Hot Seat Case # 111 Denouement: 9 year old male with acute neck swelling
Posted on: April 25, 2018, by : Haroon Shaukat MD
Jeremy Root, MD Children’s National Medical Center
Case: 9 year old male with right ear and jaw pain that suddenly within the same day spread to anterior and posterior neck swelling. His exam was significant for a hoarse voice without drooling or trismus. He had moderate to severe cervical LAD without palpable fluctuance.
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Discussion:
The rapidity of symptoms prompted pause in many of our thought processes. The “do not miss” diagnosis for all of us seemed to be retropharyngeal abscess. While the patient did not fit epidemiology of RPAs, significant rapidly progressive bilateral lymphadenopathy should raise suspicion of infection in the deep tissues of the neck. high clinical suspicion for an RPA necessitates a CT scan. If low clinical suspicion you may begin with a lateral neck x-ray, but ultimately diagnosis must be confirmed on a CT scan. Luckily most providers believed it’s reasonable to discharge the patient on oral antibiotics with strict return precautions after confirming (via CT) that the pathology is not negative airway risk (such as an RPA). Has clearly pathology represents an area risk would require admission.
Interestingly the literature suggest that finding AGAINST MEDICAL ADVICE forms does not protect a physician for medical legal challenges. The common throat of insurance refusal to pay for visits include his discharge AMA is also not founded on evidence. Intern R discussion of the clinicians conversations about risks and benefits with the patient has required in the chart.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753933/pdf/medi-95-e2788.pdf
“Patients leaving AMA are 10 times more likely to initiate a litigation process against the emergency physician and the hospital than a typical ED patient with a rate of around 1 lawsuit per 300 AMA cases.”
Denouement:
Due to the patient’s well appearance and joint decision making with father and son, the medical team agreed to send patient home after one dose of IV Unasyn. An outpatient course of Augmentin was started due to concerns for bacterial lymphadenitis and strict return precautions were provided.
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