Case: 4-year-old with Fever Presents to Family Medicine Clinic

00:01 Hi.

00:02 We’re now going to move in to a module of different acute problems in family medicine.

00:08 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.

00:19 And I’m going to make this a little bit more fun by having some pictures and some cases.

00:23 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.

00:33 All right.

00:34 So, let's start with this little girl.

00:36 Very cute.

00:36 You’re seeing a previously healthy four-year-old.

00:39 She has a two-day history of fever.

00:40 The highest fever was 39°C.

00:43 And the fever partially or completely responds to treatment with acetaminophen.

00:48 How about getting some more history because that's not – doesn’t sound that unusual.

00:51 Kids get sick all the time.

00:53 But what else is going on? Well, we know the fever partially or completely responds to acetaminophen.

01:00 The only associate symptom is some nasal congestion and dry cough.

01:03 On examination, the child's temperature is 38.5°C in your clinic or ER right now.

01:09 Pulse is 110 bpm.

01:11 She’s sitting quietly.

01:13 She is attentive.

01:14 And the rest of her physical examination is normal.

01:17 So, let’s talk about the next best step in her care.

01:19 And I’m going to let you think about this for a second.

01:22 Feel free if you want to pause here and kind of think about the way you would approach this case.

01:25 And I’m going to through some of the key components of the history.

01:31 Okay.

01:32 So, as I said, four-year-olds, they get sick all the time.

01:36 It's estimated they may spend a third of the year either in illness or recovering from acute illness.

01:41 And that's usually going to be upper respiratory infections.

01:44 She had a fever yesterday.

01:46 It was a real fever, 39°C, but not overly high.

01:50 It responds to acetaminophen.

01:52 That's good news.

01:54 She has nasal congestion and dry cough.

01:57 Very typical.

01:57 Sounds like an upper respiratory infection to me.

02:00 She's febrile in clinic and you could think about maybe getting her some antipyretics acutely.

02:06 But her pulse, 110 bpm, high for an adult, not for a kid.

02:12 So, normal for a four-year-old.

02:13 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.

02:30 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.

02:42 So, not even seeing anything in tympanic membranes, in her oropharynx that really – or in her lung exam, for example, that gives me pause.

02:51 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.

03:00 Well, she has documented fever.

03:03 Maybe we should think about a urinalysis that we've missed and not diagnosed.

03:08 Maybe this could be the incipient stages of something terrible like a meningitis.

03:14 Those are really unlikely in the face of everything, even the minimal information that's presented right here.

03:21 So therefore, a further workup for this patient isn't really necessary.

03:26 The other domain I'd like to address is well, you can also go too far in terms of treatment.

03:31 Well, let's start alternating ibuprofen with the acetaminophen and put it on a fixed schedule.

03:36 There’s a good chance that her fever will resolve as her immune system responds to this infection in the next 24 hours.

03:43 So, putting her on scheduled drugs sounds like a lot.

03:46 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.

03:57 And, of course, ibuprofen can be added later if the fever is not responding.

04:02 And so, therefore, the answer is A, continued expectant management with antipyretics.

04:07 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.

04:18 Why? It's actually going to keep her safer.

04:21 We’re avoiding performing unnecessary tests that can have spurious findings.

04:26 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.