Medical opinion please :)

[cyanide12345678]

My little girl is 20 months, no Pmh. She has had URI symptoms for 13 days. After 4 days of URI symptoms, she started spiking fevers and looking slightly worse. She had consecutive fevers for 8 days. She has been afebrile for 36 hrs. Her t max last night was 100.1 degrees, so technically not 100.4. Clinically she looked amazing throughout as long as fevers were controlled with ibuprofen/tynelol. She has been afebrile without any antipyretics for 36 hrs now. My initial assumption was bacterial superinfection vs a lingering virus. Clinically she continued to look damn amazing. She did however have 3-4 days of bilateral eye crusting in the AM, concern for conjunctivitis, but there wasn't any conjunctival injection at all,, no fissuring of lips, no mucous membrane involvement, no skin rash, no lymphadenopathy. Questionably she has either 0 Kawasaki features or 1 if you give her the conjunctivitis given the discharge she had for 3-4 days.

At day 3 of fevers I had started azithro, course is complete, probably should have done amoxicillin, which she just started 48 hours ago when fevers did not resolve. Clinically treating a likely lung infection. Multiple family members coughing and with similar URI symptoms, both me and my wife. Getting covid swabbed tomorrow.

At day 7 of fevers, I was concerned enough that I went and got her a CBC, cmp, CRP, and ESR on an outpatient basis. I know she probably needs a cxr and UA, and a viral swab, but we are still debating if we need to take her to the ER because clinically she's looking great, running like a champ, eating fried chicken. She is literally dancing around the home today. PO Intake and urine output is fine too.

Today, is day 10, she is afebrile for 36 hours out of that, but depends if you call 100.1 a fever. I personally don't, but my pediatrician father in law disagreed with me, making me wonder if she needs an ER evaluation. Like I said, looking amazing, 6 doses of amoxicillin in 90 mg/kg/day have been given. Blood work is rolling back from labs done over the weekend. Esr 74, WBC 12.6, platelets 524. Crp pending. CMP completely normal - normal albumin, normal alt (supplemental criteria for incomplete kawasakis). Labs are attached below. basically the non specific acute inflammatory reactants are up.

I guess my question is, do we take her in to the ER with her still looking amazing based on an elevated esr and t max of 100.1 last night (which would be day 9 if you count that as a fever)? Tmax on day 8 was 101.1.so definitely down trending.

We just moved cities 3 weeks ago, so do not have any local pediatrician yet unfortunately so I had to order things myself.

My best bet is a pneumonia, she's just coughing away, and now better with amoxicillin.

Does she need an echo and ER evaluation given elevated inflammatory markers to make sure no incomplete kawasakis? That's really my only big question, but she literally looks too good for it. I've been leaning towards no, I had told myself that if she spikes a fever she goes in to the ER. So is 100.1 a fever lol.

Thoughts?

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[Birdstrike]

My advice, if you're concerned at all, is to have either a pediatrician or Emergency Physician who's not a family member (and not someone on SDN) evaluate your daughter. I have kids too, and yes, it's tempting to treat minor stuff. But once it gets beyond a quick-fix, and you're thinking about labs, x-rays and echoes, it's time to get her looked at by objective eyes. I always feel better when I do that. It's not a sign of weakness. It's a sign of self awareness, and concern for your child.

Personally call one of the pediatricians on staff, introduce yourself and see if they'll work your daughter in. If you're in a new town and the ER is your only option, then go to the ER. No one will judge you for, as a physician, saying, "Hey, I think she's fine, but I'd like a second look by an objective pair of eyes just to ease my mind, that I'm not missing something." I can think of 1,000 worse reasons for being in an ER.

As much as we think we're the best at treating those most important to us, we tend to oscillate between under-reacting and over-reacting without even realizing it. You'll feel better if you get a second opinion from someone other than yourself.

 

[VA Hopeful Dr]

My advice, if you're concerned at all, is to have either a pediatrician or Emergency Physician who's not a family member (and not someone on SDN) evaluate your daughter. I have kids too, and yes, it's tempting to treat minor stuff. But once it gets beyond a quick-fix, and you're thinking about labs, x-rays and echoes, it's time to get her looked at by objective eyes. I always feel better when I do that. It's not a sign of weakness. It's a sign of self awareness, and concern for your child.

Personally call one of the pediatricians on staff, introduce yourself and see if they'll work your daughter in. If you're in a new town and the ER is your only option, then go to the ER. No one will judge you for, as a physician, saying, "Hey, I think she's fine, but I'd like a second look by an objective pair of eyes just to ease my mind, that I'm not missing something." I can think of 1,000 worse reasons for being in an ER.

As much as we think we're the best at treating those most important to us, we tend to oscillate between under-reacting and over-reacting without even realizing it. You'll feel better if you get a second opinion from someone other than yourself.

This. I'm a family doctor and my kids still have an unrelated pediatrician but I take them to whenever I think they're sick enough to warrant intervention beyond Motrin.

 

[Apollyon]

This. I'm a family doctor and my kids still have an unrelated pediatrician but I take them to whenever I think they're sick enough to warrant intervention beyond Motrin.

It must be something in the water, where y'all live!

 

[thegenius]

My little girl is 20 months, no Pmh. She has had URI symptoms for 13 days. After 4 days of URI symptoms, she started spiking fevers and looking slightly worse. She had consecutive fevers for 8 days. She has been afebrile for 36 hrs. Her t max last night was 100.1 degrees, so technically not 100.4. Clinically she looked amazing throughout as long as fevers were controlled with ibuprofen/tynelol. She has been afebrile without any antipyretics for 36 hrs now. My initial assumption was bacterial superinfection vs a lingering virus. Clinically she continued to look damn amazing. She did however have 3-4 days of bilateral eye crusting in the AM, concern for conjunctivitis, but there wasn't any conjunctival injection at all,, no fissuring of lips, no mucous membrane involvement, no skin rash, no lymphadenopathy. Questionably she has either 0 Kawasaki features or 1 if you give her the conjunctivitis given the discharge she had for 3-4 days.

At day 3 of fevers I had started azithro, course is complete, probably should have done amoxicillin, which she just started 48 hours ago when fevers did not resolve. Clinically treating a likely lung infection. Multiple family members coughing and with similar URI symptoms, both me and my wife. Getting covid swabbed tomorrow.

At day 7 of fevers, I was concerned enough that I went and got her a CBC, cmp, CRP, and ESR on an outpatient basis. I know she probably needs a cxr and UA, and a viral swab, but we are still debating if we need to take her to the ER because clinically she's looking great, running like a champ, eating fried chicken. She is literally dancing around the home today. PO Intake and urine output is fine too.

Today, is day 10, she is afebrile for 36 hours out of that, but depends if you call 100.1 a fever. I personally don't, but my pediatrician father in law disagreed with me, making me wonder if she needs an ER evaluation. Like I said, looking amazing, 6 doses of amoxicillin in 90 mg/kg/day have been given. Blood work is rolling back from labs done over the weekend. Esr 74, WBC 12.6, platelets 524. Crp pending. CMP completely normal - normal albumin, normal alt (supplemental criteria for incomplete kawasakis). Labs are attached below. basically the non specific acute inflammatory reactants are up.

I guess my question is, do we take her in to the ER with her still looking amazing based on an elevated esr and t max of 100.1 last night (which would be day 9 if you count that as a fever)? Tmax on day 8 was 101.1.so definitely down trending.

We just moved cities 3 weeks ago, so do not have any local pediatrician yet unfortunately so I had to order things myself.

My best bet is a pneumonia, she's just coughing away, and now better with amoxicillin.

Does she need an echo and ER evaluation given elevated inflammatory markers to make sure no incomplete kawasakis? That's really my only big question, but she literally looks too good for it. I've been leaning towards no, I had told myself that if she spikes a fever she goes in to the ER. So is 100.1 a fever lol.

Thoughts?

I know you are a doctor. Honestly...based on your description she clearly doesn't have a medical emergency. I don't think you can even get an ECHO at the ER. I think 99/100 ER doctors would offer basic labs / CXR (probably purely because you are a physician) and then say please see an outpatient pediatrician. I just don't think emergency services are what's needed now.

It's not the workup you seek that I think is inappropriate. And I'm sure you have looked up the diagnostic criteria for Kawasakis. I'm not particularly confident that ER doctors can make a clinical diagnosis of Kawasakis's in the ER...we usually have a medium or strong suspicion for it and either admit or call the pediatrician (or whomever makes the diagnosis) to come consult in the ER.

I do hope she gets better.

I'm kind of surprised your pediatrician father-in-law says go to the ER. For what? EM docs don't have the skillset that you need. If your girl is eating fried chicken, what is an ER doc gonna do?

 

[gyngyn]

Closing. SDN is not for medical advice.