(Credit to Dr Kelly Young, author or pemsoure.org, attending at Harbor-UCLA Peds ED. From Pediatric Emergency Medicine Conference Lecture Series)
Pertinent positives/negatives:
_
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TMs: no effusion, non-erythematous
Neck: supple
Oropharynx: no oral lesions, no evidence of pharyngitis
Lymph: No palpable lymphadenopathy
GU: Normal appearing genitourinary exam without abnormalities
GI: Abd soft, non-tender
Complaint specific findings on exam:
No hair torniquetts, No palpable deformities. No signs of trauma. No rashes, No injected sclera.
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ED COURSE:
MDM (with A/P):
_
presentation is most consistent with
_ Assessment: non-toxic, consolable , content when not being irritated infant
Given the above assessment, most diagnoses are elucidated on a careful history and physical exam and as such no further and diagnostics are indicated at this time , anticipatory guidance, and specific return precautions discussed with parents.
_ Assessment: non-toxic, consolable but fussy infant.
Given the above assessment, most diagnoses are elucidated upon the history, physical exam, period of observation, urinary analysis, flourescein exam.
_ non-infectious UA
_ eval for corneal abrasion:
_ no e/o corneal abrasion on fluorescein exam
_ with empiric opthomologic analgesic, no improvement suggestive that ocular pain is less likely source of pt’s fussiness
_ History: No identifiable source of fussiness on history
_ Exam: No identifiable source of fussiness on exam
_ assessment: persistently irritable and crying infant.
Given the above assessment pursued thorough investigation including:
birth history including drug use, maternal infection, trauma
Feeding evaluation:
Ensured that if parents use formula, ensured that parents educated on 2 ounces of formula were mixed with 1 ounce of water
Ensured that infant was gaining approximately 20 to 30 g per day and at birth weight by 10 weeks
evaluated on physical exam for possible ocular injury including retinal hemorrhage, forcing exam for corneal abrasion , hair tourniquet, Detailed genitourinary exam, and palpation on all long bones and joints for possible occult trauma
Investigated for underlying cause including laboratory analysis , EKG, Urine toxicology screen, urine analysis, skeletal survey, lumbar puncture
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does NOT meet our criteria for being reasonable for additional pursuit of these entities at this time
Infection:
sepsis, bacteremia, UTI, PNA, OM, meningitis
GI: intra-abdominal pathology, genitourinary pathology, improper feeding/nutrition
GU: torsion, rash,
Other:
nonaccidental trauma, hair tourniquet, corneal abrasion,
Disposition: home with pediatrician follow-up
_ On a detailed history and physical exam, there were no diagnoses elucidated. Given assessment as above, patient appears to be at sufficiently low risk for malignant process to be appropriate for prompt follow-up with pediatrician. Possible colic however given this is a diagnosis of exclusion requiring greater than three hours of crying per day greater than five days per week in the age range of three weeks to three months, will defer to primary pediatrician for additional serial evaluation and definitive diagnosis.