All posts with tag: "id"

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You are seeing an 8 year old girl with fever of unclear etiology for 7 days. She is well appearing. Exam reveals 1-2cm tender nodes in her left axilla and left anterior cervical areas. She has a superficial healing scratch on her left forearm, and history reveals that she has been spending time at a cousin’s house with the cousin’s new kitten. She is also noted to have hepatomegaly 2cm below the right subcostal margin, and a palpable spleen tip. She has no petechiae or purpura. The remainder of her exam is noncontributory. 

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You are evaluating a 10 year old patient who had a bone marrow transplant 2 months ago. The patient is presenting with low-grade fever, a maculopapular rash on the nape of the neck, shoulders, palms, and soles as well as nausea, vomiting, and diarrhea. The patient owns a cat but is not involved in caring for it and does not have it sleep with him. 

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During the recent “tri-demic” of influenza, RSV, and COVID disease, there was also a nationwide shortage of common oral liquid antibiotics used to treat otitis media. Which of the following antibiotics is recommended in the 2013 AAP guidelines as an alternative to amoxicillin to treat acute otitis media?

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COVID is on the rise again, with a more transmissible and immune-evading variant. Nirmatrelvir-ritonavir (brand name Paxlovid) is approved for children 12 years and older AND weighing 40 kg or more in high-risk situations.

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We are currently experiencing a “tridemic” of influenza, RSV, and COVID-19.

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You are seeing an 8 year old male with 3 days of progressively worsening redness, tenderness, and swelling of his right index finger proximal lateral nail fold and adjacent skin. The central portion of the swollen area shows a small amount of subcutaneous purulent fluid. He is right-hand dominant, otherwise healthy, and is afebrile. He admits to having a habit of biting his fingernails.

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It’s summertime, and you are seeing a 15 month old with fever and papulovesicular lesions on the palms, lateral borders of the feet and soles, and buttocks, as well as vesicles in the posterior pharynx. 

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A 17yo boy presents with fever, myalgias, headaches, swollen cervical lymph nodes, and a maculopapular rash that became vesiculopustular on his face, torso, and extremities including palms and soles. You are working in a small community ED. The triage nurse expresses concern for monkeypox. 

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You are seeing an 8 year old girl who was prescribed an oral cephalosporin antibiotic 1 week ago for rhinitis. She has 3 more days until she finishes the course. Now she has developed an itchy urticarial-like rash, although it is more fixed than urticaria typically are (does not move around nor come and go). She also has some generalized mild arthralgias and a low-grade fever to 100.2 F. 

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A 6 month old female infant is referred in from PMD for concerns regarding the GU exam. Physical examinations at the 2 and 4 month old visits were normal. There are findings of concern for an STI. 

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You are seeing a 10 month old infant with one day of fever, purpuric rash, and subcutaneous edema of bilateral extremities. He was seen in the ED one week ago for cough and congestion and diagnosed with a viral URI. At that time, COVID, influenza, and RSV were negative. On exam, his temp is 39.1. He has multiple, scattered, annular, sharply demarcated hemorrhagic plaques, mainly on his cheeks and bilateral extremities, lower > upper. He is otherwise well appearing and remainder of the physical exam is unremarkable. CBC including platelet count, CMP, coags, DIC panel, CRP, UA, and CSF were all normal.

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A seven day old neonate is brought in for a fever of 38.5 and lethargy. The baby had a home birth, and the parents have chosen a “lotus birth,” or umbilical nonseverance. The placenta remains attached to the newborn (carried around with the baby, often in a small bag), until it separates on its own, typically in 5-15 days. 

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You are seeing a 12 year old child that presents with altered mental status, fever, and history of headache and vomiting before the decline in mental status. The patient has a seizure on arrival to the ED, which resolve with lorazepam IV. The CT scan shows evidence of a subdural fluid collection. The lumbar puncture results show a neutrophilic pleocytosis with an elevated protein. Gram stain is negative. 

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What are pediatric emergency physicians seeing more of when COVID prevalence rises?

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You are seeing a 10 day old ex-full term infant with bilateral watery mucoid eye discharge, mild eyelid edema, and papillary conjunctivitis. You suspect chlamydial conjunctivitis. What is the best management?

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You are seeing a 7 year old boy who presents with dark coca-cola colored urine and puffy eyes. You suspect glomerulonephritis. Which of the following is NOT consistent with post-streptococcal glomerulonephritis (the most common cause of acute nephritis in children worldwide)?

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You are seeing a toddler with 2 days of cough, congestion, and low-grade fever, who now presents with a worsened barky cough. His vital signs in the ED are temp 38.3 C, HR 110, RR 26, BP 80/40, O2 sat 96% on room air. He has stridor when crying but none at rest. He has no history concerning for foreign body aspiration. He is not happy to be in the ED but is not toxic appearing. He is fully immunized and has no significant past medical history. 

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You are seeing a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever. 

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You are seeing a 3 year old girl who was discharged from the hospital a week ago. At that time, she presented with fever, intermittent polyarthralgias, and an evanescent salmon pink rash. She was diagnosed with new onset systemic juvenile idiopathic arthritis, treated with ibuprofen, and initially did well. She now presents with unremitting fever and rash, bruising, petechiae, gum bleeding, hepatosplenomegaly, and lethargy. Labs reveal elevated transaminases, ferritin, LDH, and triglycerides, but a low ESR.

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Your ED is providing patients who are eligible and interested in receiving the COVID-19 vaccine the opportunity to receive the 1^st dose of an mRNA vaccine approved for age 12 years and older during the ED visit. 

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You are seeing a 3 year old ex-premature infant who has a ventriculoperitoneal shunt in place. The patient presents with fever to 38.3, cough, and runny nose. There is no headache, vomiting, or altered mental status. The shunt was placed initially while in the NICU, and revised 4 months ago. 

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You are seeing a previously healthy 9-month old boy brought in for rash. The child had 3 days of fever. He was seen yesterday evening at an urgent care and diagnosed with otitis media and prescribed amoxicillin. He has never taken any antibiotics before. This morning, his fever was gone, but he developed a blanching pink maculopapular rash on the torso that spread to the extremities and face later in the afternoon. He does not seem to be itchy. He has been well appearing and eating normally throughout his illness. 

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You are seeing a 4 month old infant with fever, nasal congestion, and cough for 2 days. The baby is a previously well ex-full term infant with no past medical history, up to date on immunizations. He has been slightly less than usual but still having several wet diapers per day, and is still playful and interactive. On exam, his temperature is 38.4C, HR 135, RR 48, BP 80/40, and O2 sat 93% on room air. He has diffuse mild wheezes and minimal subcostal retractions, but no grunting, nasal flaring, stridor, cardiac murmur, hepatomegaly, or evidence of dehydration. There is no personal or family history of prior wheezing. His parents are able to return to the ED if necessary and can arrange follow-up with their pediatrician. 

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You are caring for a 19 year old woman who is breastfeeding her 2 month old infant. She has a superficial 2cm breast abscess located on her inferior breast with minimal overlying cellulitis and no involvement of the nipple. She is nontoxic, afebrile, and not septic appearing. Which of the following ED management choices is most appropriate and most likely to result in rapid improvement?

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 day old infant born via midwife-assisted water birth at home, brought in for lethargy and vomiting. Physical exam is significant for lethargy, jaundice, and fever to 38.5. He is exclusively breastfeeding. Labs include pH 7.34, ammonia 80, point of care glucose 80, urine trace ketones. [yop_poll id="172"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with 2 days of left eye redness and pain, and 1 day of fever. She recently got a new kitten and had been having itchy eyes and nasal congestion for the last 2 weeks. Her temperature is 38.3, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. She is alert, has no nuchal rigidity, and is not toxic appearing. She has left periorbital edema and erythema but her eye can be manually opened. She is PERRL, has no chemosis or proptosis, and has mild conjunctival injection but no discharge. Her extraocular movements are full, but she complains of pain with extraocular movements. Her vision is 20/20 on the right and 20/60 on the left. [yop_poll id="154"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 14 year old boy who hiked in the snow yesterday with inadequate warm clothes and footwear. He has developed swollen violaceous papules and nodules on the toes of both feet. He states that the areas are itchy and sometimes have a burning sensation. Which of the following courses of action would be appropriate?

1. Advise him to avoid further cold exposure and to use appropriate protective footwear
2. Perform gentle rewarming in 37 to 39 degree Celsius water
3. Perform a COVID-19 test
4. Reassure him that this is a benign Raynaud phenomenon

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(Click the link to comment and to vote – voting not working through email, sorry!) A 2yo child presents with a 1.5cm diameter erythematous tender fluctuant swelling in the right preauricular area. There is a small pinhole sized indentation in the center. Which of the following is not appropriate management? [yop_poll id="148"]

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Match the child with acute otitis media to appropriate therapy per AAP guidelines (all children well-appearing, non-toxic, no distress or indications of severe otalgia, symptomatic for 1 day, and have not had recent antibiotics in the last 30 days):

Child A) 5mo old with bilateral otitis media, afebrile

Child B) 18mo old with unilateral otitis media, fever to 38.5, penicillin-allergic

Child C) 27mo old with bilateral otitis media and bilateral purulent conjunctivitis and fever to 39.1

Child D) 37mo old with unilateral otitis media, fever to 39.5, penicillin-allergic

1. Oral analgesic
2. Amoxicillin 90 mg/kg/day divided BID
3. Amoxicillin-Clavulanate 90 mg/kg/day divided BID
4. Cefdinir 14 mg/kg/day

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(Click the link to comment and to vote - voting not working through email, sorry!)A recent JAMA article summarized China’s experience with 72,314 COVID-19 novel coronavirus cases (Wu & McGoogan, JAMA 2020 Feb 24 [Epub ahead of print]). Which of the following is true? [yop_poll id="141"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 12mo old child with immunizations up to date presents with fever and rash. Which of the following distributions is concerning for measles? [yop_poll id="139"]

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(Click the link to comment and to vote - voting not working through email, sorry!) Pediatric patients with sickle cell anemia have a higher susceptibility to becoming infected with which organism? [yop_poll id="136"]

(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy comes in with 2 days of fever, chills, myalgias, headache, and a few episodes of non-bloody, non-bilious vomiting. He also has a faint maculopapular rash beginning on his legs. It is influenza season. He has no past medical history. He was bitten 4 days ago by the class pet rat that the teacher bought from a commercial pet store the week before. He went hiking 3 days ago and to Disneyland 2 days ago. He has no drug allergies and takes no medications. [yop_poll id="134"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air. [yop_poll id="126"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2.5 month old baby who underwent a fever work-up yesterday and has been called back due to a positive blood culture growing gram positive cocci in clusters. The baby received the first set of immunizations at age 7 weeks. The baby is afebrile today and has been doing well and eating normally. The only treatments have been acetaminophen, last given 8 hours ago. [yop_poll id="122"]

(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis?

1. Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup
2. Children with bacterial tracheitis do not respond as well to racemic epinephrine and steroids as children with viral croup
3. Children with bacterial tracheitis may have a “steeple sign” on xray
4. Children with bacterial tracheitis most commonly have Strep pneumoniae infection

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(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="116"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 12 year old girl with PMH of sickle cell disease complicated only by 2 lifetime hospitalizations for vasoocclusive pain crisis. She presents with fever, cough, and increasing shortness of breath over the last 2 days. Her mother was recently diagnosed with influenza. CXR shows a right upper lobe infiltrate. Vital signs are: temperature 38.8, HR 130, RR 30, BP 110/60, O2 sat 96% on room air. Hemoglobin is 9 g/dL, which is the patient’s baseline. [yop_poll id="114"]

(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="113"]

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 month old with symptoms consistent with varicella. The infant is well-appearing, has no complications, and is 3 days into her illness. Her mother is pregnant. [yop_poll id="102"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a child with fever and rash x 1 day. Cognizant that we are in the middle of a measles outbreak, which of the following reassures you that this is unlikely to be measles? [yop_poll id="97"]

(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following topical antibiotics has the least efficacy against impetigo? (see pictures of impetigo here and a short article here) [yop_poll id="88"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 12 year old boy with a history of ADHD on Adderall comes in for acute onset weakness of his bilateral upper arms, particularly on the right side. He had a viral URI 1 week ago with fever, cough, congestion, sore throat, from which he had recovered. For the past week, he did not take the Adderall because he had been sick and “forgot” to resume. On physical exam, his right arm is flaccid and motionless at his side, and he is unable to use it at all. He is able to lift his left arm partly against gravity, but it is weak. He has a low-grade fever of 38, and mild neck stiffness. His mental status is normal. [yop_poll id="71"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old girl presents with a 2 cm tender lump in her right armpit. It is not fluctuant and there is no overlying redness. On history, she has a kitten, and did sustain scratches to her right hand from the kitten in the last few weeks. She had a small papule on her hand in an area of a scratch 1.5 weeks ago that mom thought was a bug bite. Parents are unsure if she has had any fevers. She is otherwise healthy and well appearing. [yop_poll id="70"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old recently moved to the U.S. from Mexico with left sided chest pain for one day, and a fever to 38.2. Lung sounds are clear, the O2 sat is 100% on room air, and the CXR is negative. The ECG shows diffuse 1mm ST elevations and PR depression. The patient is well appearing with normal vital signs and hemodynamics. [yop_poll id="49"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing an 8 month old child with viral URI symptoms and pulling at the left ear. The child has not had any fever, is fully immunized, and is well appearing and playful. The right ear is translucent. The left ear is erythematous, with no bulging, perforation, or air-fluid level. Mobility is normal on pneumatic otoscopy. The child had one previous ear infection diagnosed at age 5 months. [yop_poll id="47"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old child with cochlear implants placed 8 months ago. The child has fever, headache, vomiting, altered mental status, and meningismus. The implant sites are well healed and show no signs of local infection. [yop_poll id="46"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old is brought in because all of his fingernails and toenails are falling off, painlessly. On review of the ED electronic medical record, he was seen 6 weeks ago and diagnosed with a viral infection. What viral infection did he have? [yop_poll id="38"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]

(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]

http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]

You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]

A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]

A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]

A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus

Which of the following wild animal exposures is the lowest risk for rabies?

1. Skunk
2. Coyote
3. Raccoon
4. Fox
5. Rabbit

Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here

Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C

The use and interpretation of rapid COVID-19 tests to reduce transmission is changing slightly with new variants and increased natural and vaccine-induced immunity in the population. A positive rapid test (even a very faint line) remains a good indicator of infectivity. However, some COVID-19 symptoms are now seen early in the disease course before the rapid test is positive. These are symptoms produced by the body’s immune response (something we now have due to natural or vaccine-induced immunity) to the virus – symptoms such as nasal congestion and runny nose, fever, sore throat. Symptoms produced by the virus damaging body cells (loss of taste or smell, diarrhea, shortness of breath) come later. Thus, if someone begins having scratchy throat and runny nose, rapid tests negative, and assumes they “just have a cold,” they may unwittingly build to a higher viral load in the next few days (that would turn a rapid test positive) and infect others with COVID-19. This is the reasoning behind recommendations for repeat testing 48 hours after an initial negative in symptomatic patients and for doing throat + nasal swabs to increase test sensitivity. For more info: https://lemonadamedia.com/podcast/will-we-all-get-omicron-in-2022-with-david-agus/ and https://www.axios.com/2022/12/16/changing-thoughts-rapid-tests and follow Michael Mina @michaelmina_lab on Twitter.

We are seeing unprecedented numbers of cases of RSV, and many of our patients are older school-age children. Ever wonder when those kids can return to school? RSV is contagious up to 8 days after symptom onset, so children can return to school on the 9^th day after symptoms started. However, young infants and immunosuppressed children may shed active virus for up to 4 weeks.

While up to 10% of patients may think they have an allergy to beta-lactam antibiotics, fewer than 1% have a true IgE-mediated hypersensitivity, with concomitant risk of anaphylaxis. However, even if a true allergy is confirmed, this does not mean that the patient cannot receive any beta-lactam antibiotics. Whether or not there is likely to be cross-reactivity between the antibiotic to which the patient is allergic and another beta-lactam antibiotic depends on whether their structures share similar R side chains, as explained in this article. A handy can be kept on your mobile phone delineating which antibiotics cross react.

Parent / guardian unsure of the child's immunization history? Almost every state has an immunization registry, and EMRs are often configured to be able to access them - ask your institution's IT person how if that's possible. For a quick powerpoint on the immunizations that matter for ED care, check this out.

You've probably heard... AAP Subcommittee on Febrile Infants came out with new guidelines. The algorithms have been posted on PEMsource algorithms page, and the fever table updated to reflect them.

Also, the CDC came out with new guidelines regarding STI treatment. The summary wall poster can be found on the PEMsource On Shift tab. Some highlights: higher dose of ceftriaxone recommended for uncomplicated gonococcal infections, doxycycline only is 1st line for chlamydial infection (azithromycin no longer 1st line), and sex-specific dosing for trichomoniasis treatment. Also recommended IV regimen to treat PID is ceftriaxone + doxycycline + metronidazole; clindamycin & gentamicin now an alternate regimen.

Treating abscesses by making two smaller incisions and placing a loop through them is becoming popular, preferred by many over traditional I&D. For a review of the technique: https://pemcincinnati.com/blog/loop-abscess/ Don’t have a vessel loop? You can use the cuff of any glove – doesn’t need to be sterile as abscesses themselves aren’t! 

Of course, we're going to test everyone for COVID, but this handy chart from National Jewish helps differentiate the common symptoms and course of COVID-19 with those of colds, influenza, and allergies

A trio of recent publications on pediatric UTI offer some insights. First, Mattoo et al offer a review of UTI diagnosis and management in children. Nadeem et al studied the optimal WBC cutoffs for diagnosing UTI, balancing overdiagnosis/overtreatment with underdiagnosis/missed UTIs, based on the specific gravity and found them to be: 3 WBC/hpf for spec grav < 1.011, 6 WBC/hpf for 1.011-1.020, and 8 WBC/hpf for spec grav > 1.020. And Liang et al reviewed 2144 PED visits in < 2yo and calculated likelihood ratios and posttest probabilities for various urinalysis findings. UTI prevalence was 9.2%, which the authors used as the pretest probability. Likelihood ratios for leukocytes were: 1+ 2.79. 2+ 7.53, 3+ 37.68. Nitrite positivity carried a LR of 25.35. WBC/hpf at 5-10 had a LR of 1.2 (95CI 0.7-2.04), 10-20 LR 1.82, 20-50 LR 11.18. Few bacteria had an LR of 1.46, moderate 6.05, many 14.04. 

To remember the difference in antibiotic regimens for chlamydia cervicitis / urethritis vs pelvic inflammatory disease, rap this in your head: Ceph 10 x 50 for GC is nifty; give Zith 1 gram for the chlam, but doxy 14 days BID is needed for PID

Here's a great way to store your N-95 for re-use

Respiratory virus season is here, and we all know that the FDA recommends against the use of OTC cough medications in children < 4 years old (due to too many adverse effects and lack of efficacy). Some studies have shown honey to be something useful we can recommend to frustrated parents, but how exactly is it administered? Studies tested from 2.5mL to 10gm (5mL of honey = ~ 7gm). Pulling the results together, 5mL of honey can be mixed in any non-caffeinated drink, such as warm lemon water, herbal tea, or warm skim milk, and given at bedtime or up to TID. Giving it longer than 3 days had no added benefit. There is some evidence that dark honey is more effective. (Oduwole et al Cochrane Database Syst Rev 2018 Apr 10;4:CD007094).

Staying with the topic of urine... investigators at University of Pittsburgh have derived and validated a UTI risk calculator for patients aged 2-23 months. The calculator (UTICalc) is linked from the On Shift page of PEMsource under the heading Neonatal / Infant, and can be found at https://uticalc.pitt.edu/ The study by Shaikh et al was published online on April 16, 2018 at JAMA pediatrics here. Some highlights: derived on consecutive 2-23mo old febrile patients evaluated in ED for UTI, 542 with UTI and 1144 matched controls without UTI. Validated on a dataset of 380 patients, 30 with UTI. Investigators estimate sensitivity of UTICalc at 95-100% and state that use of the calculator results in approximately 10 patients tested for every 1 UTI found; UTICalc outperformed the current AAP algorithm in both of these outcomes. Users can also enter urinalysis dip, micro, and gram stain results to obtain post-test probabilities. Investigators suggest testing when pre-test probability is 2% or higher, and treating when post-test probability is 5% or higher. Further validation is warranted, but UTICalc may be useful in shared decision making with parents to give a ballpark risk estimate.

Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885

Use a glass test tube or specimen tube to press on a rash to see if it blanches - remember, petechiae and purpura don't blanch. You can also use a glass test tube as a mini-anoscope to blanch surrounding mucosa and assist in identifying anal fissures in infants. (Anal fissures are one of the many possible causes of GI bleeding in children - check out pemplaybook.org's latest podcast on GI bleeding) (From https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/)  

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The AAP Otitis Media (OM) guidelines note that the majority of OM spontaneously resolves, with a number needed to treat (NNT) with antibiotics of 15-20 in low risk cases. Clinicians and parents can elect an "observation option" in select patients that are nontoxic, have temperature < 39 C, have had ear pain for < 48 hours, and have mild ear pain, and have no otorrhea; this applies to children aged 6-23 months with unilateral OM, and children > 24 months with bilateral OM. If symptoms persist for 48-72 hours, then antibiotics should be started.

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If due to a combination of low rates due to public health measures, low risk due to vaccinations and treatments available, COVID is under control and poses no additional morbidity or mortality risk to you, your family, or your patients, and your hospital no longer requires masks for patients or physicians, would you still wear a mask for your PED shifts?

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How should ED's handle patients with mild URI symptoms who mostly want a COVID test?

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You are seeing a 30 day old full term infant whose parents thought the baby felt warm, checked the temperature with an infrared mid-forehead thermometer, and it read 100.4. They did not give any antipyretics and came straight to the ED. The rectal temperature in the ED is 99. Mother received prenatal care, there were no complications, and she was GBS negative. There are no ill contacts and the baby is well-appearing and feeding normally.

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The new AAP Subcommittee on the Febrile Infant guidelines for managing febrile 8-60 day olds gives the option to perform an LP for febrile 22-28 day olds only if inflammatory markers, if obtained, are abnormal (Temp > 38.5, Procalcitonin > 0.5 ng/mL, CRP > 20 mg/dL, ANC > 4500-5200). This is an option even for the infant with a + UA. If an LP is not performed, they do recommend admission to the hospital and treatment with parenteral antibiotics. This is a change from prior practice, where concerns about masking meningitis obviated administration of parenteral antibiotics without performing the LP. What are your thoughts?

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You have diagnosed an 11 year old boy who has a PMH of mild intermittent asthma with COVID (he has been symptomatic with fever, vomiting, cough, and myalgias for 2 days). Currently, his RR is 20, SaO2 98% on room air, and his lungs are clear to auscultation. He has home albuterol MDI with spacer available. You discharge him with a portable pulse oximeter. For what persistent SaO2 would you tell the parent to bring him back to the ED?

(Click the link to comment and to vote - voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A 17mo old is brought in for rhinorrhea and mild cough. The patient is well-appearing, has no past medical history, is not on any medications, and is up to date on immunizations. Physical examination is normal. Vital signs are: temperature 35.8 rectal, heart rate 100, respiratory rate 24, blood pressure 85/42, pulse ox 100% on room air. The child is wearing a standard hospital gown and was brought in wearing appropriate clothing for the ambient mild outdoor weather. What would you do given the hypothermic rectal temperature? [poll id="54"]  

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Your emergency medicine colleague has a 7mo old, immunized, well-appearing, no PMH, with a fever of 40 C and no other symptoms. They have been scrupulously self-isolating, wiping down packages, etc. Your colleague has adhered to maximal PPE use including using N95s usually at work. No one around the child has been symptomatic. Your colleague asks what work-up you suggest in this era of COVID. [poll id="50"]

(Click the link to comment and to vote – voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 3yo child whose parents are essential workers and have recently tested positive for COVID-19. The child has had 3 days of fever, vomiting and diarrhea a few times per day with intermittent mild abdominal pain, and has a nonspecific blanching macular rash on the trunk and somewhat on the extremities. The child is well-appearing with good perfusion and hemodynamically stable, but is febrile in the ED. There are no respiratory symptoms, distress, nor hypoxia. [poll id="49"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Couldn't put every possibility, so pick the one closest to what you are doing. Also, your choice may depend on your hospital's recommendations and your PPE availability [poll id="46"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Parents bring a 15mo old non-black uncircumcised well-appearing fully immunized male with 3 hours of fever and no other symptoms. His temperature is 39 C. You find no clear source for the fever on exam. It is wintertime and his siblings all have URIs but this patient has no cough or congestion. He has not had any prior UTIs. Do you catheterize him for urine to rule out UTI? [poll id="45"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Reviving an old one since it's pretty relevant again. Added some commentary in the Comments section. [poll id="19"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="39"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 15 month old brought in for simple febrile seizure lasting 2 minutes. The child is back to baseline and well appearing. The vital signs are temperature 40.4 C, HR 175, RR 30, BP 80/40. Exam reveals no source for infection. The child has no vaccinations at all by parent choice. [poll id="38"]  

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="36"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a patient with a simple small abscess and no or minimal overlying cellulitis, nontoxic and afebrile, immunizations up to date, no prior abscesses. After successful incision and drainage, what treatment would you give? [poll id="27"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day. [poll id="25"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A repeat - since we are in the throes of influenza season right now, and this is a particularly controversial issue. Many emergency medicine FOAM bloggers have argued against the use of oseltamivir, such as here. But, the CDC continues to recommend it for high risk patients presenting with < 48 hours of symptoms, citing their reasoning here. To complicate things further, the "definition" of influenza-like illness basically includes nearly all kids seen in the ED in the wintertime - fever and cough or sore throat, and point-of-care tests are not very sensitive. [poll id="19"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Got this one from a recent EM physician facebook group post. You see a mother with symptoms of influenza. Her 3 day old asymptomatic full-term infant is tested and is POC influenza+. There is good follow-up and the patient is healthy, afebrile, feeding well, etc. [poll id="22"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics. [poll id="21"]

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="19"]

A 2 month old was seen in the ED 36 hours ago with a temperature of 39.2. The CBC had a WBC of 11.2 with 70% lymphocytes and no bandemia. Urinalysis was negative. The lab calls you to report that 1 of 2 blood culture bottles is growing gram positive cocci in clusters. You call the patient and the parent reports that he is doing well, is now thought to be afebrile (tactile, parents have not checked the temperature in 24 hours), and is feeding well. What do you do? (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="18"]

You are seeing a 6 year old with a wet-sounding cough for 4 days and fever to 39 C for 3 days. You hear crackles in the right lower lobe; there is no wheezing. CXR shows no infiltrates. Do you diagnose a "clinical pneumonia" with false negative CXR and treat with antibiotics? [poll id="10"]

Vote! But for something other than President... You are seeing a 3mo old with clinical bronchiolitis who is otherwise well-appearing, tolerating po's, not in significant respiratory distress, afebrile, has good follow-up. At what O2 sat do you admit the patient for supplementary O2? The AAP says: [poll id="9"]

You are seeing a 35 month old boy with fever and sore throat x 2 days. He has no cough or runny nose, but his sister also had fever and sore throat recently, and his mom has a cough. His temp is 38.5. He has no tonsillar exudate or palatal petechiae, and only tender cervical lymphadenopathy. He is otherwise well appearing, previously healthy, and is well hydrated. [poll id="6"]

You're seeing a febrile well-appearing 29-60 day old with clear lab evidence of UTI and benign CBC. Do you do an LP? Do you admit and do you give parenteral antibiotics? What about for a 61-90 day old?