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Fever Case I
2.
3. 4. 5. 6. 7.
Differential diagnoses
Main diagnosis
What emergency (danger) and priority (important) signs do you notice from the picture?
Temperature: 39.7C, pulse: 170/min, RR: 30/min, capillary refill 4 seconds. Cold hands and feet
Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns
Emergency treatment
Airway management? Oxygen? Intravenous fluids? Anticonvulsants?
Immediate investigations?
Blood sugar
(Ref. Chart 2 p. 5-6)
History
Baby Jone is a 6 month old boy, who was brought to the hospital with a two day history of fever, lethargy and decreased feeding. He had not been drinking well for about 2 days. He had vomited several times each day. His mother had taken his temperature and this registered 39.70C axillary. On arrival in the hospital he was lethargic.
Examination
Jone was lying with his eyes closed, but was rousable.
Vital signs: temperature: 39.7C, pulse: 170/min, RR: 30/min, capillary refill: 4 seconds; cold hands and feet Weight: 7.0 kg Chest: normal air entry both sides Cardiovascular: both heart sounds were audible and there was no murmur Abdominal examination: soft, bowel sounds were present; liver was palpable 1 cm below the right costal margin Neurology: lethargic, no neck stiffness, fontanelle normal Mouth: slightly dry, no oral thrush Ears: clear, no discharge Skin: fine rash on trunk, arms and face
Differential diagnoses
List possible causes of the illness Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p. 151)
Immunization history
Infectious contacts Malaria endemic area
Investigations
Blood glucose Urine microscopy (and culture if available) (Ref. p. 185) Clean catch technique Supra-Pubic Aspirate (Ref. p. 350) Malaria microscopy of rapid diagnostic test (RDT) Lumbar puncture if signs suggest meningitis Blood culture if possible
Suprapubic aspirate
Urine
Protein / Glucose : Nitrate / Leucocyte esterase : Blood: Microscopy: nil 3+ 1+
20 x 106/l n(<13)
500 x 106/l
Diagnosis
Summary of findings:
Urine examination abnormal Blood examination shows mild anaemia, mild neutrophilia with significant left shift, thrombocytopenia No other signs of focal infections
Urinary tract infection/Urosepsis
Treatment
(Ref. p. 184) Ampicillin and gentamicin IV/ IM initially or a third generation cephalosporin, such as ceftriaxone. Consider complications such as pyelonephritis or septicaemia
Give parenteral treatment until fever subsides and/or urine culture results improve; switch then to an appropriate oral antibiotic
Depending on local sensitivity patterns different drug regime may be chosen
Supportive Care
Fever management (Ref. p. 305) Nutritional management (Ref. 298-299) Fluid management (Ref. p. 304)
Give initially IV fluids because of signs of shock, but then reduce the rate
Monitoring
The infant should be checked by nurses frequently (at least every 3 hours) and by doctors at least twice a day Use a Monitoring chart (Ref. p. 320, 413)
Follow up
Investigate for renal abnormality Renal ultrasound if possible Recheck platelet count to see if thrombocytopenia resolves
Summary
Infant with systemic infection due to urinary tract infection
Frequent monitoring
Follow-up