It was my first week practicing medicine. I must admit, I was drowning. I did not feel prepared for family medicine.
I felt like I did not know anything about how to practice as a clinician.I knew how to diagnose diseases, what tests to order to diagnose, and first-line treatments. However, I was struggling with laboratory results that had abnormal findings – I did not know what to do next. All the while getting ready to see the next patient.
And then bam… I made my first mistake with a patient.
Everyone makes mistakes. Even the most seasoned and expert physician, physician assistant, or nurse practitioner. If any provider tells you that they have not made a mistake, or missed something, they are lying. It’s not something that is easy to talk about because we all have pride and ego to some extent. Today I will discuss my case, what I did, and what I should have done.
My patient was a newborn (<29 days) that was brought in for a fever. Many times, when I see this complaint on the chart, the patient will come in, and the temperature on exam will be 99.3 degrees Fahrenheit.
In this case, the patient’s temperature was 100.7 degrees Fahrenheit rectally. I went into the exam room and spoke with the parents and examined the patient.The patient was alert, smiling, and interactive. Normal fontanelles and moist mucous membranes.
The patient was taking a bottle well, and making normal amounts of wet, and “poopy” diapers. Clinically the patient looked like she was doing well.
With further examination, the patient’s heart and lung auscultation were unremarkable; tympanic membranes were clear without any signs of infection, no apparent meningeal signs. The only finding was some increased posterior nasal drainage and a slightly erythematous posterior pharynx.
This patient met two out the five Centor Criteria (Age and Fever), so I performed a rapid strep swab in the office.This was negative.Group A strep DNA confirmation testing turned out to be negative as well.
Since the patient was eating well, still making wet diapers, and was interactive, I gave the parents ER precautions and thought that it was likely a viral upper respiratory infection being the cause of the fever.
I sent the patient home, and when I walked into my office, my supervising physician walked in to see how things were going, and I told him about the last case. He responded, “you sent them to the ER, right?”
I looked perplexed. I felt a pitting in my stomach. And in my head, I said: “what did I miss?”. The case seemed like a slam dunk. An easy viral URI.
In this case, all patients under 29 days with a temperature over 100.4 degrees Fahrenheit need inpatient management and workup for an etiology of their fever.
I ran to the closest telephone to try to call the parents.The phone rang incessantly, but no answer. I continued to feel worse and worse as time elapsed. For some unknown reason, I decided to run outside to see if the family was still around, and thankfully they were there.
The parents and patient were standing out front waiting on a relative to pick them up. I explained the situation to the parents and that there is some additional testing that I could not provide in office to make sure there was not something serious going on that could be treated.
Once in the ER, a urinalysis was performed, as well as a complete blood count and chest x-ray – all normal. The patient was then transferred to the nearest pediatric hospital and underwent a lumbar puncture, blood culture, HSV, RSV, CRP, ESR, and influenza testing – again all normal.
The patient was started on prophylactic antibiotics, and was released from the hospital two days later with a diagnosis of……
A viral upper respiratory infection.
Even though my intuition was correct, regarding the final diagnosis, you can see further testing needed to be done to rule out more serious etiologies.
Studies of infants and young children with fever have shown to be dramatically reduced since the initiation of immunizations. Rates of meningitis (caused by Hib) have decreased more than 99% since the 1990’s.Pneumococcal infection has reduced by 77% from 1998 to 2005 and is expected to further reduce with increased vaccinations.
Even in children that are unvaccinated or partially vaccinated the rate of pneumococcal infections have reduced, believed to be due to herd immunity.
Even though the underlying etiology of my patient’s fever was due to a viral URI, the most common etiology of bacterial infection in children less than three months is a UTI. In those three months to three years of age, the most common etiology is pneumonia (Am Fam Physician. 2013 Feb 15;87(4):254-260).
So, what is a fever? What were my pitfall in this case?
A fever, in children under three years of age, is considered to be a rectal temperature of at least 100.4 degrees Fahrenheit. Axillary, temporal, or tympanic temperatures have been shown to not be reliable measurements.
History and physical examination are essential in these cases, just as with every patient encounter. Screening for vaccine status, as well as immunocompromising conditions such as asplenia, HIV, or cancer, should be included in the history taking.
However, history and physical exam alone are not enough, so early testing and imaging are important.
Urinalysis and culture should be performed for all children two years and younger. This test is often not done however due to the difficulty associated with acquiring a specimen. UTI is a common cause of fever in a child, wherein the first three months, it is more common in boys (more common in uncircumcised patients). After three months of age, UTIs are more common in girls.
A complete blood count and blood culture should be done in all patient’s three months and younger with a fever. WBC and neutrophil levels are used, and an elevation is consistent with a serious bacterial infection.
In all febrile neonates, a lumbar puncture should be completed to rule out meningitis. In febrile infants and young children, this should be considered as well, if signs of meningitis are present.
A chest x-ray should be completed in all neonates with fever, especially those with respiratory symptoms. In those with diarrhea, stool culture and fecal leukocyte studies should be performed.
Other testing that can be done less commonly, but as you can see above were done in my patient, include an ESR, CRP, and HSV testing.
After all cultures have been completed, patient’s that are hospitalized should receive empiric antibiotic therapy. The choice of antibiotics is based on location and resistance factors. The most common organisms include GBS, E. coli, Listeria, and Enterococcus (Am Fam Physician. 2013 Feb 15;87(4):254-260).
The following table are the recommendations from the AAFP on empiric antibiotic therapies:
I hope you have learned, from this case, that mistakes are going to happen in medicine. That is why medicine is considered an art, and where the phrase, “practicing medicine” comes from.
Our job is first to do no harm. I know I learned a tremendous amount from this case, and I feel like I have learned the most in my career when I made mistakes.
This was my first mistake in practice, I have made more since that time, and I am certain that I will make more in the future.
Learn from your mistakes.Turn them into lessons to grow from, and to become a better clinician in the future, for your patients.