This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. No localizing symptoms of URI or intraabdominal pathology, low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems. Doubt pneumonia or pyelonephritis. Doubt meningitis or appendicitis.
Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u
LOW RISK, <2 y old
This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up.
LOW RISK, >2 y old
This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. The mechanism is of low energy. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit.
Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge
HIGH RISK:
This pediatric patient presents with a history concerning for a serious intracranial injury. Unable to clear patient with PECARN rules given ***. Will obtain CT imaging to rule out intracranial injury or skull fracture. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey.
Plan: CT scan head/neck, pain control, reassess
TYPICAL VASO-OCCLUSIVE CRISIS
This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Considered alternate etiologies of this patient’s pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies but doubt these are likely.
Will plan for pain control using patient’s pain management plan, basic labs/reticulocyte count, likely discharge
ACUTE CHEST SYNDROME
This patient with known SCD presents with chest/back pain consistent with vaso-occlusive crisis but concerning for acute chest syndrome; this presentation is different than the patient’s typical pain crisis. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely.
Plan: labs, pain control, fluids, low threshold to transfuse to Hb>9, CXR, discuss with hematology, likely admit
SPLENIC SEQUESTRATION OR STROKE
This patient with sickle cell disease presents with altered mental status, highly concerning for severe range anemia or stroke. Splenic sequestration is also on the differential, although ***given this patient’s age it is quite unlikely that they still have functioning splenic tissue. I considered, but think less likely, other etiologies of altered mental status such as infection, metabolic derangements, or ICH. This symptom constellation is concerning given the underlying medical comorbidities.
Plan: basic labs, reticulocyte count, consider hemolysis labs, XR chest, neuroimaging, probable stroke code activation, neuro and hematology consults, admit
LOW RISK
This *** patient presents with knee pain, suspicious for ***. Able to flex and extend although somewhat limited by pain. Considered, but doubt, tibial plateau fracture, septic arthritis, other acute unstable fracture, or significant neurovascular compromise.
Plan: XR, pain control, reassessment
HI RISK – Tibial Plateau
This *** patient presents with knee pain suspicious for a tibial plateau fracture given history, exam, and mechanism. No e/o compartment syndrome, septic arthritis, other acute fracture. Range of motion is ***. Will get plain films, consider CT, likely ortho consultation, pain control, NWB.
PEARLS:
This is an ill-appearing *** who presents with lethargy. Differential includes sepsis, congenital heart disease, hypovolemia and hypoxemic states, endocrine emergencies like CAH or thyroiditis, trauma, inborn errors of metabolism, seizures, electrolyte derangements, or intestinal catastrophe. Given this undifferentiated sick neonate, will work up broadly, empiric broad-spectrum antibiotics***, trial of 10cc/kg fluid bolus, resuscitative measures and will consider early airway intervention.
Pearls: For a sick kid use THE MISFITS:
Trauma: consider FAST and CTH
– consider vitamin K and Ca if bleeding
Heart disease, hypovolemia, hypoxia
Endocrine (CAH, thyrotoxicosis)
Metabolic – lytes
Inborn errors
Seizures
Formula mishaps
Intestinal catastrophes (volvulus, intuss, NEC)
Toxins
Sepsis
Differential Diagnosis: Cough, wheezing, asthma exacerbation, pneumonia, seasonal allergies, viral syndrome, Pneumothorax.
Rationale: Given the history of cough, difficulty breathing, wheeze and history of asthma, the patient’s symptoms may be attributed to either viral syndrome, pneumonia, acute asthma exacerbation or pneumothorax. Most likely, this represents an acute asthma exacerbation.
1) STAT bronchodilator therapy and steroids will be given, with re-assessments between nebulized treatments.
2) If worsening or persistent symptoms occur, the patient may require critical care management or admission to the hospital.
General Appearance: alert, no apparent distress, appropriately interactive with examiner
Skin: no lesions, no jaundice
Head/Fontanelles: normocephalic, AF_____x_______, RR normal bilaterally
EENT: conjunctiva clear, nares patent, normal oral mucosa, ears normal placement, TM’s clear bilaterally
Neck: full range of motion
Lungs: CTA bilaterally, no adventitious breath sounds
CV: normal S1, S2, RRR without murmur normal femoral pulses
Abdomen: soft, no hepatosplenomegaly or masses
Extremities: no deformities
Hips: negative Barlow/Ortolani, > 60° abduction
Genitourinary: Male: testes descended, circ/uncirc // Female: normal external genitalia
Neurologic: moves all extremities symmetrically, normal tone, responds to clap, positive moro, grasp/suck/root/toe grasp
General- well-appearing developmentally-appropriate child in NAD, playing in exam room
Head: atraumatic, normocephalic,
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes nml bilat
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity
CV- RRR, nml S1, S2 w no murmurs
Respiratory- CTAB, no wheezing or crackles
Abdomen- Soft, NTND, no rigidity, no rebound, no guarding,
Extremities- warm, symmetric tone, nml muscle development and strength
Skin- moist; without rash or erythema
*** is a ***y/o child who presents with abdominal pain, vomiting, anorexia, concerning for appendicitis. Differential includes gastritis or early gastroenteritis, although history suggests appy is at least equally likely. Intussusception, Meckel’s also a possibility but would be atypical given patient age. Similarly volvulus or malrotation unlikely given otherwise well-appearing patient without peritonitic/rigid abdomen. Unlikely to represent UTI given no dysuria, no suprapubic tenderness. Would be an atypical presentation of pneumonia and patient is normoxemic without dyspnea or cough. Low index of suspicion for ***gynececological etiologies such as torsion, TOA, or ectopic given *** OR ***testicular torsion, orchitis/epididymitis given ***.
Plan: ***
*** is a *** y/o otherwise healthy *** with midepigastric pain worsened with eating, most consistent with gastritis. Reassuring that his pain was relieved with OTC antacids. Differential includes GERD, early gastroenteritis, PUD. Low suspicion for referred cardiac etiologies given age and lack of fmhx early heart disease. Denying chest pain. No infectious symptoms (tachypnea, fever/chills, etc) to suggest bacterial infection such as PNA or biliary tree infection. No urinary symptoms to suggest UTI, no RLQ or migratory pain or fever to indicate a concern for appy. No blood/mucus in stool to suggest invasive bacterial species. Otherwise well-appearing child, tolerating adequate PO and not dehydrated.
Plan: discharge to home with return precautions, encourage PO hydration, ***recommend OTC meds such as ranitidine, tums
EM DOT PHRASES 