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Evidence based medicine doesn't preclude good clinical acumen.  The
kid got unnecessary antibiotics at the pcp visit and then you were
presented with someone who looked good, but had red flags.  You did
good by the kid, but that doesn't mean that evidence based medicine
failed him...

B2

On Fri, Jan 14, 2011 at 9:39 AM,  <[log in to unmask]> wrote:
> I too, once again attempt to follow strict evidence based medicine...
> ?
> is this evidence based?
> ?
> A few days ago I saw a 12 yo male with a hx of having a couple of days of low grade fevers 12 days prior to me seeing him. Tmax was 100.9. He went to see his PMD 12 days ago, at the time the fevers started and was diagnosed with a "systemic infection" and placed on abx. The fevers went away and the child finished the abx 1-2 days prior to me seeing him. He came to the ER because the fevers started again, x 1 day, Tmax 100.9.
> His VS otherwise were normal, he looked fine, and his only complaint was a vague upper back pain. No C/T/L/S Spine tenderness, no paraspinal masses, no swelling, no nothing...
> Again, VSS, Normal exam, Clear breath sounds, nl Neuro exam, everything on exam nl. This was a big, big??boarderline obese... Smiling in the room. No complaints otherwise. The back exam was nl.
> Thinking why would a healthy kid be comlaining of this vague upper back, not producible, looks like a stoic kid......I said why would would I do a CXR....Clear Breath Sounds, O2 sat 100 on RA, no sob, no tenderness on exam, everything nl.....kid looked great....no cough....
> ?
> Well, I did a CBC, Blood Culture, CRP and a CXR.
> ?
> WBC normal, Hgb 9.8, plat and diff nl...MCV 70's...
> ?
> CRP 14
> ?
> CXR: T9 with 50% loss of vertebral body height...
> ?
> went back into the room, took more history and examined the kid again, no point tenderness, nl back exam, nl exam t/o, nl belly exam....mild vague tendenress? on exam upper back...
> ?
> Asked about travel and TB exposure...Pott's dx?
> ?
> Traveled to Mexico a few months ago, brother with + PPD 7 years ago and was tx.
> ?
> Oh, and by the way....every now and than my left leg feels heavy....
> ?
> hmmmm...added on a CMP
> ?
> CMP: Lytes nl?? Calcium 11, Protein 10, Globulin 7.6, now?I am really worried...
>
> ?
> I ordered a?CT scan of the chest and an MRI of the T/L spine.....wanted to look at spine, discs and wanted a good look at the cord....
> ?
> ?
> CT Chest: picks up a large retroperitoneal mass in the abdomen
> ?
> MRI T/L spine: essentially every vert. with destructive metastatic lesions, minmal cord abutting at one level, but no compression
> ?
> Radiology added on a CT abdomen which showed a large retroperitoneal mass....
> ?
> horrible, horrible?case....
> ?
>
> ?
> Dr. Todd Zimmerman
>
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>
> -----Original Message-----
> From: Scarfone, Richard &lt;[log in to unmask]&gt;
> To: [log in to unmask]
> Sent: Fri, Jan 14, 2011 11:18 am
> Subject: Re: crp
>
>
>
>
> Obviously, I wasn't at the bedside and so I don't want to pass judgment on your
> management. By your own admission, though, the lab work was probably not
> indicated.
>
> I have found that my time is much better spent patiently explaining to worried
> parents why tests are not likely to be revealing, instead of ordering
> unnecessary tests. I almost never encounter parents who don't respond well to
> that approach. Inappropriate tests are fraught with problems. Pain for the
> child, costs, radiation exposure, delays in patient care are just a few.
> Further, they often lead to more unnecessary testing: the CBC that clots and
> needs to be repeated, the elevated potassium that may or may not be due to
> hemolysis, the shadow on the CXR that leads to a chest CT.
>
> Recently, a 9-year-old boy was transferred to us after being seen for throat and
> mild abdominal pain. The docs at the referring hospital had obtained an
> abdominal CT. We diagnosed him with strep pharyngitis and sent him home. The
> dose of unnecessary radiation that he was exposed to was equivalent to that of
> hundreds of CXRs.
>
> Thanks to vaccines, our landscape is covered with febrile children who have
> viral illnesses who won't be aided by testing. Thanks to recently published
> multicenter studies, we have compelling data to guide our decision making about
> when head CTs can be safely omitted in the setting of head trauma.
>
> It's very rare when a test reveals an unsuspected diagnosis. Often when it comes
> to testing, less is more.
>
> Rich
>
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]]
> On Behalf Of Don Zweig [[log in to unmask]]
> Sent: Thursday, January 13, 2011 9:37 PM
> To: [log in to unmask]
> Subject: Re: crp
>
> I of course did send kid home. I Saw her back today and she was completely well
> and the hematuria was gone/resolved.  I did not repeat the crp.
>
> Don - via iPhone
>
> On Jan 13, 2011, at 10:43 AM, Gill Winnik &lt;[log in to unmask]&gt; wrote:
>
> &gt; This story is a great example why one should not give in to parental pressure
> and do what is right for the PATIENT!
> &gt; Since you have done the tests already...and the child looks well.... I would
> have discharged the child with a close follow up.
> &gt;
> &gt; Giora (Gill) Winnik MD
> &gt; Maimonides Medical Center
> &gt; Brooklyn NY
> &gt; 718-283-6021
> &gt;
> &gt;
> &gt;
> &gt; -----Original Message-----
> &gt; From: Pediatric Emergency Medicine Discussion List on behalf of don zweig
> &gt; Sent: Wed 1/12/2011 10:04 PM
> &gt; To: [log in to unmask]
> &gt; Subject: crp
> &gt;
> &gt; How do you use the crp in evaluating kids?  How do you interpret a high crp
> with low sed rate.  I had a 8 yo with headache, decreased appetite and
> dizziness. No nvd.  Neg pmh.  Vitals normal with t=37.4 oral.  min cough.  no
> dysuria.  Labs show normal wbc and diff, noraml chem7, lft, cxr.  Very healthy
> appearing with large tonsils that are not inflamed. no nodes. supple neck.  crp
> ws 38. i was hoping for normal.  urine showed 80 red cells, 4 wbc, no back and
> 39 epith cells.  no abd or flank pain.
> &gt;
> &gt; Should i go with my impressing that she is well.  I did labs because mother
> was concerned, child seemed to be usually healthy and not a complainer..  Was
> shooting for reassurance.  did not image brain or tap.
> &gt;
> &gt; help
> &gt;
> &gt; don
> &gt;
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