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Todd,
This patient distinguished himself by his duration of illness and an unusual complaint (back pain). You responded appropriately by being more aggressive in pursuing a diagnosis.
What would be inappropriate would be to use a case like this to justify getting CTs on all children who come in with back pain. I'm going to continue to resist the temptation to look for zebras in every patient, yet remain vigilant to look for those not following a typical clinical course.

Rich

________________________________
From: [log in to unmask] [[log in to unmask]]
Sent: Friday, January 14, 2011 12:39 PM
To: Scarfone, Richard; [log in to unmask]
Subject: Re: crp

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 <[log in to unmask]>
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]<mailto:[log in to unmask]>]

On Behalf Of Don Zweig [[log in to unmask]<mailto:[log in to unmask]>]

Sent: Thursday, January 13, 2011 9:37 PM

To: [log in to unmask]<mailto:[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 <[log in to unmask]<mailto:[log in to unmask]>> wrote:



> This story is a great example why one should not give in to parental pressure

and do what is right for the PATIENT!

> Since you have done the tests already...and the child looks well.... I would

have discharged the child with a close follow up.

>

> Giora (Gill) Winnik MD

> Maimonides Medical Center

> Brooklyn NY

> 718-283-6021

>

>

>

> -----Original Message-----

> From: Pediatric Emergency Medicine Discussion List on behalf of don zweig

> Sent: Wed 1/12/2011 10:04 PM

> To: [log in to unmask]<mailto:[log in to unmask]>

> Subject: crp

>

> 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.

>

> 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.

>

> help

>

> don

>

> For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the

message: info PED-EM-L

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>

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