The Payle family have been your patients since the couple married and Mrs. Payle has brought her daughter and son in to you regularly since they were born. She tends to fuss over her children and, on occasion, can be quite demanding. Today is one such occasion. She has pressured your receptionist for a ?fit-in? appointment for Jimmy who is now four years old. As you enter the room Mrs. Payle announces: "Doctor you have to give me some antibiotics for Jimmy!"
The last time you saw Jimmy was two weeks previously when he was treated for a urinary tract infection. Mrs. Payle indicates that, since then, Jimmy has been lethargic, irritable and whiny and particularly in the past three days when he also seemed to have a mild fever. On questioning, Mrs. Payle recalls that Samantha, Jimmy?s 6-year-old sister, has been complaining "off and on" of a sore throat but she continues to have lots of energy and go to school.
Jimmy is alert and cooperative on physical examination. He appears pale but is in no obvious distress. He is 101cm tall and weighs 17kg. Temperature is 38.5oC. Blood pressure is 92/56 mmHg. Heart rate is 130/min. Respiratory rate is 24. You are able to palpate several cervical lymph nodes. The liver border is palpated below the costal margin. You think that you can feel the spleen. Jimmy?s chest is clear on auscultation. His neurological exam is normal. You already know that Jimmy has no known allergies. Besides the liquid Tylenol his mother gave him last night, he is not taking any medications.
You suspect that Jimmy might have infectious mononucleosis and/or a streptococcal throat infection. You wonder about prescribing penicillin but take a throat culture and also arrange for Jimmy to have some laboratory investigations and to return for a follow-up appointment to reassess the patient and discuss the results.
Suggested Initial Learning Issues: There are three weeks for this case and students will receive additional information each week. The following list is therefore a suggested list to start from.
* Briefly review the case presentation and your approach to it as a family physician: normal growth parameters and vital signs in children; approaches to history and physical examination in a child. * Describe the approach and differential diagnosis of lymphadenopathy in a 4-year-old child. * What are appropriate laboratory investigations for Jimmy? * What will be your approach in prescribing antiobiotics? Discuss ways to decrease Unnecessary physician prescriptions along with ways to reduce patient expectations in regard to antiobiotics. Obtain practice guidelines for prescribing antibiotics. * Other issues discussed at the case presentation: o referrals from family physician to specialist and expectations by each. The goals and challenges in determining a diagnosis. Effect of disease prevalence in a patient population - relationship to diagnosis. o antiobiotic exposure in children: does it set a pattern for later diseases? o the invasiveness of tests and testing in children. Is the approach different to that in adults?