What’s Your Diagnosis? The Child With a Syndrome
March 17, 2021
Posted by Andy Jagoda MD in: What's Your Diagnosis , trackback
Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Pediatric Acute Demyelinating Syndromes: Identification and Management in the Emergency Department right.
Case Presentation: The Child With a Syndrome: Considerations for Management in the Emergency Department
A 13-month-old girl presents to the ED for evaluation of fever…
- Her fever began earlier in the day. It was treated successfully with acetaminophen but returned, prompting her parents to bring her to the ED. The girl is up-to-date on her immunizations. She has no past medical or surgical history. She has been tolerating an oral diet of formula and solid food, with no vomiting or diarrhea. She has been having good urine output, with wet diapers.
- Her vital signs are as follows: temperature, 38.7°C (101.7°F); heart rate, 125 beats/min; respiratory rate, 16 breaths/min; blood pressure, 96/60 mm Hg; and oxygen saturation, 100% on room air. The physical examination is unremarkable except for a hairy patch over her lower back in the midline, estimated at the S1-S2 location.
- You are concerned about undiagnosed spina bifida and a urinary tract infection. Upon questioning the father, he reports that the child has had 2 prior urinary tract infections that responded to antibiotics.
- As you leave the room, you ask yourself several questions: What laboratory testing is most appropriate in the evaluation of this patient? Should imaging studies, such as ultrasound, be performed? If the patient has an infection, which antibiotics are most appropriate? For outpatient management, what is appropriate follow-up? Does she need to see a specialist?
A bedside ultrasound demonstrated incomplete bladder emptying with a postvoid residual. The urinalysis was positive for nitrites, leukocyte esterase, and 50 WBC/HPF, with many bacteria. The girl was admitted for IV antibiotics. Outpatient evaluation confirmed a meningomyelocele in the sacral region. The patient and family were connected with a spina bifida specialist at a regional children’s hospital for co-management.