pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP


OK, if you’ve been a reader of this column in the past, I know you can do it; so put on your white coat, get your stethoscope and let me watch how you “see” this next patient.

Picking up the chart you see that he is a new patient to you, named Ryan.   He is eight years old, and he lives with his mother who has been divorced for four years.

The nurse has taken his height, weight, and temperature (which were all normal) and has written on the chart “Fevers for six months!”

As you enter the room, you find him to be a red-headed youngster sitting curled up on his mother’s lap, somewhat frightened.

To synthesize his history, his mother tells you that she is very concerned that something is “really” wrong with Ryan.

He has had fevers on and off for about six months. He seems to have more illnesses than he should and has a very weak stomach, vomiting occasionally, but no diarrhea.

He occasionally comes in from play, lies down, moans that his stomach hurts, and watches TV or reads.

There are no sweats associated with the fever, joint or muscle pains, or rashes. They have not been out of the country or traveled or eaten exotic-type foods.

He usually has fevers 2-3 times per week, lasting for a day or less and responds to aspirin.

On physical examination you find that he is extremely shy but seems to “warm up” to you as you progress.   A thorough examination is entirely within normal limits, including muscles, joints, skin, liver, heart, lungs, etc., all the things that you are aware might be associated with chronic fever.

Well, what to do?   Because he is not in difficulty at present you decide to run a battery of lab tests and have the mom keep a careful log of symptoms, temperature, and anything that might be associated with it.

Before their next visit, all of the lab work that you have ordered comes back entirely within normal limits. (For you medical types: a CBC, Sed rate, CRP, Chem-profile, febrile aggluttinins, and both rheumatoid and lupus tests.)

When he returns, you explain all these tests to the mother but find that he has had a fever to 102-104 nearly every weekday morning and occasionally on Sundays.

This has meant that he has only been to school two days in two weeks and questioning deeper you find that he has, in fact, missed 75% of school days so far this year!

It seems to you like Ryan has “school phobia,” but when you mention it to the mother, she breaks down in tears saying she knows something is wrong because of the pain and fever.

Boy_TemperatureA firm believer in mother’s intuition, you order bowel x-rays, repeat the blood and urine counts, as well as order immune tests. He will also continue to keep his log.

Two weeks later you are pleased to tell Ryan’s mother that all of the x-rays and lab tests are again normal, but puzzled to find the same fever and stomach ache pattern on his log.

To make a long story short, after several visits Ryan’s mother’s frustration and concern rubs off on you and you admit him to the hospital for observation and workup, where you personally catch him rubbing the thermometer on his pajamas to make it hot so cancel the admission.

A great deal of time is spent by the nurse and yourself helping Ryan and his mother; and you feel good having “cracked” a very difficult case. (But you wonder how you are ever going to code it for her insurance company.)

“School Phobia” must be carefully delineated from “truancy.”

Truancy occurs in a child who just wants to do something other than go to school and does it. He may be a poor student and frequently becomes involved in delinquent type activities.

School Phobia on the other hand is most often a child who struggles with an irrational fear of leaving home or being at school, most often occurs in girls, and often resolved with parenting techniques.

There is frequently a physical complaint like recurrent abdominal pains, leg aches, headaches, diarrhea, vomiting, urination, or dizziness. The lab and physical examination are usually normal.

The most common precipitating factor is separation anxiety.   If the parents have been over-protective, over-solicitous, or over-dependent, it is difficult for the child to develop his independence. Sometimes anxiety is transmitted to the child from the parents who may be depressed or anxious themselves.

School Phobia can occur in any age but frequently is seen in the early elementary ages and then again at entrance into junior or senior high.

There are other causes of School Phobia, like intimidation by bullies, prolonged illness, frequent school changes, fear of failure, or loss of a loved one.

You know that Ryan’s fever was a broad manifestation of an underlying emotional problem, which will probably only be temporary. You decide not to confront him immediately but arrange for several counseling sessions with him and his mother.

Now that the “pressure” has been taken off, the first thing you need to do is help mother not feel embarrassed about having a very imaginative youngster.

Fortunately, you find that, with Ryan, merely using parenting with firm insistence that he attend school “no matter what” is enough to resolve his protesting within three weeks.

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