous expectations of our physicians and health care system in general. Don't order too much, but don't waste resources. Don't order too little or you'll miss things and upset patients.

Amen

 

[thegenius]

I have a discussion with our admin (I'm the ED director) when it comes to sepsis and stroke metrics etc. It's basically, "We can over order (holds hands wide) in order to diagnose this much illness (holds hands closer together.) Or we can be more cautious and we're going to miss a few things that present atypically but won't waste a bunch of resources." Which one do you think they tell me to do?

Which ever one makes them more money.

The answer to every question like this comes down to money

 

[TooMuchResearch]

Great article, God forbid in America that we say or do anything that might offend the patient. I've been out of residency 10 years and I feel like just in that short period of time patients have gotten even more demanding and difficult to please. Luckily I work in a hospital that is still run by a doctor who "gets it."

I agree with the article that much of our testing in America is driven by fear of malpractice and trying to satisfy patients. I could probably eliminate 50% of my testing if I didn't have to worry about malpractice or making people happy ordering useless tests. We could discharge most people from the lobby without seeing them. We are a country with ridiculous expectations of our physicians and health care system in general. Don't order too much, but don't waste resources. Don't order too little or you'll miss things and upset patients.

I have a discussion with our admin (I'm the ED director) when it comes to sepsis and stroke metrics etc. It's basically, "We can over order (holds hands wide) in order to diagnose this much illness (holds hands closer together.) Or we can be more cautious and we're going to miss a few things that present atypically but won't waste a bunch of resources." Which one do you think they tell me to do?

I order much more expansive workups then I ever did in residency and I don't really find more illness the majority of the time. I definitely spend more patient and government money and blast abnormal labs and vital signs that could be but probably aren't infection with broad spectrum antibiotics. Our director recently informed me that I'm a bit of a minimalist compared to my peers. I just can't figure how that's the case.

 

[thegenius]

I order much more expansive workups then I ever did in residency and I don't really find more illness the majority of the time. I definitely spend more patient and government money and blast abnormal labs and vital signs that could be but probably aren't infection with broad spectrum antibiotics. Our director recently informed me that I'm a bit of a minimalist compared to my peers. I just can't figure how that's the case.

Maybe I went to a conservative residency, but my workups are more-or-less the same. Unless otherwise dictated by government muggles insistent I follow protocol for every single person that has a fever.

A few areas that I've changed...

if a young male or female has abdominal pain, has normal vitals and a normal exam, I used to lab + CT/US them maybe 50% of the time. Now I still generally lab them, but my CT/US has gone down to < 10%. Even then, I don't find pathology. I probably shouldn't even lab them and just say "hey....you are not dying, there is nothing to do here, I'll give ya dicyclomine and zofran. Get out"

I also more regularly send home low risk chest pains without setting them up for an outpatient stress test. If you're < 60, had chest pain (not having chest pain), have normal or unchanged EKGs, and two neg trops...I probably discharge them 80-90% of the time unless there are extenuating circumstances. I also use the HEART score to back me up. I used to admit several of those 40-60 yo patients

I'm ordering less and less stuff for routine (lower) extremity cellulitis. I don't care how big it is. If you ain't vital-sign sick and don't have a ton of comorbidities, I will d/c you with appropriate antibiotics. Most of the time these patients literally just sit in the hospital picking their nose except for 1-2 times a day they get an IV antibiotic. Then they just sit around. Doing absolutely nothing while those who actually need the hospital board in the ED? Most of these cellulitis do not need acute hospital care. I've not had a single case return very sick. I've had a few return who allegedly failed outpatient therapy, but I have a hard time trusting the muggles.

 

[RustedFox]

My responses are in italics. I've changed a lot over the years, too.

if a young male or female has abdominal pain, has normal vitals and a normal exam, I used to lab + CT/US them maybe 50% of the time. Now I still generally lab them, but my CT/US has gone down to < 10%. Even then, I don't find pathology. I probably shouldn't even lab them and just say "hey....you are not dying, there is nothing to do here, I'll give ya dicyclomine and zofran. Get out"

Anyone under the age of 50, I do this all the time. I just happen to work in a shop where my average patient is a 76 year old female. There's no escaping that workup. I seriously work in the "United States Capital of Old People".

I also more regularly send home low risk chest pains without setting them up for an outpatient stress test. If you're < 60, had chest pain (not having chest pain), have normal or unchanged EKGs, and two neg trops...I probably discharge them 80-90% of the time unless there are extenuating circumstances. I also use the HEART score to back me up. I used to admit several of those 40-60 yo patients

I admitted a 37 year old for chest pain two shifts ago. Hospitalist called me an idiot. Cath'd. 99% LAD lesion. Young people aren't healthy anymore. If they are healthy, they're generally not in the ER. Good on you for doing the right thing, though.

I'm ordering less and less stuff for routine (lower) extremity cellulitis. I don't care how big it is. If you ain't vital-sign sick and don't have a ton of comorbidities, I will d/c you with appropriate antibiotics. Most of the time these patients literally just sit in the hospital picking their nose except for 1-2 times a day they get an IV antibiotic. Then they just sit around. Doing absolutely nothing while those who actually need the hospital board in the ED? Most of these cellulitis do not need acute hospital care. I've not had a single case return very sick. I've had a few return who allegedly failed outpatient therapy, but I have a hard time trusting the muggles.

As long as there's no complications/comorbidities such as DM/Immunologic drugs/vasculopathy, I do this as well. Unfortunately, the disphit (sic) FPs around here regularly send me patients "For IV antibiotics". I had a discussion with one particularly bad offender two weeks ago, and pointed her to a list of drugs with 100% bioequivalence between PO and IV forms. The only thing I got was a nastygram from administration, scolding me for "harming relations between the community and the hospital".

 

[VA Hopeful Dr]

My responses are in italics. I've changed a lot over the years, too.

if a young male or female has abdominal pain, has normal vitals and a normal exam, I used to lab + CT/US them maybe 50% of the time. Now I still generally lab them, but my CT/US has gone down to < 10%. Even then, I don't find pathology. I probably shouldn't even lab them and just say "hey....you are not dying, there is nothing to do here, I'll give ya dicyclomine and zofran. Get out"

Anyone under the age of 50, I do this all the time. I just happen to work in a shop where my average patient is a 76 year old female. There's no escaping that workup. I seriously work in the "United States Capital of Old People".

I also more regularly send home low risk chest pains without setting them up for an outpatient stress test. If you're < 60, had chest pain (not having chest pain), have normal or unchanged EKGs, and two neg trops...I probably discharge them 80-90% of the time unless there are extenuating circumstances. I also use the HEART score to back me up. I used to admit several of those 40-60 yo patients

I admitted a 37 year old for chest pain two shifts ago. Hospitalist called me an idiot. Cath'd. 99% LAD lesion. Young people aren't healthy anymore. If they are healthy, they're generally not in the ER. Good on you for doing the right thing, though.

I'm ordering less and less stuff for routine (lower) extremity cellulitis. I don't care how big it is. If you ain't vital-sign sick and don't have a ton of comorbidities, I will d/c you with appropriate antibiotics. Most of the time these patients literally just sit in the hospital picking their nose except for 1-2 times a day they get an IV antibiotic. Then they just sit around. Doing absolutely nothing while those who actually need the hospital board in the ED? Most of these cellulitis do not need acute hospital care. I've not had a single case return very sick. I've had a few return who allegedly failed outpatient therapy, but I have a hard time trusting the muggles.

As long as there's no complications/comorbidities such as DM/Immunologic drugs/vasculopathy, I do this as well. Unfortunately, the disphit (sic) FPs around here regularly send me patients "For IV antibiotics". I had a discussion with one particularly bad offender two weeks ago, and pointed her to a list of drugs with 100% bioequivalence between PO and IV forms. The only thing I got was a nastygram from administration, scolding me for "harming relations between the community and the hospital".

For that last, I've started doing more IM Rocephin to try and avoid having to do that.

 

[thegenius]

I also more regularly send home low risk chest pains without setting them up for an outpatient stress test. If you're < 60, had chest pain (not having chest pain), have normal or unchanged EKGs, and two neg trops...I probably discharge them 80-90% of the time unless there are extenuating circumstances. I also use the HEART score to back me up. I used to admit several of those 40-60 yo patients

I admitted a 37 year old for chest pain two shifts ago. Hospitalist called me an idiot. Cath'd. 99% LAD lesion. Young people aren't healthy anymore. If they are healthy, they're generally not in the ER. Good on you for doing the right thing, though.

Your guy had an abnormal EKG though right, or ruled in?

 

[RustedFox]

Your guy had an abnormal EKG though right, or ruled in?

Oh, oh, oh. Totally forgot about this. Sorry.

"Nonspecific EKG"
EVERY risk factor in the book.

GIANT Mexican dude. He was seriously 5-foot-6 by 5-foot-6 by 5-foot-6. Buttery. Smokey. Hypertensive. +Family history.
Hospitalist cried: "But he's not on any meds for HTN or DM or HLD."
"Yep; but he should be. I'm telling you; I'm not sending butterboy back to the hacienda."

 

[RustedFox]

For that last, I've started doing more IM Rocephin to try and avoid having to do that.

There's no activity against MRSA with rocephin.
Dude, please... IM Rocephin? That's so 1998.

 

[thegenius]

There's no activity against MRSA with rocephin.
Dude, please... IM Rocephin? That's so 1998.

Maybe he meant it for beta-hemolytic strep. Or MSSA. a.k.a non-purulent cellulitis
I heard it hurts like a mofo too

 

[RustedFox]

Maybe he meant it for beta-hemolytic strep. Or MSSA. a.k.a non-purulent cellulitis
I heard it hurts like a mofo too

It all hurts like crazy. I've had a few nasty cellulitis-es myself (thanks, housecat!)
But for realsies, if you're not treating cellulitis like its MRSA, you're doing it wrong.

 

[VA Hopeful Dr]

It all hurts like crazy. I've had a few nasty cellulitis-es myself (thanks, housecat!)
But for realsies, if you're not treating cellulitis like its MRSA, you're doing it wrong.

Nah.

Also recommended as a one time dose for pyelo if you're treating with oral cephalosporins (our bactrim and quinoline resistance rates to e coli are >20%).

 

[scummie]

Nah.

Also recommended as a one time dose for pyelo if you're treating with oral cephalosporins (our bactrim and quinoline resistance rates to e coli are >20%).

That was the practice during residencey as well. One good dose of rocephin, typically IV, and PO cephalexin to go home.

 

[Birdstrike]

It all hurts like crazy. I've had a few nasty cellulitis-es myself (thanks, housecat!)
But for realsies, if you're not treating cellulitis like its MRSA, you're doing it wrong.

Doxycycline all day long. I had a wart burned off my toe a few weeks ago. Started turning red.

Doxy > boom > now looks like toe heaven

 

[thegenius]

We not only take care of general, routine, run-of-the-mill muggles, but also muggles who allegedly are nurses.

Mom muggle and Dad muggle bring in there cute little, snot-nosed, 2 yr old female mugglelita because of a fever of 106 at home (in ED was 104R) She has snot pouring out of her nose and she is coloring in a book. This cute mugglelita still has the potential to learn and grow and become someone who can be informed about their health and make good decisions growing up. So I'll just call her a cute little girl from now on.

Me: "Why did you come in today? How can I help?" as I'm making funny faces at the girl, making her laugh.

Mother Muggle: "She has a fever. and runny nose and coughing. I measured her temperature at home with a temporal thermometer and it said 106." (I clarified it was 106 and not 100.6). "She wasn't eating and drinking as much today and her diaper isn't as wet as it normally is. I called the advice nurse and she said she might be dehydrated and to come into the ER."

Me: "Her fever started today? She was fine yesterday? And she hasn't been eating or drinking as much over the past 6-8 hours?"

Mother Muggle: "Yes Yes and Yes. She did have a little bit of juice earlier today but didn't drink the entire sippy cup."

Me: "And the nurse practicioner on the phone thought she might be dehyrated? Are you serious? Dehydrated because she isn't drinking as much as normal for half the day?"

Mother Muggle nods.

Me: THIS WAS A NURSE PRACTITIONER YOU TALKED TO? SHE SOUNDS LIKE AN IMPOSTOR, ACTUALLY

Mother and Father Muggle weakly giggle.

An on proceeds the relatively short visit, a little bit of tylenol, motrin, apple juice, and discharge.

 

[Groove]

@RustedFox, I thought of you today when reading this article since this was in your neck of the woods. You guys have some interesting characters over there in FL. I was trying to figure out if this was a muggle or something else entirely... Definitely not a snowbird.

Florida cops arrest man who said he stole pool floats to use for sex

A Florida man arrested in the theft of stolen pool floats told cops he used the inflatables for sex instead of raping women, court papers show.

 

[RustedFox]

@RustedFox, I thought of you today when reading this article since this was in your neck of the woods. You guys have some interesting characters over there in FL. I was trying to figure out if this was a muggle or something else entirely... Definitely not a snowbird.

Florida cops arrest man who said he stole pool floats to use for sex

They just mentioned this on my typical radio station down here. Made me sit up and go "hunnh?"

 

[Perrotfish]

We not only take care of general, routine, run-of-the-mill muggles, but also muggles who allegedly are nurses.

Mom muggle and Dad muggle bring in there cute little, snot-nosed, 2 yr old female mugglelita because of a fever of 106 at home (in ED was 104R) She has snot pouring out of her nose and she is coloring in a book. This cute mugglelita still has the potential to learn and grow and become someone who can be informed about their health and make good decisions growing up. So I'll just call her a cute little girl from now on.

Me: "Why did you come in today? How can I help?" as I'm making funny faces at the girl, making her laugh.

Mother Muggle: "She has a fever. and runny nose and coughing. I measured her temperature at home with a temporal thermometer and it said 106." (I clarified it was 106 and not 100.6). "She wasn't eating and drinking as much today and her diaper isn't as wet as it normally is. I called the advice nurse and she said she might be dehydrated and to come into the ER."

Me: "Her fever started today? She was fine yesterday? And she hasn't been eating or drinking as much over the past 6-8 hours?"

Mother Muggle: "Yes Yes and Yes. She did have a little bit of juice earlier today but didn't drink the entire sippy cup."

Me: "And the nurse practicioner on the phone thought she might be dehyrated? Are you serious? Dehydrated because she isn't drinking as much as normal for half the day?"

Mother Muggle nods.

Me: THIS WAS A NURSE PRACTITIONER YOU TALKED TO? SHE SOUNDS LIKE AN IMPOSTOR, ACTUALLY

Mother and Father Muggle weakly giggle.

An on proceeds the relatively short visit, a little bit of tylenol, motrin, apple juice, and discharge.

I think you're throwing too much shade at this.

1) An advice nurse usually isn't an NP, its an RN or LVN with a book of telephone protocols.

2) I would imagine this family got sent to the ED primarily for fever of 106, were also told to keep their kid hydrated, and the parents misunderstood the reason they were being told to come in

3) There is evidence that children with a temperature of 106 or higher are much more likely to have an underlying bacterial infection. Whether or not you really need to Xray and lab all of them is controversial (there aren't a lot of studies). Whether or not you base your assessment on their reported temperature or a lower temperature in the ED is controversial. At a minimum, though, any sane telephone protocol is going to recommend a kid with a 106 fever get a physical exam as soon as possible. If the office is closed, out of appointments, or doesn't have an attached lab then they're getting sent to the ED.

 

[WildcatS11]

We not only take care of general, routine, run-of-the-mill muggles, but also muggles who allegedly are nurses.

Mom muggle and Dad muggle bring in there cute little, snot-nosed, 2 yr old female mugglelita because of a fever of 106 at home (in ED was 104R) She has snot pouring out of her nose and she is coloring in a book. This cute mugglelita still has the potential to learn and grow and become someone who can be informed about their health and make good decisions growing up. So I'll just call her a cute little girl from now on.

Me: "Why did you come in today? How can I help?" as I'm making funny faces at the girl, making her laugh.

Mother Muggle: "She has a fever. and runny nose and coughing. I measured her temperature at home with a temporal thermometer and it said 106." (I clarified it was 106 and not 100.6). "She wasn't eating and drinking as much today and her diaper isn't as wet as it normally is. I called the advice nurse and she said she might be dehydrated and to come into the ER."

Me: "Her fever started today? She was fine yesterday? And she hasn't been eating or drinking as much over the past 6-8 hours?"

Mother Muggle: "Yes Yes and Yes. She did have a little bit of juice earlier today but didn't drink the entire sippy cup."

Me: "And the nurse practicioner on the phone thought she might be dehyrated? Are you serious? Dehydrated because she isn't drinking as much as normal for half the day?"

Mother Muggle nods.

Me: THIS WAS A NURSE PRACTITIONER YOU TALKED TO? SHE SOUNDS LIKE AN IMPOSTOR, ACTUALLY

Mother and Father Muggle weakly giggle.

An on proceeds the relatively short visit, a little bit of tylenol, motrin, apple juice, and discharge.

Honestly, I can't imagine my child having a fever of 106 degrees and not at least giving some thought to something bad going on. I don't think I've even seen a temp of 106 outside of heat stroke or sympathomimetic intoxication.

 

[RustedFox]

I think you're throwing too much shade at this.

1) An advice nurse usually isn't an NP, its an RN or LVN with a book of telephone protocols.

2) I would imagine this family got sent to the ED primarily for fever of 106, were also told to keep their kid hydrated, and the parents misunderstood the reason they were being told to come in

3) There is evidence that children with a temperature of 106 or higher are much more likely to have an underlying bacterial infection. Whether or not you really need to Xray and lab all of them is controversial (there aren't a lot of studies). Whether or not you base your assessment on their reported temperature or a lower temperature in the ED is controversial. At a minimum, though, any sane telephone protocol is going to recommend a kid with a 106 fever get a physical exam as soon as possible. If the office is closed, out of appointments, or doesn't have an attached lab then they're getting sent to the ED.

I think the idea is that the muggles are so muggled that they can't read a thermometer correctly.

 

[TooMuchResearch]

I think the idea is that the muggles are so muggled that they can't read a thermometer correctly.

What, you've never seen a kid with a 120 degree F fever? I have. I know it because the parents swore it wasn't 102. I asked them to throw out the thermometer.

 

[RustedFox]

What, you've never seen a kid with a 120 degree F fever? I have. I know it because the parents swore it wasn't 102. I asked them to throw out the thermometer.

The older muggles say similarly stupid things about BP all the time.
"Da nurse at my cahhdiologist's awffice said dat my blood presshaah was 230/300."
They're insistent that not only is such a pressure possible, but it was their pressure.

 

[Birdstrike]

The older muggles say similarly stupid things about BP all the time.
"Da nurse at my cahhdiologist's awffice said dat my blood presshaah was 230/300."
They're insistent that not only is such a pressure possible, but it was their pressure.

"My doctor says, 'We gonna write you up' cuz everything I got is so imPOSSible he's never seen it. Every doctor I've ever had says I'm one in a
M E E L L I O N!"

 

[Zebra Hunter]

It all hurts like crazy. I've had a few nasty cellulitis-es myself (thanks, housecat!)
But for realsies, if you're not treating cellulitis like its MRSA, you're doing it wrong.

90% of cellulitis is due to strep. I routinely treat with just cephalexin if no significant risk factors for MDROs, additional MRSA coverage is not necessary. There have been a couple RCTs in recent years demonstrating this.

Clinical Trial: Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial

To date, no trial has assessed the effectiveness of antibiotics that target community-associated methicillin-resistant Staphylococcus aureus in the treatme

academic.oup.com

Cephalexin Plus Trimethoprim-Sulfamethoxazole for Clinical Cure of Cellulitis

(questionable improved outcomes for combo therapy in modified ITT analysis, however, clearly no difference in ITT analysis)

 

[thegenius]

Honestly, I can't imagine my child having a fever of 106 degrees and not at least giving some thought to something bad going on. I don't think I've even seen a temp of 106 outside of heat stroke or sympathomimetic intoxication.

this little girl had anything but a heat stroke
She had snot running out of her nose and her fever was 104

 

[KGflyboy]

this little girl had anything but a heat stroke
She had snot running out of her nose and her fever was 104

I think many people, especially the Pediatric EM folks, would have sent her home if she was well appearing with otherwise normal vitals. There isn't any reason to go looking for a source of fever in an otherwise healthy kid when the history and exam provides a very likely source of fever. In this case, the kid had signs and symptoms of URI.

What sort of tests do those of you who who think this needs a workup typically order in this situation? I could maybe see doing a CXR to look for PNA with this high of fever and cough, but with clear lungs this is still likely just a kid with a URI.

What sort of labs would be indicated? Would a CBC be helpful in this situation? It's likely not going to help you differentiate a cold from sepsis. Would you get a UA to check for a UTI? Without cathing this kid, you won't get a reliable sample. Even if you do go to the extent of getting a cathed specimen, I still don't know why you need to look for a hidden source of fever in a kid with a very clear source of fever based on hx and exam. If you take away the URI symptoms, then I would be more suspicious about a UTI and discuss the pros and cons of testing for UTI in an otherwise we'll appearing 2 year old with the parents.

Would you get a respiratory pcr panel? I am perplexed by how many of these I see ordered in situations like this when it is incredibly unlikely to impact and clinical decisions.

Would you LP this kid? That seems like way too much of a workup in this situation.

I'm back to my original conclusion. I would have done the exact same thing as you plus or minus a CXR, depending on how confident I was in my auscultation exam. I would not have stuck that kid for labs, swabbed their nose for a respiratory panel, or even started an IV.

Motrin -> po challenge -> recheck vitals -> home.

 

[Perrotfish]

I think many people, especially the Pediatric EM folks, would have sent her home if she was well appearing with otherwise normal vitals. There isn't any reason to go looking for a source of fever in an otherwise healthy kid when the history and exam provides a very likely source of fever. In this case, the kid had signs and symptoms of URI.

What sort of tests do those of you who who think this needs a workup typically order in this situation? I could maybe see doing a CXR to look for PNA with this high of fever and cough, but with clear lungs this is still likely just a kid with a URI.

What sort of labs would be indicated? Would a CBC be helpful in this situation? It's likely not going to help you differentiate a cold from sepsis. Would you get a UA to check for a UTI? Without cathing this kid, you won't get a reliable sample. Even if you do go to the extent of getting a cathed specimen, I still don't know why you need to look for a hidden source of fever in a kid with a very clear source of fever based on hx and exam. If you take away the URI symptoms, then I would be more suspicious about a UTI and discuss the pros and cons of testing for UTI in an otherwise we'll appearing 2 year old with the parents.

Would you get a respiratory pcr panel? I am perplexed by how many of these I see ordered in situations like this when it is incredibly unlikely to impact and clinical decisions.

Would you LP this kid? That seems like way too much of a workup in this situation.

I'm back to my original conclusion. I would have done the exact same thing as you plus or minus a CXR, depending on how confident I was in my auscultation exam. I would not have stuck that kid for labs, swabbed their nose for a respiratory panel, or even started an IV.

Motrin -> po challenge -> recheck vitals -> home.

I deal with this a couple of times per year, which is in line with the rate of hyperpyrexia in the study I linked. The is no there is no universal algorithm on this, but what I do:

1) Non toxic appearing child with reported temp at home of 106 and temp of < 106 (but still febrile) in clinic: Urinalysis/Urine culture, chest Xray, and rapid strep if not clearly coughing. Follow up in 24 hours with no other treatment if all the labs are fine.

2) Non toxic appearing child with measured temp of 106 in clinic: Urinalysis/urine culture, Chest Xray, rapid strep if not coughing, send out RVP, blood culture, CBC/ESR (to trend, if necessary), and shot of ceftriaxone even if all the labs are fine. Follow up in 24 hours.

The problem with writing it off as having an obvious source of infection is that a significant percentage of bacterial infections in children follow viral infections. RSV has an association w/ UTI, Adeno has an association with pneumonia, and flu is basically a temporary immunodeficiency and has a temporary association with every kind of bacterial infection there is. My rate of finding underlying bacterial infections has been around 40%, which is basically in line with the study I cited above considering the small sample size

You're not wrong to do what you do, I think you could get a dozen Peds ID docs in a room and they would all have different opinions about this, but I lean more conservative.

 

[thegenius]

I deal with this a couple of times per year, which is in line with the rate of hyperpyrexia in the study I linked. The is no there is no universal algorithm on this, but what I do:

1) Non toxic appearing child with reported temp at home of 106 and temp of < 106 (but still febrile) in clinic: Urinalysis/Urine culture, chest Xray, and rapid strep if not clearly coughing. Follow up in 24 hours with no other treatment if all the labs are fine.

2) Non toxic appearing child with measured temp of 106 in clinic: Urinalysis/urine culture, Chest Xray, rapid strep if not coughing, send out RVP, blood culture, CBC/ESR (to trend, if necessary), and shot of ceftriaxone even if all the labs are fine. Follow up in 24 hours.

The problem with writing it off as having an obvious source of infection is that a significant percentage of bacterial infections in children follow viral infections. RSV has an association w/ UTI, Adeno has an association with pneumonia, and flu is basically a temporary immunodeficiency and has a temporary association with every kind of bacterial infection there is. My rate of finding underlying bacterial infections has been around 40%, which is basically in line with the study I cited above considering the small sample size

You're not wrong to do what you do, I think you could get a dozen Peds ID docs in a room and they would all have different opinions about this, but I lean more conservative.

I would do these things if there wasn't a source of fever by history or exam, seems like a lot though if you have a source like an acute URI