Hot Seat #174: Denouement

Posted on: August 30, 2021, by :

The case: A 4 year old with febrile seizures with persistent fevers and managing parental expectations around the workup.

Here’s how you answered the questions:

The interpretation of an equivocal urinalysis is a common dilemma in pediatric emergency medicine. In this case, a well appearing child presents with a fever without a focus, complicated by a febrile seizure. We found a wide range of initial approaches to the patient, with a plurality of junior and senior clinicians choosing just to perform a point of care glucose and covid swab, and fewer choosing more laboratory studies. The provider in this case obtained a urinalysis with the results above, and respondents were split as to whether this urinalysis warranted treatment with antibiotics. Ultimately the patient was discharged home off antibiotics, but a urine culture was not sent prior to discharge.

When the patient’s fever persisted days later, a majority of senior clinicians felt follow-up in the primary care provider’s office was appropriate, whereas junior respondents preferred return to the emergency department for evaluation. The group discussed the difficulty that families have had during the covid-19 pandemic with primary care provider availability, which influenced some people to choose ED follow-up instead. The patient returned to the emergency department, and had a repeat urinalysis that was similar to the first, and other than mild congestion, still did not have any obvious localizing symptoms for her fever. A slight majority of senior respondents chose to discharge the patient home again without antibiotics, whereas junior respondents slightly favored starting outpatient antibiotics for UTI.

This patient was discharged home on antibiotics, but 2 days later her urine culture was negative, and she was clinically improving, so antibiotics were discontinued. This case highlights a number of important points: the difficulty of interpreting an equivocal urinalysis in the setting of a fever without a clear source, the variability of practice patterns regarding when to send a urinalysis, the importance of ensuring a urine culture is sent with a urinalysis, and the pressure felt by providers to find and treat a fever source (especially after a febrile seizure).

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Walter Palmer

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