1. Initial assessment of stability of patient:
1.1. Pediatric Assessment Triangle:
1.2. Toxic Appearing.
1.2.1. Emergent interventions/diagnostics precluded full H&P at this time.
1.3. Non-toxic Appearing,
1.3.1. normal
1.3.1.1. appearance,
1.3.1.2. work of breathing,
1.3.1.3. circulation to skin,
1.3.2. AVPU
2. General Pediatric History
2.1. General Pediatric Information:
2.2. Lethargy/AMS
2.3. Vaccine UTD
2.4. Comorbidities
2.5. Birth/family history
2.6. History suggestive of patient's level of sickness:
2.7. Well-hydrated based upon hx of PO intake/frequency of urinary output
2.8. Any findings suggestive of neglect or non-accidental trauma
3. Complaint Specifics of history
3.1. Temperature
3.1.1. Recorded objectively,
3.1.2. Subjective fever
3.1.3. Highest recorded temperate
3.1.4. Method recorded
3.1.5. Anti-Pyretics being administered at home
3.1.6. Time of last anti-pyretic prior to arrival ED
3.1.7. Duration of persistence of fever
3.1.8. Onset of illness
3.1.9. Rigors - uncontrollable shaking consistent with rigors
4. Localizing symptoms (to the extent is possible to ascertain by child/care giver)
4.1. Ear pain suspected by parents.
4.2. Sore throat suspected by parents.
4.3. Injected sclera per parents.
4.4. Rhinorrhea.
4.5. cough - productive/non-productive
4.6. Nb/nb vomiting.
4.7. Nb/non-melanotic/normal color diarrhea.
4.8. Indications of abdominal pain.
4.9. Poor PO tolerance.
4.10. Rash
4.10.1. Location of rash
4.10.2. Petechiae
4.11. Joint pain.
4.12. Indications suggestive of myalgias
5. No suspect source elucidated by interview with care giver.
6. REVIEW OF SYSTEMS (Pediatric):
6.1. Constitutional:
6.1.1. no, mild, moderate, severe distress
6.1.2. rigors,
6.2. ENT:
6.2.1. rhinorrhea,
6.2.2. otalgia
6.2.2.1. given pulling at ears,
6.2.3. s/s suggestive of sore throat,
6.2.3.1. per-orbital / intra-oral lesions,
6.3. Eyes:
6.3.1. injected sclera
6.4. Cardiac:
6.4.1. no cardiac history
6.4.2. diastolic flow murmur on cardiac auscultation.
6.5. Pulmonary:
6.5.1. s/s suggestive of shortness of breath,
6.5.1.1. no history of cyanosis,
6.5.2. cough - no,mild non productive,no new,no productive
6.6. GI:
6.6.1. abdominal pain suspected by parents,
6.6.2. vomiting,
6.6.3. BRBPR, dark tarry stool,
6.6.4. diarrhea
6.7. GU:
6.7.1. GU / peri rectal rash,
6.7.2. s/s suggestive of verses unknown if dysuria,
6.8. Neuro:
6.8.1. lethary,
6.8.2. nuccal regidity,
6.9. MSK:
6.9.1. no recent trauma
6.9.2. no indications of joint pain, limitations in mobility, swollen joints.
6.9.3. no focal asymmetry in weakness noted
6.10. Skin:
6.10.1. no rashes, specifically also no petechiae
6.11. ID:
6.11.1. no recent antibiotics,
7. PMH/PSH/PSFH:
7.1. PMH/PSH:
7.1.1. none
7.2. SH:
7.2.1. domiciled,
7.2.1.1. lives with family,
7.3. FH:
7.3.1. reviewed and non-contributory to patient's presenting complaint.
8. EXAM:
8.1. VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-accesses patient):
8.2. HR:
8.2.1. repeated after patient not agitated
8.3. BP:
8.3.1. repeated after pt not agitated and BP normalized
8.3.2. hypotensive.
8.4. O2 sat:
8.4.1. no hypoxia on my interpretation of oximtery
8.5. RR:
8.5.1. repeated after pt not agitated and normalization of RR
9. PHYSICAL EXAM:
9.1. Constitutional:
9.1.1. well-nourished,
9.1.2. no,mild,moderate,severe distress,
9.2. HEENT:
9.2.1. Head: atraumatic head,
9.2.2. Eye:
9.2.2.1. no peri-orbital erythema nor swelling,
9.2.2.1.1. EOM grossly intact,
9.2.2.1.2. Nose: rhinorrhea,
9.2.3. Ear exam:
9.2.3.1. mobile, non-erythematous TM with white reflex,
9.2.3.2. non-mobile, erythmeatous TM,
9.2.3.2.1. on left
9.2.3.2.2. on right
9.2.3.3. discharge from ears,
9.2.4. Throat exam:
9.2.4.1. no erythema, no purulent exudate,
9.2.4.2. no deviated uvula,
9.2.4.3. mildly swollen tonsilles
9.2.4.4. mildly swollen cervical lymph nodes
9.2.4.5. erythema at base of throat,
9.2.4.6. purulent exudate,
9.2.4.7. cervical lymphadenopathy,
9.2.4.8. No torticollis,
9.2.4.9. No stridor,
9.3. GI:
9.3.1. abdomen soft,
9.3.2. abdomen non-tender in all 4 quadrants,
9.3.3. TTP - diffusely, in RUQ, in RLQ, in LLQ, in LUQ, in epigastric region,
9.4. Pulmonary:
9.4.1. Lungs:
9.4.1.1. CBTA,
9.4.1.2. rhoncherous breath sounds
9.4.1.3. on left, on right, at base, at superior aspect,
9.4.1.4. wheezing - expiratory only, inspiratory and expiratory, significant decreased aeration
9.4.1.5. focal at
9.4.1.6. throughout
9.4.1.7. rales,
9.4.2. Respiratory effort:
9.4.2.1. No respiratory distress, non-labored breathing, no retractions,
9.5. Cardiovascular:
9.5.1. no r/m/g,
9.6. MSK:
9.6.1. no deformities,
9.6.2. moving all extremities
9.7. Skin:
9.7.1. No rashes.
9.8. GU exam:
9.8.1. No rashes/abnormalities of skin in GU / peri rectal area.
9.8.2. Male specific exam: Testicular exam: palpable testis without tenderness, normal testicular lie, able to elicit cremaster reflexes,
9.8.2.1. Female specific exam: No suprapubic / RLQ / LLQ TTP
9.9. Neuro:
9.9.1. Normal LOC.
9.9.2. Acting normal per parents.
9.9.3. No nuccal rigidity
9.9.4. No gross focal neurological deficits.
9.9.5. Age appropriate milestones
10. ED COURSE and MDM:
10.1. Working Impression/Empiric Management:
10.1.1. Evaluation for Potential Pediatric Fever
10.2. Diagnostically:
10.2.1. Labs:
10.2.1.1. CBC,
10.2.1.2. BMP,
10.2.1.3. LFTs/lipase,
10.2.1.4. UA (cathed),
10.2.1.5. Urine Cx
10.2.1.6. lactate
10.2.1.7. Blood Cx
10.2.1.7.1. x1
10.2.1.8. Radiographically:
10.2.1.8.1. CXR
10.2.1.8.2. Abd XR
10.2.1.9. Influenza, Biofire
10.2.1.10. CRP,
10.2.1.11. ESR,
10.2.2. To evaluate for
10.2.2.1. CBC:
10.2.2.1.1. luekocytosis,
10.2.2.1.2. bands,
10.2.2.1.3. thrombocytopenic - ? suspected consumptive process - ITP, TTP,
10.2.2.1.4. pancytopenia
10.2.2.1.5. blood line malignancy
10.2.2.2. BMP:
10.2.2.2.1. BUN/Cr >20 suggestive of prerenal process,
10.2.2.2.2. Anion gap
10.2.2.2.3. acidotic suggested by low bicarb,
10.2.2.3. LFTs/lipase:
10.2.2.3.1. laboratory evidence of hepato-biliary pathology.
10.2.2.4. UA: From catheterized specimen given patient not potty trained.
10.2.2.4.1. gram stain
10.2.2.5. Urine Cx sent with follow mechanism in place
10.2.2.6. Markers of inflammation
10.2.2.6.1. CRP, ESR
10.2.2.7. Radiographically:
10.2.2.7.1. CXR: PNA
10.2.2.7.2. XR of joint / extremity of suspect: effusion, osteosacroma
10.2.2.7.3. Advanced Imaging: US abdomen
10.2.2.8. Therapeutically:
10.2.2.8.1. Empirically: IVF 20 cc/kg,
10.2.2.8.2. Anti-pyretics / Analgesics: acetaminophen, ibuprofen,
10.2.2.8.3. Anti-emetics: ondansetron (zofran)
11. Assessment/Plan:
12. Evaluate for toxicity. Vaccines UTD for age of patient.
12.1. Toxic appearing pediatric patient.
12.1.1. High risk for deterioration -> full septic work up/tx
12.1.1.1. Diagnostically:
12.1.1.1.1. CBC, BCx x1, Lactate, UA (cathed) w/ micro, UCx, CXR, LP
12.1.1.1.2. stool studies indicated given pt has diarrhea
12.1.1.2. Therapeutically:
12.1.1.2.1. Abx:
12.1.1.3. Dipso: Admitted
12.2. Non-toxic. Utilized risk stratification criteria to inform diagnostics, therapeutics, and disposition:
12.2.1. 0- 90 days.
12.2.1.1. Philadelphia criteria employed.
12.2.1.1.1. Meets inclusion criteria:
12.2.1.1.2. Meets all low risk criteria, will discharge without antibiotics.
12.2.1.1.3. High risk, IV abx and admit
12.2.1.1.4. ((Performance))
12.2.1.2. Rochester criteria employed:
12.2.1.2.1. Meets inclusion criteria:
12.2.1.2.2. Meets all low risk criteria, will discharge without antibiotics.
12.2.1.2.3. High risk, IV abx and admit.
12.2.1.2.4. ((Performance))
12.2.1.3. Boston criteria employed:
12.2.1.3.1. Meets inclusion criteria:
12.2.1.3.2. Meets all low risk criteria, will discharge WITH empiric antibiotics.
12.2.1.3.3. High risk, IV abx and admit.
12.2.1.3.4. ((Performance))
12.2.1.4. Baraff synthesis of Rochester, Philadelphia, and Boston criteria:
12.2.1.4.1. Meets criteria:
12.2.1.4.2. Two Options:
12.2.1.5. Febrile infant. (conservative approach, risk factors or no follow up)
12.2.1.5.1. Incomplete development of blood brain barrier, incomplete vaccination status.
12.2.1.5.2. Dipso: Admitted
12.2.1.6. Afebrile in ED with no hx of recent antipyretics.
12.2.1.6.1. Therefore suspect pt is truly afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
12.2.1.7. Afebrile in ED with recent anti-pyretic use with observation showing no fever.
12.2.1.7.1. Given history of recent anti-pyretic, patient was observed in the emergency department for duration of time where based upon time of administration of antipyretics and known duration of action of anti-pyresis, lack of fever on repeat vital signs not likely attributable to anti-pyretics. Therefore patient is likely afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
12.2.2. 3mo - 3 yr.
12.2.2.1. Afebrile in ED with no hx of recent antipyretics.
12.2.2.1.1. Therefore suspect pt is afebrile. Tx bacterial infection. If well hydrated, d/c.
12.2.2.1.2. Treat any evidence of bacterial source.
12.2.2.1.3. T 38 - 39 in ED (febrile without hyperpyrexia).
12.2.2.1.4. Therefore suspect pt is febrile though not sufficiently high fever to warrant additional diagnostics given on thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
12.2.2.1.5. Treat any evidence of bacterial source.
12.2.2.2. Temp < 39 in ED with recent anti-pyretic use.
12.2.2.2.1. Shared decision. Wait until wears off v return precautions.
12.2.2.2.2. Treat any evidence of bacterial source.
12.2.2.3. T > 39 (hyperpyrexia) in 90d - 3 mo.
12.2.2.3.1. With clear suspect source, treat if bacterial source.
12.2.2.3.2. Fever of unclear source. Will risk stratify and guide diagnostics for possible UTI based upon pre-test probabilities:
12.2.3. > 3 y/o.
12.2.3.1. Treat any evidence of bacterial source.
12.2.3.2. Be a doctor.
12.2.3.2.1. No evidence of bacterial source on hx/exam. Suspect fever of benign etiology, likely viral source. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
12.2.4. Persistent fever if patient for > 5 days in non-toxic, vaccinated patient.
12.2.4.1. Given fever without remittence for >= 5 days, pt evaluated for Kawasaki disease:
12.2.4.1.1. Assess for classic Kawasaki Disease Criteria:
12.2.4.1.2. Meets sufficient criteria for incomplete but not not full Kawasaki Disease:
12.3. Plan:
12.3.1. Your call Doc!
13. Re-evaluation:
13.1. Improved on re-evaluation.
13.1.1. On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with normal level of alertness, repeat cardio-pulmonary-abdominal exam benign, and parents are amenable to discharge after observation period in the ED.
13.1.1.1. Abdominal Benign. Repeat abdominal exam did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
13.1.2. Respiratory status
13.1.3. No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.