View source for MDM for different chief complaints (peds)

{{Peds top}} [[MDM for different chief complaints]]."
==Asthma Exacerbation - Mild==
_ y/o patient with history of asthma presenting with mild asthma exacerbation. Patient given albuterol, atrovent and steroids. Unlikely pneumothorax or pneumonia given history of asthma, physical exam findings and significant improvement with treatment. On re-assessment patient has normal vital signs without signs of respiratory distress or increased work of breathing.  _Patient and parents were given strict ED return precautions and agree with assessment and plan. _Albuterol rx refilled. Will follow-up with PMD in next few days.

==Asthma Exacerbation - Severe==
_ y/o patient with history of asthma presenting with severe asthma exacerbation. Vitals notable for tachypnea, hypoxia and tachycardia. _Patient was given albuterol, atrovent, steroids and epinephrine. On re-assessment the patient still has significant increased work of breathing and tight breath sounds. _ CXR negative for pneumonia or pneumothorax. Although patient does not require intubation at this time, they will be admitted for continuous albuterol treatment and close monitoring. Parents agree with this plan and all questions were answered. 



==Allergic Reaction/Anaphylaxis==


_ y/o patient presenting with allergic rxn/ anaphylaxis likely due to _. Patient presented with respiratory distress_ urticaria _ and GI symptoms. Patient immediately received epinephrine IM, benadryl IM/ IV, methylprednisolone IV, famotidine IV/PO. After receiving epi pt was tachycardic but that subsided. Patient’s respiratory distress improved after medication. Given sudden onset shortness of breath considered other diagnosis including foreign body aspiration (symmetric breath sounds), asthma exacerbation (unlikely given no hx of asthma and rash as well as rapid onset), and infection (pt not febrile and symptoms improved with anaphylaxis treatment). Will DC home with rx for epi-pen given that they have been symptoms free for at least 4 hours from initial presentation. Instructed to avoid offending agents and to follow up with an allergist for skin testing. _ Patient will be admitted given the severity of their initial presentation and since they _he/she required repeated doses of epinephrine IM or had poor response to initial treatment.


==Abdominal Pain (0 - 3 months)==

_y/o child presents with abdominal distension +/- vomiting and fevers. Patient has a _normal birthing history, no hx of NICU stay or other complications. Based on labs, abdominal KUB, ultrasound I have low suspicion for necrotizing enterocolitis, pyloric stenosis, volvulus, torsion, toxic megacolon, incarcerated inguinal hernia, constipation or acute gastroenteritis. _Patient was given antipyretic and oral rehydration solution. _Tolerated PO in department. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Will be discharged home with parents to f/u with their PMD. _ Will be discharged home with parents and return tomorrow for belly recheck. 


== Abdominal Pain ( 3 months - 3 years)==

_ y/o child presenting with abdominal pain +/- vomiting and fevers. Vitals are within normal limits, patient is non-toxic and tolerated PO. Less likely Intussusception given reassuring ultrasound, no hx of bloody stool, no asymptomatic periods between episodes, no lethargy or palpable mass. Meckel’s diverticulum is possible but would be atypical without a reported history of rectal bleeding. Volvulus and malrotation is unlikely given otherwise well-appearing patient without rigid/distended abdomen. I have low suspicion for appendicitis, torsion, HSP (no palpable purpura) and UTI (reassuring UA). Parents were notified that intussusception could potentially still be the source of the pain despite having a reassuring ultrasound on this visit. Should the patient appear to be in pain once again they were told to immediately return to ED again.

==Abdominal Pain (3 years - Adult)==


_y/o child presenting with abdominal pain +/- vomiting and fevers. Vitals are normal, patient is _non-toxic/toxic appearing. Abdominal exam without peritonitis or distension. _No Mcburney's tenderness, Murphys tenderness or flank pain. Unlikely appendicitis, UTI/Pyelo, cholecystitis given reassuring abdominal exam and labs/UA. Low index of suspicion for gynecological emergencies such as ovarian torsion, TOA or ectopic pregnancy. _Low index of suspicion for male genitourinary emergencies such as testicular torsion, paraphimosis, orchitis or epididymitis given reassuring exam and ultrasound findings. Unlikely DKA given normal POC glucose. Unlikely HSP (no palpable purpura, no joint pains or hematuria). Patient was given appropriate analgesia and passed the PO trial. They will follow up with their PMD and were given strict ED return precautions 


==Acute Gastroenteritis==

_ y/o patient presenting with nonbloody nonbilious vomiting _and nonbloody diarrhea most likely due to acute gastroenteritis. Pt has low grade fever, sick contacts with similar symptoms and no abdominal pain thus this likely does not represent an acute abdominal process such as appendicitis. Patient appears well hydrated and able to tolerate PO. _Patient appears clinically dehydrated and was given 20cc/kg fluid bolus along with antiemetic after which they were able to pass PO trial. Parents were informed about the importance of keeping the patient hydrated and washing hands to prevent it from spreading to others. Patient and family were told that this could represent early appendicitis and they were told to look out for symptoms such as RLQ pain and to promptly return to ED should this occur. They were also told to come back if the patient shows signs of dehydration (decreased wet diapers, darker urine, no tears) or can’t tolerate PO fluids. Parents understand and agree with the plan and will f/u with PCP this week. 


==Chest Pain/Palpitations==

_ y/o child presenting with chest pain/palpitations. Differential includes WPW, brugada, HOCM, ARVD, SVT, aortic dissection, endocarditis, myocarditis, pericarditis, GERD & musculoskeletal pain among others. _Vitals are normal and the patient is clinically well appearing. _No high risk features of chest pain such as: chest pain with exertion, chest pain with associated syncope, marfanoid body habitus, recent strep pharyngitis infection or family history of sudden cardiac death in relatives at a young age. Exam without murmurs, pericardial rub or CHF.  EKG is _ normal sinus rhythm, normal PR, qRS, QTc intervals, normal axis, normal ST-T wave intervals. There is no evidence of complete/incomplete bundle branch blocks, ST elevation, delta wave, epsilon wave, dagger-like Q-waves or SVT. _CXR negative for pneumonia, pneumothorax, pleural effusion or widened mediastinum. _ Cardiology was consulted, recommend_.  _Patient will be discharged home with PMD and/or cardiology follow up. 

==Conjunctivitis==


_ y/o patient with conjunctivitis likely bacterial vs viral. Based on history and physical exam doubt herpes simplex keratitis, gonorrheal conjunctivitis, chlamydial conjunctivitis, orbital cellulitis, acute angle closure glaucoma or  uveitis. No ocular trauma. Patient given _ for antibiotics and told to follow up with primary doctor. All questions answered. Patient and family agrees with assessment and plan. Strict ED return precautions were provided.

==Constipation==


_ y/o patient presenting with hard stools for _days. Stools are nonbloody and appears to be related to diet (_). I have very low suspicion for SBO, volvulus, cystic fibrosis, or Hirschsprung disease. Family was given tips to improve diet such as increasing water intake, increasing fiber and the 4 “P” diet (pears, plums, peaches, and prunes). Patient also given Rx for Miralax and the family was informed on how to use it. Family were given return precautions and told to f/u with PMD

==Croup==


_ y/o patient _ UTD on childhood vaccines presenting with _ days of barking cough and fever at home with_ stridor on exam most likely secondary to croup. Patient has no muffled voice or significant fever. Patient is nonseptic in appearance with no copious drooling or secretions. Doubt anaphylaxis, epiglottitis, bacterial tracheitis, laryngotracheomalacia, foreigh body airway obstruction, peritonsillar abscess, retropharyngeal abscess. Patient was given dexamethasone, racemic epinephrine and observed in ED for 3 hours. Will DC home with rx for a second dose of dexamethasone in 72 hours. _ Will admit given patients persistent respiratory symptoms, stridor at rest and requiring  ≥2 treatments with epinephrine. Family agrees with plan.


==Fever==

_ y/o patient _ UTD on childhood vaccines, otherwise healthy, full term presenting with fever. Currently well appearing and nontoxic. Given history and exam, low suspicion for serious bacterial infection including meningitis, pneumonia, or bacteremia. No meningismus, otherwise at baseline activity level with low suspicion for CNS infection. Query likely viral etiology. Discussed low risk but possible UTI and offered urine sampling, _ UA performed, _UA deferred after shared decision making with parents. No evidence of strep pharyngitis at this time. No evidence of torsion. Given history and exam, no overt evidence of emergent intrabdominal process, corneal abrasion or tourniquets causing fussiness.Fever resolved with antipyretic. Patient now consolable and well appearing in ED.  Patient is tolerating PO and appears well hydrated. Discussed alternating tylenol and ibuprofen as directed over the counter for antipyresis.

Discussed strict return precautions for worsening of symptoms, increased respiratory effort, signs of CNS infection including but not limited to changes in mental status or vomiting, or fever for more than 5 days. Discussed prompt follow up with primary pediatrician in 24-48 hours for recheck or return to ED sooner if concern or if cannot schedule appointment. 


==Febrile Seizure==

_ y/o patient presenting with febrile seizure. Patient had one episode of simple seizure that lasted less than 5 min and did not recur or require antiepileptic treatment. No apparent underlying cause of seizure and no postictal state. Patient has no evidence of meningitis (HA, photophobia, neck stiffness or AMS), no focal neuro exam to indicate mass, no hx of epilepsy and no altered status to indicate hypoglycemia or electrolyte abnormality. Given that the patient is not immunocompromised and at an appropriate age w/o evidence of meningeal signs, LP was deemed inappropriate for this patient. Patient was treated with antipyretics and was well appearing in ED. Family reassured and told to f/u with PMD and return if another seizure occurs within 24 hours or pt appears ill or has any other concerning symptoms. Family agreed with plan and all questions were answered. 

==Head Injury - Low Risk==

_ y/o patient presenting with head trauma. Given mechanism, history, and physical exam findings, I have a low suspicion for intracranial hemorrhage, basilar skull fracture, increased intracranial pressure/impending herniation, DAI, non-accidental trauma or c-spine injury. Patient’s GCS is 15, mechanism is low energy and there is no history of LOC . Based on PECARN rules, the patient has a low risk of serious intracranial injury and therefore CT head is NOT recommended. Patient is well appearing and tolerating PO with no other injuries. Patient is safe for DC home at this time. _Patient was observed for 4-6 hours in the department then discharged home. Patient and family were advised to f/u with PMD and instructed on appropriate return precautions. 



==Head Injury - High Risk==


_ y/o patient presenting with very concerning story for a serious intracranial injury. Unable to clear patient with PECARN rules given that HPI and exam were notable for _. Will obtain CT imaging of head & neck to rule out intracranial injury or C-spine injury. Patient is protecting their airway and otherwise has an unremarkable secondary trauma survey. C-collar in place. CT imaging shows _. 

_Neurosurgery emergently consulted. _Patient admitted for overnight observation given persistent neurologic deficits. _Patient observed in ER for 4-6 hours, C-collar removed and was discharged home with close PMD follow up. 


==Otitis Media==


_ y/o patient _UTD on childhood vaccines presenting with L/R ear pain found to have acute otitis media. No evidence of mastoiditis, sinusitis and patient at baseline mental status making intracranial abscess, meningitis unlikely. Patient tolerating POs. Pain controlled in emergency room and parents instructed on outpatient pain control. Parents given strict return precautions and agreed with assessment and plan. Antibiotics _


==Sore Throat==

_ y/o patient presenting with sore throat. Vitals within normal limits. Unlikely strep throat: No LAD, cough present, afebrile, no pharyngeal exudate. Unlikely EBV/Mono: No prolonged course, no posterior LAD, no splenomegaly. No peritonsillar abscess: No LAD, no hot potato voice, no uvular displacement, no redness or swelling in tonsillar area, afebrile. No retropharyngeal abscess: No neck pain with movement, no dysphagia, no LAD, no croup like cough, afebrile. No obstructive processes such as obstructive goiter or ludwigs angina. Patient was given appropriate analgesia _and dexamethasone. Will DC home with PMD follow up and strict ED return precautions. 

==Toxic Ingestion==

_ y/o patient ingested _ [insert quantity + ingested object] approximately _ minutes_hours ago. Patient is _non-toxic appearing. Core temperature is normal. No evidence of tachycardia, bradycardia, tachypnea or bradypnea. Pupils are normal in size. Skin is normal; not dry or diaphoretic. No evidence of lethargy, or agitation. Bowel sounds are normal. Offending agent was removed. Poison control contacted_ . _ activated charcoal given. Labs including cbc, bmp, VBG, urine tox, salicylate, acetaminophen and lactate were normal.  EKG is normal and without evidence of QTc or QRS prolongation.  _Patient was admitted for further observation. _Patient was discharged home after being observed for 4-6 hours in the department. Will D/C home with close PMD follow up. 


==UTI==

_ y/o patient presenting with fever and malaise concerning for UTI. _Patient is UTD on immunizations, otherwise healthy, not immunocompromised. _Patient is circumsized. _ Patient is uncircumsized. Patient is extremely well appearing, mentating well, at baseline per parents, lucid and without meningeal signs. Nonfocal neuro exam with low suspicion for CNS infection. No respiratory distress with low suspicion for pneumonia. No abdominal pain and benign abdominal exam with low suspicion for atypical appendicitis. No overt findings for vulvovaginitis_. UA with WBC, leuk esterase, nitrites and bacteria. Urine culture was sent. Will treat with Keflex_ . Tolerating PO including juice and crackers in ED. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Appendicitis return precautions discussed.
 

==Viral URI==

_ y/o child who is _ UTD on childhood vaccines presenting with cough, nasal congestion, fever and fussiness. Patient was given antipyretic with resolution of fever and improvement in vital signs. Exam without evidence of pharyngitis, acute otitis media, meningeal signs (neck stiffness, non-blanching maculopapular rash, brudnizki or kernig sign) or Kawasaki disease  (bilateral conjunctivitis, mucosal lesions, cervical adenopathy or extremity changes). Viral respiratory panel _negative for SARS-COVID 19, RSV, Influenza A/B. Parents were instructed appropriate hydration and alternating Tylenol and Motrin (if > 6 months of age). Strict ED return precautions were provided. 



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[[Category:Pediatrics]]