Pediatric Primary Care Case Studies (63 page)

Sources of Diagnostic Error

In developing an initial differential diagnosis, the clinician’s past experience plays a significant role in what diagnostic possibilities are considered (Redelmeier, 2005). Other pitfalls include a reliance on initial impression and not reconsidering other diagnoses in light of new data obtained during reevaluations as well as making a decision about a diagnosis based on how the information is presented (framing). Framing effects cause small changes in wording to alter management decisions (Redelmeier). Additionally, clinicians can rely heavily on diagnostic technology or an assertive colleague’s opinion. To overcome these possibilities, a person must reconsider their diagnostic options when the colleague is more distant. Lastly, the clinician may prematurely close the diagnostic possibilities; this is known as premature closure (Redelmeier). In this case, the predominance of fever, fatigue, lack of exudative tonsillitis, and significant elevations of transaminases all pointed to CMV (Hurt & Tammaro, 2007). Because most cases of IM are EBV related, the diagnosis needed to be reconsidered in light of the negative serology and the persistent illness.

The serology to diagnose CMV includes anti-CMV IgM, spin-amplified urine culture for CMV with pp65 antigen detection, and CMV PCR. In this case, the least expensive test was ordered because the child was slowly improving. The anti-CMV IgM was significantly elevated.

The results come back on day 21 of illness; the child’s fever is effervescing, and the child is starting to take shorter naps. The school is sending in a tutor and the child is able to stay up for longer periods. A reevaluation is done after 7 days. One month after the initial presentation, the child is improved enough to go back to school, but gymnastics classes are not allowed during the first week of resumed school attendance to make sure the child is able to handle school academics before gymnastics is added.

When should the child with IM be allowed to participate in sports?

Splenic rupture is most common within 4 to 21 days after the onset of symptoms (Waninger & Harcke, 2005). Usually during the first few weeks of infection, there is spleen enlargement as a result of lymphocytic infiltration. Although splenomegaly is more common with EBV IM, it can occur with heterophile-negative mononucleosis (Hurt & Tammaro, 2007). Although some authors recommend imaging the spleen prior to return to play, there is variability in the normal size of the spleen in children (Waninger & Harcke). Clearly before an athlete returns to play, he or she should be afebrile, well hydrated, and free from the symptoms of IM. Splenic rupture after 28 days of the onset of illness is rare, but still can occur (Waninger & Harcke). It is important to limit activity in the first 21 days and then, in an asymptomatic athlete, allow a gradual return to play while avoiding activities that put the spleen at risk. The return to full activity should be paced depending on the individual presentation; abrupt increases in exercise should be avoided.

Maya adds one class of gymnastics per week over the next 3 weeks and recovers uneventfully from her CMV IM. The child is followed up 1 month after school was resumed. The family appreciates the concern for the child’s condition.

Key Points from the Case

1. When developing a differential diagnosis, it is important to reevaluate your initial impression based on the developing clinical presentation.

2. Diagnostic testing must be done in an organized fashion considering the most likely diagnosis based on history and physical examination.

3. Sensitivity, specificity, and predictive value are important to consider in the interpretation of laboratory testing.

4. Ethnic, cultural, and personal beliefs must be considered in developing a plan of care for the pediatric patient.

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Chapter 17

The Wheezing Child

Deborah A. Bohan

Wheezing is a common presenting symptom of respiratory illness in children. Although the most frequent cause of wheezing in children is asthma, conditions in the respiratory, gastrointestinal, cardiovascular, and other systems can cause children to have problems exchanging air. Problems can range from minimal to life-threatening in severity. The primary care provider needs to sort it all out efficiently, effectively, and inexpensively with the least stress possible to the child and family. Obtaining a detailed history (including family history) and focused physical exam will help in making an accurate diagnosis.

Educational Objectives

1.   Describe the prevalence and epidemiology of asthma.

2.   Understand the definition of asthma and describe its pathophysiology.

3.   Recognize the symptoms of asthma.

4.   Establish an appropriate asthma management plan based on new National Heart, Lung and Blood Institute (NHLBI) guidelines.

   Case Presentation and Discussion

James Washington is a 4-year-old black male who recently moved to the area with his family. James comes to your office with his mother, Mary Washington, with a chief complaint of difficulty breathing and cough. His symptoms started this morning shortly after waking up, although his mom says he has had some congestion and a runny nose for the past 2–3 days.

History

The important parts of the history in a child with wheezing depend, in part, upon whether a diagnosis such as asthma has been made previously and the reason for the current evaluation. Is this an initial diagnosis, a disease monitoring visit, or an acute exacerbation? In the case of a wheezing child, the history should focus on the presenting symptoms, precipitating factors, and typical symptom patterns.

What other historical data do you need to collect from James?

Important additional information to obtain includes:

•   Previous history of dyspnea, wheezing, or persistent cough

•   Previous office, clinic, or emergency department visits for this same complaint

•   Previous hospitalizations or intubations