Hot Seat #55: 8 wo bounceback w/ fussiness
Posted on: April 16, 2015, by : Evan Sherman
by Evan Sherman, Children’s National
with Pavan Zaveri, Children’s National
The Case
8wo otherwise healthy M presents to the ED with URI sx, vomiting, and “fussiness” for the past few days. He was brought to the ED 3 days ago by his grandmother for similar sx (although he wasn’t vomiting at the time). During that visit, he had appropriate VS and a reassuring exam, was diagnosed with URI and colic, and discharged home. Today, he developed a tactile fever, “strong” NBNB emesis after feeds (“like an adult”), and L eye redness. Of note, the patient was in the care of his grandmother over the past few days, but today is brought in by his mother. Mom doesn’t know much about how the patient was doing over the past few days, and didn’t know he had been seen in the ED 3 days ago.
ROS: POing, voiding and stooling normally. 14mo sister and mother both with URI sx.
BH: Full term, NSVD, no complications, went home with mom
PMH/PSH: Negative
Vaccines: Hasn’t gotten 2m vaccines yet
SH: Lives with mom, dad, and 14mo sister. Occasionally cared for by maternal grandmother.
FH: Negative
PE: T 37.5 (rectal), HR 150, RR 46, BP 94/44, S 100% on RA
Alert, appropriate, no distress
L inferomedial conjunctival injection, no discharge, PERRL
Mild nasal congestion
Coarse BS, no focality, no resp distress
Abd soft, NTND, normoactive BS
Otherwise completely normal exam
Questions for you:
Re-examination
The ED provider decided to obtain a CMP and CBC. Blood culture was drawn and held. CMP was completely normal. The CBC showed:
WBC 14.4 (with a benign diff), Hgb 7.1, Plt 607
MCV 91, MCH 29.9, MCHC 32.9, RDW 17.1
A more directed family history from mom reveals only an uncle with sickle cell trait, no other heme problems that she knows of.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
From the hot seat….
Wow! First crack. Surprisingly Dewesh and Dave haven’t stepped up quite yet. Well, I think I’ll have to defer the wonderful medical differential to our true brainiacs (is that a word)? But the key features of this case that trigger a response are age, “fussiness” (love how it was in quotes from the beginning in the case), and different care providers. This makes me think about a study a fellow once wanted to do of “Do revisits under 28 days suggest a higher likelihood of non-accidental trauma in the first 6 months.” With NAT on the differential, it’s an interesting consideration.
When taking the history, we often take things just at face value and what’s available…but really making that extra phone call (dad, please call mom so I can get answers to all the I don’t know’s you’re telling me) to call grandmother can be invaluable. We like to believe that mothers will have all the information, but sometimes (especially in our younger mothers), they don’t even know what they’re supposed to know in mothering, let alone when things have gone awry. At the same time, strained relationships in the family such as between mother and her mother (or worse the father’s mother) are sometimes not the best thing to exacerbate an already confusing situation. It’s all a judgment call and that’s the art of medicine that I think we often forget/dismiss in our efforts to ensure we are using the evidence and science.
Fussiness of course has its own broad differential from sepsis, serious bacterial infection, hair tourniquets, incarcerated hernias, hunger, NAT/neglect, inborn errors of metabolism, reflux and much more, it can often take a fair amount of observation and sometimes some digging there to identify what the parent/caregiver means by fussiness. Often our residents don’t take the time to get the details and it becomes incumbent on us to spend a few minutes getting more history which develops the rapport needed to make the sound management plan coming up. Factors important to me are the usual historical facts such as onset, provoke/palliate (how do you soothe the baby), quality/frequency, radiation (what else do you notice bothering the baby), severity, and timing (how many times, how long, etc.). It’s the basics that we often overlook in getting straight to the workup efficiently.
And, of course last but not least, the age….8 week-olds are unreliable. They can hide so much in terms of distress, pain, troubles, etc. until they are about to crump. Of course, that’s an exaggeration, but just a thought to throw caution out there. Much of the fussiness differential applies to the age aspect as well. Fortunately, most of our hospitalist colleagues also have a healthy respect for the small infant that admitting for observation is an acceptable treatment even up to this age. Clearly, some further evaluation may be warranted depending on other historical aspects extracted and whether to head down a surgical, traumatic, metabolic, infectious or hematologic pathway or some combination thereof before proceeding with admission for this anemic infant.