What’s Your Diagnosis? A 6-Month-Old Boy Who Presents With Poor Weight Gain
March 3, 2020


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Welcome to this month’s What’s Your Diagnosis Challenge!

Case Presentation: a 6-month-old boy who presents with poor weight gain

Your first patient is a previously healthy, vaccinated 6-month-old boy who presents with poor weight gain. The child has been seen by his primary care provider multiple times within the last several weeks, and the mother is very concerned because he has not shown any improvement. read more

What’s Your Diagnosis? Diagnosis and Management of Acute Gastroenteritis
February 24, 2020


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Welcome to this month’s What’s Your Diagnosis Challenge!

Case Presentation: Diagnosis and Management of Acute Gastroenteritis

You are working in the ED on a busy morning when you meet an otherwise healthy 42-year-old man reporting 2 days with 5 to 10 watery, nonbloody, unformed stools and persistent nausea, anorexia, and 1 to 2 episodes of nonbloody emesis each day. He is mildly tachycardic, but afebrile, and is normotensive. He is alert and conversant but appears mildly uncomfortable. He has dry mucous membranes and diffuse abdominal pain, with minimal tenderness on exam. He denies any recent hospitalizations, antibiotic use, foreign travel, or sick contacts. read more

Clinical Pathway for Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
February 18, 2020


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Click to review the Clinical Pathway for Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Hyperglycemic emergencies ? diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) ? are common presentations in the ED that require swift, specialized management strategies. Uncovering the precipitating event is critical to management, as morbidity and mortality are related more to the trigger than the DKA/HHS itself. read more

Test Your Knowledge: Rash and Fever in the Pediatric Patient
January 21, 2020


Posted by Andy Jagoda, MD in: Brain Tease , 1 comment so far

Rash and fever are some of the most common chief complaints presenting in emergency medicine. The evaluation of skin rashes in the febrile pediatric patient includes a broad differential diagnosis and utilizing the signs and symptoms to identify red flags, such as hemodynamic instability, erythroderma, desquamation, petechiae/purpura, mucous membrane involvement, and severe pain, in the history and physical examination that require a high index of suspicion for worrisome disease.

Test your knowledge of characteristics of common rashes in a pediatric patients!

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Review this Pediatric Emergency Medicine Practice issue to get up-to-date on common and life-threatening skin rashes with fever in children, guidance for differentiating the types of infections based on signs and symptoms, indications for diagnostic studies, and recommendations for treatment of pediatric skin rash with fever in the emergency department.

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What’s Your Diagnosis? A 1-year-old Boy With Rhinorrhea
January 3, 2020


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Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check out if you got last month’s case right, about a 4-year-old with fever, right leg pain, and difficulty walking. Click here to check out the answer!

Case Presentation: a 1-year-old boy with rhinorrhea, congestion, cough, and fever

You arrive to a busy afternoon shift in the ED. Your first patient is a 1-year-old boy with rhinorrhea, congestion, cough, and 3 days of fever up to 39.4?C (103?F), measured rectally. His parents state that he has been playful at home and continues to eat and drink normally. They have been giving him acetaminophen and ibuprofen sporadically, but today he developed a generalized rash, and they became concerned. His vital signs are as follows: temperature, 38.7?C (101.7?F); heart rate, 135 beats/min; and blood pressure, 85/55 mm Hg. On examination, the rash is macular, erythematous, and blanching, but his eyes and mouth appear normal.

Does he need laboratory workup, or can you safely offer supportive care? Should he be on isolation, either for his own safety or for the safety of others? read more

Test Your Knowledge: Pediatric Septic Arthritis and Osteomyelitis Management in the ED
December 18, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Patients with SA or OM classically present with fever, ill appearance, malaise, pain, and swelling of the involved joint. Given the large differential diagnosis for a limping child, obtaining a thorough history and physical examination is paramount to narrowing the differential diagnosis and to obtain the appropriate testing and treatments.

Test your knowledge!

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Review this Pediatric Emergency Medicine Practice issue to get up-to-date evidence-based recommendations for the diagnosis and management of pediatric patients with septic arthritis and/or osteomyelitis and offers guidance for appropriate antibiotic treatment.

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Pitfalls To Avoid With Septic Arthritis And Osteomyelitis In Pediatric Patients
December 11, 2019


Posted by Andy Jagoda, MD in: Risk Management Pitfalls , add a comment

Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other.

The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial.

These risk management pitfalls will help you avoid unwanted outcomes in pediatric patients with septic arthritis and osteomyelitis in your ED.

1. ?The patient did not have a fever, so I attributed the pain to minor aches and pains.? read more

Influenza Risk Management Pitfalls to Avoid in the Emergency Department
December 11, 2019


Posted by Andy Jagoda, MD in: Risk Management Pitfalls , add a comment

Patients presenting to the ED with ?influenza-like illness? (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management.

Because influenza infections can present with a wide range of nonspecific clinical signs and symptoms and numerous possible complications, emergency clinicians must be keenly alert to this possible diagnosis. A knowledge of the local seasonal prevalence of influenza as well as the specific strains circulating within a particular region are crucial for appropriate diagnostic and treatment decisions and will help to limit unnecessary testing when empiric therapy would be more appropriate.

These risk management pitfalls will help you avoid unwanted outcomes when treating a patient with a flu-like symptoms in the ED.

1. ?The fever was low-grade; I thought the baby just had a cold.?
The presenting signs and symptoms of influenza infection are nonspecific, and a diagnosis based on clinical presentation alone becomes less accurate in children aged < 3 years. Although many children will experience a mild disease course and can be managed with supportive therapy, patients aged < 2 years are at high risk for a more severe clinical course. Be vigilant and have a high index of suspicion for possible influenza infection in high-risk populations, especially when disease prevalence is high.

2. ?The patient had an infiltrate on chest x-ray, so bacterial pneumonia appeared to be the clear diagnosis.? read more

What’s Your Diagnosis? A 4-year-old with fever, right leg pain, and difficulty walking
November 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case right, about a 7-year-old boy after a generalized seizure lasting 2 minutes Click here to check out the answer! read more

Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients
November 7, 2019


Posted by Andy Jagoda, MD in: Clinical Pathways , add a comment

Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness.

Acute bronchiolitis is the most common lower respiratory tract infection in young children that leads to emergency department visits and hospitalizations. Bronchiolitis is a clinical diagnosis, and diagnostic laboratory and radiographic tests play a limited role in most cases. While studies have demonstrated a lack of efficacy for bronchodilators and corticosteroids, more recent studies suggest a potential role for combination therapies and high-flow nasal cannula therapy. Frequent evaluation of patient clinical status including respiratory rate, work of breathing, oxygen saturation, and the ability to take oral fluids are important in determining safe disposition.

This summary of the treatment recommendations for pediatric bronchiolitis, supported by various guidelines provides, a systematic approach to ED assessment of such patients.

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Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients

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