M.D., 3 years old from,was admitted for the first time in a hospital on june 18, 2007.
Chief complaint: fever and rashes
History of present illness:
Condition started 5 days prior to admission as sudden onset of fever, temperature range= 38-38.5C. Patient was given Paracetamol 5 ml every 4 hours which afforded temporary relief. Decrease in the appetite was noted. Parents did not seek consult because of financial difficulty. The morning prior to admission, temperature was noted to be 39C and parents noted rashes on the face which gradually spread.
(+) cough
(+) soft watery stool 1-2 episodes/day
(-) vomiting
Past history:
Prenatal: Mother is G2P2002. Had prenatal check up at the health center. No meternal illness incurred during the entire gestation. Took multivitamins regularly.
Natal: patient was delivered at home assisted by a midwife. Good spontaneous crying was noted right after delivery. BR= 2/2
Postnatal: Patient was breastfed since birth up to 6 months old. Solid food was introduced at 5 moths old. Developmental milestones 鈥?unremarkable.
Immunization status: complete primary immunization done at the health center.
P.E: examined a conscious, febrile patient with the following vital signs
HR= 100/min RR=25/min Temp= 39C
Weight= 13Kg
Skin: (+) maculopapular rashes from the face down to the upper chest
HEENT: (+) 鈥渞edness鈥?of the eyes, (-) eye discharge, (+) watery nasal discharge, (-) tonsillopharyngeal congestion
Neck: supple
C/L鈥?equal chest expansion, harsh breath sounds
CVS: regular rate and rhythm
Abd: flat, soft, normoactive bowel sounds
GUT: grossly male
Ext: (-) rashes, good pulses
Questions:
1. What is your impression?
2. Make a formulation
3. Give at least 3 differential diagnosis
4. Discuss the case neisseria meningitis
do a spinal tap and start antibiotics Allergic rxn of some kind maybe? What yr are you? Did you order a chest x-ray if there was harsh breathing? although the CVS was normal. Tonsillitis? What kind of rash and where on body? Is it itchy? Tiny dots or larger circles? I have no medical training but it sounds like an allergic reaction. Is the rash hives (or whatever the medical term for that is)? Viral exanthems are a dime a dozen in little kids. You left out the most important part of the exam, by the way: Does the kid look sick? You're probably dealing with either an enterovirus or adenovirus, but that doesn't help you much. I'm guessing the kid's studies are going to be nothing to excite you, and he'll drive you nuts until he gets well all own his own. Measles is my first impression,(Koplic`s spots may be noted earlier on buccal mucosa)
Chicken pox and
Mumps are also rarely possible with similar picture.
Immunological tests confirm the diagnosis.
Treatment is supportive and symptomatic 1.What is your impression?
>>Measles (Rubella)
2.Make a formulation
>>The maculopapular rashes from face going down,fever,eye redness,watery nasal discharge,throat congestion,harsh breath sounds are highly suggestive as the signs and symptoms of measles.
3.Give at least 3 differential diagnosis
>>enterovirus, scarlet fever, Kawasaki's disease, infectious mononucleosis, toxoplasmosis, drug eruption.
4.Discuss the case:
In measles,patient catches infection and develops fever. Incubation period takes place then the rashes apppear 3-5 days from the onset of symptoms which distribution is centifugal usually from face going down outwards. Other signs and symptoms become obvious which include conjunctivitis (eye redness), coryza (running nose), congestion of upper respiratoy tract, spots on the mouth called Koplik's spots -which the pathognomonic sign of the disease, there will be sort of chest infection and when it gets complicated it develops into pneumonia. Diarrhea or watery stools could be caused by a secondary infection as its . Your patient was vaccinated so most commonly there are reasons for the failure to confer immunity most likely the vaccination was inadequate. viral illness. i am assuming the child is not lethargic suggesting encephalitis/meningits; also I note child has a supple neck.
measels is common and pattern of rash fits. Has associated conjunctivits and pneumonitits with overall picture of upper and lower respiratory viral illness. Expect improvement in approx. 48 hrs after onset of rash and rash fades to brown fom red. This is rare given the history of supposedly up to date vaccinations.
Check the history of vacciantions again and review history for possible infectious contacts. Diagnosis is based on overall picture and serology. if child is very ill consider other investigations like CXR (chest x-ray) to rule out pneumonia, +/- LP (lumbar puncture) if CNS (central nervous system) signs or symptoms.
differential diagnosis
1) of respiratory illness with rash: Mycoplasma pneumonia has associated rash, upper and lower resp.signs and symptoms and other manifestations.
2)rash spreading to periphery: Rubella, here rash resembles measels but patient is not as sick.
3) rash with fever: Rocky mountain spotted fever, this is not as likely a cause here but this illness must not be missed, has a high fatality rate. Rash begins centripetaly after approx. 4 to 5 days of illness, children often have associated abd. pains that can be severe. Usually in spring summer, difficult Dx, can do punch Bx of lesion looking for rickettsiae.
most likely Dx is measels also,
this is a reportable illness.
there is risk of developing pneumonia and post infectious neurological syndromes
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