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Acute Problems: A Child with Fever – Family Medicine | Lecturio

November 15, 2019


Hi. We’re now going to move in to a module
of different acute problems in family medicine. And I thought it might be worthwhile before we begin to just reiterate the general approach that
a family doctor would take to acute management of problems. And I’m going to make this a little bit more fun by having some pictures and some cases. So, as we go through, feel free to pause and reflect about
the way you would think about a case, and then we can go through some of the
answers that we have for some of our questions. All right. So, let’s start with this little girl. Very cute. You’re seeing a previously
healthy four-year-old. She has a two-day history of fever. The highest fever was 39°C. And the fever partially or completely
responds to treatment with acetaminophen. How about getting some more
history because that’s not – doesn’t sound that unusual. Kids get sick all the time. But what else is going on? Well, we know the fever partially or
completely responds to acetaminophen. The only associate symptom is
some nasal congestion and dry cough. On examination, the child’s temperature is 38.5°C
in your clinic or ER right now. Pulse is 110 bpm. She’s sitting quietly. She is attentive. And the rest of her
physical examination is normal. So, let’s talk about the
next best step in her care. And I’m going to let you
think about this for a second. Feel free if you want to pause here and kind of think about the
way you would approach this case. And I’m going to through some of
the key components of the history. Okay. So, as I said, four-year-olds,
they get sick all the time. It’s estimated they may spend a third of the year
either in illness or recovering from acute illness. And that’s usually going to be
upper respiratory infections. She had a fever yesterday. It was a real fever, 39°C, but not overly high. It responds to acetaminophen. That’s good news. She has nasal congestion and dry cough. Very typical. Sounds like an upper
respiratory infection to me. She’s febrile in clinic and you could think about maybe
getting her some antipyretics acutely. But her pulse, 110 bpm, high
for an adult, not for a kid. So, normal for a four-year-old. One thing I’m missing in the
history is her other related symptoms, what’s her intake been like
in terms of food and liquids, sick contacts, but doesn’t necessarily change
my management for this patient, especially as I get to the physical exam. Is she not – is she really soporific? Is she not able to
respond to you? No, she is quiet, but she’s attentive, and she’s got normal
physical examinations. So, not even seeing anything
in tympanic membranes, in her oropharynx that really – or in her lung exam, for
example, that gives me pause. So, this is a – it’s natural to want to do something
to help and to go beyond, and maybe that means something more
in terms of the diagnostic realm. Well, she has documented fever. Maybe we should think about a urinalysis
that we’ve missed and not diagnosed. Maybe this could be the incipient stages
of something terrible like a meningitis. Those are really unlikely
in the face of everything, even the minimal information
that’s presented right here. So therefore, a further workup for
this patient isn’t really necessary. The othe domain I’d like to address is well, you can also go too
far in terms of treatment. Well, let’s start alternating ibuprofen with
the acetaminophen and put it on a fixed schedule. There’s a good chance
that her fever will resolve as her immune system responds to
this infection in the next 24 hours. So, putting her on scheduled
drugs sounds like a lot. She’s probably not completely
happy because she’s sick, but if she can take it as needed and the fever responds, then I think it’s fine to continue
just with acetaminophen. And, of course, ibuprofen can be added
later if the fever is not responding. And so, therefore, the answer is A, continued
expectant management with antipyretics. And so again, doing as much
intervention as is necessary, but not overextending ourselves in terms of the diagnosis
or the therapeutics in cases like this is really important. Why? It’s actually going to keep her safer. We’re avoiding performing unnecessary tests
that can have spurious findings. We’re avoiding adding treatment
that may give her more side effects without really helping the goal of having
her feel better or avoid complications.

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