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3 wk F - fussy
Enter ED room
• Mother holding swaddled infant who is crying
• Father sitting next to them in chair
• Preschool aged older brother playing with
  videogame on exam table
• Smell of stale smoke
• Parents look tired
What brings you to the ED?
• Past several days she seems more fussy
• She hasn’t been feeding well either – 2 ounces
  every 4 hours
• Today we just couldn’t get her to settle
  down, she’s been crying like this all morning
What else do you want to know?
• Onset:
  – She just became more fussy maybe 2 days ago.
    She awoke that morning fussy and its just been
    getting worse since. Her eating’s been getting
    worse as she gets fussier.
• Duration / Intensity:
  – All the time she’s fussy now. We could get her
    quiet yesterday but we can’t today.
What else do you want to know?
• Exacerbating / Remitting factors:
  – She’s used to calm down when we swaddled and
    held her. Now nothing works. Its worse at
    night, she kept us up all last night.
• Associated Symptoms:
  – Constitutional:
     • Hasn’t felt warm, but we never measured her temp
  – HEENT:
     • No red eyes or discharge, no congestion/runny nose
What else do you want to know?
• Associated Symptoms:
  – CV:
     • No lips or extremities blue, doesn’t tire or sweat with
       feeds
  – Pulm:
     • No coughing or wheezing, hasn’t been working harder
       to breath
  – GI:
     • No vomiting/spit up, no back arching, 3-4 dirty diapers
       seedy yellow diapers per day, no blood in the stool
What else do you want to know?
• Associated Symptoms:
  – GU:
     • 3-4 wet diapers past day
  – Neuro:
     • No abnormal movements, no apnea
  – Skin:
     • No rashes, no yellow discoloration
Additional History
• Birth hx:
  – 37 wks via SVD to G2P2 mother. Went home with
    mom after 2 days in the well-baby nursery. Mom
    had prenatal care, she thinks that her serologies
    were negative, she was GBBS positive and
    received antibiotics prior to delivery. Mom had
    gonorrhea early in the pregnancy, but was treated
    and repeat test was negative. She’s does not have
    HSV
Additional History
•   PMH: Has been healthy until now
•   PSH: None
•   Meds: Takes multi-vitamin
•   Allergies: None known
•   Family Hx: Heart disease in grandparents
•   Diet: Similac advance, 2 oz every 2-3 hrs
Additional History
• Social: Lives with parents and older
  sister, both parents work, attends
  daycare, received Hep B shot prior to d/c from
  hospital at birth, nobody is sick at home –
  unsure if anyone is sick at daycare.
Summary of History
• 3 week old, former FT gestation complicated
  by maternal gonorrhea infection (treated)
  who p/w 2 day history of progressive
  inconsolability with decreased PO intake and
  decreased UOP.
Differential
• Tier I/Ie:
   – Cardio: congenital heart disease
   – ID: UTI, meningitis, occult bacteremia
   – GI: colic, reflux; intussusception
   – Other: inborn error metabolism, NAT
• Tier II/III:
   – GI: constipation, milk protein allergy
   – Other: hair tourniquet
Physical Exam

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Presentation4

  • 1. 3 wk F - fussy
  • 2. Enter ED room • Mother holding swaddled infant who is crying • Father sitting next to them in chair • Preschool aged older brother playing with videogame on exam table • Smell of stale smoke • Parents look tired
  • 3. What brings you to the ED? • Past several days she seems more fussy • She hasn’t been feeding well either – 2 ounces every 4 hours • Today we just couldn’t get her to settle down, she’s been crying like this all morning
  • 4. What else do you want to know? • Onset: – She just became more fussy maybe 2 days ago. She awoke that morning fussy and its just been getting worse since. Her eating’s been getting worse as she gets fussier. • Duration / Intensity: – All the time she’s fussy now. We could get her quiet yesterday but we can’t today.
  • 5. What else do you want to know? • Exacerbating / Remitting factors: – She’s used to calm down when we swaddled and held her. Now nothing works. Its worse at night, she kept us up all last night. • Associated Symptoms: – Constitutional: • Hasn’t felt warm, but we never measured her temp – HEENT: • No red eyes or discharge, no congestion/runny nose
  • 6. What else do you want to know? • Associated Symptoms: – CV: • No lips or extremities blue, doesn’t tire or sweat with feeds – Pulm: • No coughing or wheezing, hasn’t been working harder to breath – GI: • No vomiting/spit up, no back arching, 3-4 dirty diapers seedy yellow diapers per day, no blood in the stool
  • 7. What else do you want to know? • Associated Symptoms: – GU: • 3-4 wet diapers past day – Neuro: • No abnormal movements, no apnea – Skin: • No rashes, no yellow discoloration
  • 8. Additional History • Birth hx: – 37 wks via SVD to G2P2 mother. Went home with mom after 2 days in the well-baby nursery. Mom had prenatal care, she thinks that her serologies were negative, she was GBBS positive and received antibiotics prior to delivery. Mom had gonorrhea early in the pregnancy, but was treated and repeat test was negative. She’s does not have HSV
  • 9. Additional History • PMH: Has been healthy until now • PSH: None • Meds: Takes multi-vitamin • Allergies: None known • Family Hx: Heart disease in grandparents • Diet: Similac advance, 2 oz every 2-3 hrs
  • 10. Additional History • Social: Lives with parents and older sister, both parents work, attends daycare, received Hep B shot prior to d/c from hospital at birth, nobody is sick at home – unsure if anyone is sick at daycare.
  • 11. Summary of History • 3 week old, former FT gestation complicated by maternal gonorrhea infection (treated) who p/w 2 day history of progressive inconsolability with decreased PO intake and decreased UOP.
  • 12. Differential • Tier I/Ie: – Cardio: congenital heart disease – ID: UTI, meningitis, occult bacteremia – GI: colic, reflux; intussusception – Other: inborn error metabolism, NAT • Tier II/III: – GI: constipation, milk protein allergy – Other: hair tourniquet