Peds ED Focused H&P:
HPI: 27 m/o African American M with no significant PMHx returns to peds ED this morning with father, c/o persistent fever despite medication. Patient seen 2 days ago (8/29/20) in QHC peds ED by Dr. Sherman for fever and ear pain x 1 wk. Dx’d acute otitis media b/l. Rx’d Amoxicillin, Ibuprofen, and Dimetapp. Father reports persistently elevated temperature, increased from 103 to 105 at home. Responds to ibuprofen, but returns to 104-105 within 5-6 hrs. Father reports compliance with medications from previous visit. Last doses of Amox and Ibu given last night at 10 PM. Parents decided to return to ED this morning as temperature remains elevated to 105 F oral. Father denies vomiting or diarrhea, 3-4 diapers daily, tolerating liquids.
PMHx: No significant PMHx noted. Pt cesrian delivery. Up to date on vaccinations. No immunocompromised.
PSHx: No surgical history.
Medications:
- Amoxicillin 400 mg PO BID x 10 days (indication – acute OM)
- Deimtapp (brompheniramine-phenylephrine) 1-2.5 mg/5mL PO Q 8hrs PRN (indication – cough/congestion)
- Ibuprofen 140 mg PO Soln Q 6 hrs PRN (indication – fever)
Allergies: NKDA.
FamHx: non-contributory.
SocHx: No recent travel. No one else at home sick. No known COVID contacts.
ROS: Significant for decreased appetite and fever.
PE:
- GenSurv: Pt active, alert, crying loudly. Resistant to exam. Appears well developed for age.
- VS: Rectal temp 105. HR 158. Resps 26. O2 Sat 97% ORA.
- Skin: Very warm to the touch and diaphoretic. Good turgor. No jaundice, cyanosis, or rashes noted.
- HEENT: Nose normal. Mucus membranes moist. Mouth normal. TM dull, injected with straw-colored fluid b/l.
- Pulm: CTA b/l. No wheezing or adventitious sounds.
- Cardiac: Tachy above 120. S1, S2 present. No murmurs, rubs, or gallops noted.
- Abd: Soft, NTTP. BS x 4.
- Exts: FROM. 5/5 strength UE & LE b/l. No C/C/E. Distal pulses bounding. Cap refill <2 secs.
Labs:
- CBC w/diff: pending
- Blood C&S: pending.
- BMP: order d/c’d (insufficient draw)
Assessment: 27 m/o male with PMHx fever and OM presents for fever of unknown etiology refractory to medication.
Plan:
- Fever – 105 F rectal at registration. Ibu 150 mg PO soln given. Applied cold sponge bath. Reassess temperature. Consider NS IV 300 ml.
- R/O bacteremia – CBC w/diff, CMP, and blood cultures drawn. Empirical Ceftriaxone 752.5 mg IM given. CBC shows leukocytosis (14k) with elevated ANC (9.15) and bands (8%). No left shift.
- D/c amoxicillin. Continue Ibuprofen and temp monitor at home. Encourage fluid. RTC tomorrow for reassessment and second dose IM Ceftriaxone.
Article for Site Eval:
Bacteriologic and clinical efficacy of one day vs. three day intramuscular ceftriaxone for treatment of nonresponsive acute otitis media in children
- PMID: 11099083
- DOI: 10.1097/00006454-200011000-00003
Abstract
Background: One dose of intramuscular ceftriaxone has been recently licensed in the United States for the treatment of acute otitis media. However, data regarding the bacteriologic and clinical efficacy of this regimen in the treatment of nonresponsive acute otitis media are incomplete.
Objectives: To determine the bacteriologic and clinical efficacy of a 1-day 50-mg/kg vs. a 3-day 50-mg/kg/day intramuscular ceftriaxone regimen in the treatment of nonresponsive acute otitis media in children.
Patients and methods: In an open, prospective study 109 patients ages 3 to 36 months with culture-proved, nonresponsive acute otitis media were randomized to receive 1 (n = 49) or 3 (n = 60) 50-mg/kg/day intramuscular ceftriaxone doses, respectively. Middle ear fluid was aspirated for culture by tympanocentesis on the day of enrollment (Day 1); a second tympanocentesis with middle ear fluid culture was performed on Days 4 to 5. Additional middle ear fluid cultures were obtained if clinical relapse occurred after completion of therapy. Bacteriologic failure was defined by positive cultures on Days 4 to 5. Patients were followed until Day 28 after completion of therapy. Susceptibility of the middle ear pathogens was measured by E-test.
Results: Organisms recovered (n = 133) were Streptococcus pneumoniae (30 and 35 isolates for the 1-day and 3-day treatment group, respectively), Haemophilus influenzae (26 and 38, respectively) and Moraxella catarrhalis (n = 4). Of the 30 S. pneumoniae isolated from the 1-day group, 27 (90%) and 6 (20%) were nonsusceptible to penicillin and ceftriaxone, respectively; 9 of 27 (33%) were fully resistant to penicillin. Thirty-four (97%) and 6 (17%) of the 35 S. pneumoniae isolated from the 3-day group were nonsusceptible to penicillin and ceftriaxone, respectively; 16 of 34 (47%) were fully resistant to penicillin. Bacterial eradication of all H. influenzae and penicillin-susceptible S. pneumoniae was achieved in both treatment groups. Bacterial eradication of 14 of 27 (52%) and 33 of 34 (97%) penicillin-nonsusceptible S. pneumoniae was achieved in the 1-day and 3-day group, respectively. Seven (50%) of the 14 patients from the 2 groups who did not achieve bacterial eradication did not improve clinically on Days 4 to 5 and required additional ceftriaxone treatment.
Conclusion: The 3-day intramuscular ceftriaxone regimen was significantly superior to the 1-day intramuscular ceftriaxone regimen in the treatment of nonresponsive acute otitis media caused by penicillin-resistant S. pneumoniae.
Site Visit Summary:
I felt well prepared for both of my site evaluations on this rotation. My medication flashcards were appropriate and my article directly related to my case presentation from the first eval. A few areas I could improve on are how much detail to include in the assessment and plan portion of my H&P’s, most notably doses and timing of proposed medications.
My verbal presentation was confident, but I need to convey the important information more concisely. I will continue to improve my ability to edit myself and tailor my verbal presentations in a manner that is appropriate to the case being presented as well as the healthcare context (ED vs. NICU vs. outpatient primary care).
Typhon Rotation Totals:
Reflection on Rotation:
Pediatrics at QHC was the most diverse rotation so far. Diverse in terms of clinical context (emergency medicine, labor & delivery, NICU, and primary care) as well as patients (neonates, toddlers, children, and adolescents). The clinical approach towards problem solving is very different in peds based on context as well as the patients age. The health-related concerns and social issues of a teenager are very different than those of a 2-year-old, yet I might see both of these patients back-to-back in the peds ED or primary care setting.
Trying to establish rapport with young patients was fun and challenging. At first I wasn’t quite sure how to approach toddlers and children. After a few days I found that being overly cautious with my approach made kids nervous and even scared, and the best approach was to be confident and cheerful (when appropriate) as soon as I stepped in the room. This usually put parents’ minds at ease as well.
Parents were also an important resource, not only with eliciting history but also in explaining things to their children and showing them how stethoscopes and ophthalmoscopes work. I was fortunate in that I did not run into any argumentative parents, which for some reason I was worried would be a regular problem before this visit. Most parents were grateful for our services and at the very least willing to listen to whatever advice and counseling their children’s clinicians had to offer.
I found pediatrics to be one of the most uplifting specialties I’ve encountered so far on my rotations. I could see myself being very happy working with young patients in a general specialty such as EM, urgent care, or primary care.
