Fever and rash Flashcards
7 year-old female from Cavite, consulted for fever
What are you going to ask in the history?
HISTORY
1 week PTC, while at school, patient complained of a vague headache. At the clinic, she was noted to have low-grade fever. She was sent home on Paracetamol with only temporary relief of fever.
1 day PTA, patient had fever of 39.8C with associated pink spots on her abdomen and crampy abdominal pain. Fever persisted despite giving two doses of Paracetamol.
Persistent fever and three episodes of diarrhea (greenish, watery, no blood) prompted consult.
PAST MEDICAL HISTORY
Had chicken pox last year, no known allergies, no asthma
FAMILY MEDICAL HISTORY
Unremarkable
BIRTH AND MATERNAL HISTORY
Born full term to a 25-year-old G2P1 mother with unremarkable birth and maternal history.
IMMUNIZATIONS
Completed EPI, given 1 dose of MMR; Hep B, DTap and Hib boosters as a toddler, given influenza vaccine 3 months ago
NUTRITION
Mix-fed, given age-appropriate milk formula
Started complementary feeding at 5 mos
Eats 3 meals a day (has school lunch), eats 2 snacks consisting of junkfood and fishballs from a nearby vendor
DEVELOPMENTAL
At par with age, no problems at school
What are you going to do in the PE?
PHYSICAL EXAM
Awake, ambulatory but weak, not in distress
BP 105/70, HR 55, RR 20, T 40C
Wt 22 kg (z 0), Ht 130 cm (z +1)
Pink conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy
Equal chest expansion, clear breath sounds, no retractions
Adynamic precordium, loud S1 S2, PMI not displaced, regular rhythm, no murmurs
(+) Pink, non-pruritic macular rash on chest, abdomen and back, flat abdomen, soft, hyperactive bowel sounds, liver edge 2 cm below right costal margin, slightly tender
Pink nail beds, full pulses, no edema, good CRT
What laboratory exams would you request?
CBC
Urinalysis
EKG
Stool exam
Dengue IgG, IgM
stool culture
blood culture
CBC: Hgb 130, Hct 0.38, WBC 8.5, N 55%, L 41%, M 3%, E 1%, Plt 280
Urinalysis: Yellow, clear, pH 7, SG 1.01, WBC 1/hpf, RBC 0/hpf, glucose none, nitrite negative, protein none, casts none
Stool exam: Greenish brown, mucoid, PMN 5-10, no ova/parasite seen
FOBT: negative
Dengue IgG non-reactive, IgM non-reactive
Stool culture: negative
Blood culture: Growth of Salmonella typhi
What are the salient features of this case?
[ ] Persistent 1 week fever low > high grade
[ ] Rose spots, abdominal pain and diarrhea
[ ] Bradycardia, rose spots, borborygmi, tender hepatomegaly
What are the differentials?
*Bacterial (AGE, Typhoid, Shigellosis)
*Viral exanthems (measles, rubella)
*Other viral illnesses (dengue, coxsackie, viral hepatitis)
*Parasitic (amebiasis, schistosomiasis)
Immunologic causes
Kawasaki disease
Scarlet fever
Toxic shock syndrome
Interpret lab results
What is the management for this case?
[ ] Emergency measures
[ ] Antibiotics (IV Ceftriaxone 75 mkd, oral Cefixime 15mkd for 7-10 days)
[ ] Preventive measures (handwashing, food preparation, etc)
Preventive Pediatrics
[ ] Developmental surveillance
[ ] Atopy screen
[ ] Monitor weight, height
[ ] Blood pressure
[ ] Eye exam
[ ] Immunizations
[ ] Deworming (albendazole 400 mg q6mos, mebendazole 500 mg q6mos)
[ ] Dental care
[ ] Nutrition counseling
[ ] Physical activity
[ ] Injury and poisoning prevention
[ ] Child maltreatment prevention
[ ] Counseling on lead and toxicant exposure
If this is a case of MEASLES, what are the clinical presentation?
3Cs
cough
coryza
conjunctivitis
Enanthem: koplik spots; red lesions with bluish white spots in premolar area; appears before the rash; onset: 1-4 days before rash
Infectious: 3 days before to 4-6 days after rash
Exanthem: Maculopapular lesions –> desquamation
cephalocaudal progression with confluence of rash on face and upper trunk
If this is a case of MEASLES, what would you request?
CBCPC : dec WBC, inc lymphocytes, low N
Measles IgG, IgM
Measles PCR
ESR, CRP – Normal
Viral culture
Chest xray if prolonged cough
If this is a case of MEASLES, what are your differentials?
Kawasaki disease
Rubella
EBV
Adeno
If this is a case of Rubella or German measles, what are the clinical manifestations?
low grade fever
sore throat
red eyes with or without eye pain
headache
malaise
anorexia
rash –> first manifestation
macules coalesce– > centrifugal (face and distal extremities), no desquamation
Enanthem: Forscheimer spots: appears same time as the rash, petechiae/rose colored spots on soft palate
What is the enanthem for measles?
Koplik spots; red lesions with bluish white spots in premolar area; appears before the rash; onset: 1-4 days before rash
What is the enanthem for Rubella?
Enanthem: Forscheimer spots: appears same time as the rash, petechiae/rose colored spots on soft palate
