Q 1:
You are evaluating a 3-year-old boy in the urgent care clinic for fever. His mother tells you that
he had been well until yesterday, when he had a temperature that she recorded by oral
thermometer at 103°F (39.5°C). He has had a clear nasal discharge, cough, and one episode of
emesis. At the time of your evaluation, the patient is eating ice chips from a cup that he is holding
while he is sitting on the bed. He has a temperature of 102.7°F (39.3°C), a heart rate of 140
beats/min, a respiratory rate of 30 breaths/min, and a blood pressure of 110/66 mm Hg. He has
coarse breath sounds with good air movement bilaterally. His pulses are strong throughout. His
capillary refill time is between 3 and 4 seconds in his hands and 2 seconds in his feet.
Of the following, the BEST plan of management is
A. blood pressure measurement and pulse oximetry in the four extremities
B. echocardiography for coarctation of the aorta
C. empiric intravenous antibiotics for suspected bacteremia
D. inotropic therapy with dopamine for shock
E. repetition of the perfusion examination with the patient supine and hands warmed
Answer
E
The febrile child in the vignette has delayed capillary refill in his hands, but not in his feet,
which can be explained by the ice chips that he is holding. His perfusion, and specifically his
capillary refill, should be re-evaluated when his hands have been warmed. A febrile patient may
have diminished perfusion, but a differential capillary refill is unexpected. All other aspects of his
physical examination and behavior suggest fever without diminished perfusion, and neither
empiric antibiotics nor inotropic therapy is warranted. Coarctation leads to differential blood
pressure and pulse findings when extremities that receive their blood flow proximal to the area of
coarctation are compared with those that are distal. Blood pressure measurement and pulse
oximetry in all four extremities are redundant tests in a 3-year-old child and would not yield
relevant clinical information.
Answer
E
The febrile child in the vignette has delayed capillary refill in his hands, but not in his feet,
which can be explained by the ice chips that he is holding. His perfusion, and specifically his
capillary refill, should be re-evaluated when his hands have been warmed. A febrile patient may
have diminished perfusion, but a differential capillary refill is unexpected. All other aspects of his
physical examination and behavior suggest fever without diminished perfusion, and neither
empiric antibiotics nor inotropic therapy is warranted. Coarctation leads to differential blood
pressure and pulse findings when extremities that receive their blood flow proximal to the area of
coarctation are compared with those that are distal. Blood pressure measurement and pulse
oximetry in all four extremities are redundant tests in a 3-year-old child and would not yield
relevant clinical information.
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