Nancy Gilchrist MD, Children’s National Medical Center

The Case
A 5 year old male has persistent tachycardia despite an otherwise reassuring exam.

Here’s How You Answered Our Questions:

Discussion:
Great discussion for this case! We talked about the optimal timing and logistics of obtaining a cardiology consult and echo for a patient like this, as well as our level of concern for serious diagnoses and whether this patient required any further observation.

Regarding timing, almost everyone preferred to perform a workup prior to the consult, but agreed that a cardiology consult for this child was likely inevitable, so if we happened to see or speak with cardiology about something else, a “heads up” for them would be a nice courtesy.

Our teaching attending for the week, Shilpa Patel, gave us an excellent breakdown of the differential (and a cool method for organizing a differential!).

Dave Mathison was the one rogue commenter who argued for discharge, as we had essentially ruled out serious diagnoses with our normal workup thus far. Those in our live discussion, however, preferred to admit on IV fluids, with the thought being that more benign diagnoses (dehydration, toxin ingestion e.g. caffeine) would resolve, while the scary ones would “declare themselves” (sepsis, myocarditis, heart failure). We did have a good sidebar on the difficulty of establishing the diagnosis of myocarditis, which is not ruled out by a normal echo or EKG, and we speculated on the frequency with which patients with subclinical myocarditis pass through our ED.

Denouement:
Given the persistent tachycardia, the patient was admitted to the hospitalist service for observation overnight. During his admission, the patient continued to have periods of asymptomatic tachycardia without other vital sign instability or arrhythmia. He was discharged home the following day without a clear cause for the tachycardia. Cardiology followed the patient during his admission and will continue to follow him as an outpatient.

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