Case 21 - 12 year old female with fever

Question 1

Influenza epidemiology

Answer 1

15-42% of preschool and school-age children are affected per year, usually self limiting and patients improve in 2-5 days

Question 2

Risk factors for complications with flu

Answer 2

children <5 years, chronic pulmonary disease, congenital heart disease, immunosuppression

Question 3

Complications of flu

Answer 3

• otitis media
• streptococcal pneumonia
• lower resp tract infections
• neurologic (aseptic meningitis, GBS)
• myositis and myocarditis

Question 4

Obesity epidemiology in children

Answer 4

• 15% of kids 6-19 are overweight
• affects hispanic and african american kids more
• rates are increasing

Question 5

Complications of obesity in children

Answer 5

• T2DM
• high cholesterol - 10% kids 2-19
• hypertension
• metabolic syndrome
• musculoskeletal - blount’s disease, SCFE
• GI disorders - steatosis, gallbladder dz
• GYN - PCOS, early menarche
• psychosocial - depression, bullying, low self-esteem
• OSA, asthma

Question 6

Lung sounds indicating consolidation

Answer 6

egophany, tactile fremitus, dullness to percussion, crackles, whispered pectroliloquy

Question 7

Lung sounds that do not indicate consolidation

Answer 7

wheezes ( assoc with spasms) , ronchi ( assoc with secretions)

Question 8

Differential diagnosis for fever, cough, myalgias in 12 year old

Answer 8

1. influenza - characterized by upper and lower resp tract sx accompanied by systemic sx, high fever, abrupt onset
2. Pneumonia - crackles, tachypnea, consolidation, decreased breath sounds in one field
   - typical pneumonia - streptococcal, atypical (mycoplasma or chlamydia), viral (flu, RSV, adeno)
3. Bronchitis - self limited inflammation of large airways of lung, often production of purulent sputum, usually viral, lung exam can include ronchi and wheezes
   Less likely: URI, asthma exacerbation, Group A strep pharyngitis, bronchiolitis (infants)

Question 9

McIsaac Score

Answer 9

Indicates whether to test for strep throat

• one point for fever >38, cough absent, tonsillar exudate, tender anterior cervical lymphadenopathy
• plus one point for under 15, less one point for greater than 45
• test for 2-3 points, empirically treat for 4 points or higher

Question 10

Chest x-ray

Answer 10

• in community, only if patient is not responding to treatment
• all children with pneumonia should have x-ray if admitted to hospital

Question 11

Management of influenza

Answer 11

• antivirals decrease duration if given within first 48 hours,
• supportive treatment - ibuprofen, fluids, cough syrup

Question 12

Management of bronchitis

Answer 12

• albuterol for those who are wheezing

- mostly not antibiotics because mostly viral

Question 13

Management of pneumonia

Answer 13

• children three months to adolescence - amoxicillin to treat streptocccal
• school aged children with sx of atypical pneumonia - rx with azithromycin
• admit all infants, and older chlidren if hypoxemic, grunting or having trouble feeding

Question 14

Obesity management

Answer 14

• use motivating terminology
• advise whole family to change eating habits (5-2-1-0) - 5 fruits and veggies per day, 2 hours or less TV, 1 hours of physical activity per day, 0 surgary drinks
• set reasonable weight loss goals, reduce energy-dense foods, structured meals, diet and activity monitoring

Question 15

Screening for obesity complications

Answer 15

• check A1c and fasting glucose in all kids >95%ile and kids >85%ile at high risk
• check fasting lipids on every child >85%ile
• treat kids with LDL >190 or >160 with risk factors
• steatosis - AST/ALT for all kids >95%ile and kids >85%ile at high risk, refer to GI for 2XULN