CASE MANAGEMENT CONFERENCE

Silla, Earica Tuquero, Frances Owen Runes, Perly Martinez, Mark Luwiz
February 18, 2013 Basilio Valdes Hall Our Lady of Lourdes Hospital
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IDENTIFYING DATA

R.C. 10 y/o Male Roman Catholic Mandaluyong City January 3, 2013 8:30 pm

CHIEF COMPLAINT
Rashes for 2 days

SOURCE AND RELIABILITY

Mother and patient 85%

HISTORY OF PRESENT ILLNESS

3 days PTA

Fever : remittent, 38 - 39 C Headache : frontal, throbbing Throat pain Vomiting : 2x previously ingested food Epigastric pain : intermittent, burning,
localized, Gr 6/10, 1-2 mins

Consult Self- med

: None : Paracetamol
No relief

(4.9 mkdose)

HISTORY OF PRESENT ILLNESS

2 days PTA

Fever Throat pain Epig. pain Rashes

: Intermittent, 38 - 39 C

: decreased, Gr 4/10 : nape, chest, both UE

macular, erythematous non-pruritic, non-tender

Consult Self- med

: None
: Paracetamol
4.9 mkdose

Temporary relief
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HISTORY OF PRESENT ILLNESS

1 day PTA

Fever Throat pain Epig. Pain Rashes

: Intermittent, 38 - 39 C : decreased : whole neck, chest and back, UE/ LE

maculopapular, erythematous, rough
non-pruritic, non-tender facial sparing

Tongue Consult Self- med

: Hyperemic w/ prominent papillae : None

: Paracetamol (4.9 mkdose)

Temporary relief
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HISTORY OF PRESENT ILLNESS

Day of Admission
Symptoms
Consult

: persisted : OLLH ER

Admission

REVIEW OF SYSTEMS
General Skin
HEENT Respiratory Cardiovascular Gastrointestinal Musculoskeletal
: (-) weight loss/gain.
: (-) bruising, pruritus, ulcers changes in the hair or nails : (-) tearing, epistaxis, nasoaural discharge : (-) cough, hemoptysis, dyspnea : (-) chestpain, syncope, palpitations

: (-) diarrhea, constipation

: (-) deformity, joint swelling/tenderness, limitation of movement

Genitourinary

: (-) dysuria, hematuria, frequency

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PAST MEDICAL HISTORY

Congenital Heart Disease

At birth Referral
2D echo

: Pediatric Cardiologist
: VSD

Meds

: Digoxin (Lanoxin) till 1 year old

1 year of age Repeat 2D echo Meds Follow up

: VSD ~ 0.2 cm

: Digoxin d/c : regular

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Maternal History

27 y/o Primigravid Pregnancy

: unremarkable

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Birth History

Full term, NSD Government Hospital December 23, 2002 BW: 2600 gms

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IMMUNIZATION HISTORY
VACCINES BCG DPT AGE At birth 2 months 4 months 6 months 2 years 2 months 4 months 6 months 2 years At birth 1 month 1 year 2 months 4 months 2 years 9 months 1 & 3 months

Polio

Hepatitis B

HIB

1 2 3 Booster 1 2 3 Booster 1 2 3 1 2 3

Measles MMR

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FEEDING HISTORY

Birth - 3 mos : breast milk 3 mos onwards : formula milk Solid food : 6 months Current diet : rice, meat, vegetables
eggs, fish

(-) allergies

15

FAMILY HISTORY
Hypertension Bronchial Asthma Diabetes Mellitus Colon Cancer : both sides : maternal side : mother : maternal side

(-)

Heart disease Tuberculosis Thyroid disease Seizure disorder

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SOCIAL HISTORY

HOME/ENVIRONMENT
House

: 2-story apartment Parents : separated Guardian : maternal grandparents Drinking water : water purifying station Garbage : daily Toxic exposure : vehicular smoke : P. Gomez Elementary School : Grade 4 : Good
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EDUCATION
School Level

Grades

SOCIAL HISTORY

ACTIVITIES
Plays computer games Watches TV

Surfs the internet

No sports

DRUGS

No exposure to cigarette smoke, alcohol, illicit drug

SEXUALITY
Denies attraction to opposite or same sex.

SAFETY
Walks to school via main road where vehicles pass
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PHYSICAL EXAMINATION
GENERAL
Awake, coherent, ambulatory, weak- looking, not in cardiorespiratory distress

VITAL SIGNS
HR RR : 118 : 23 BP : 110/ 70 Temp : 39.7 C

ANTHROPOMETRICS
Wt Ht BMI : 51.2 Kg : 144 cms : 24. 69 kg/m2 (112 lbs) ( 4 8) (p>95 %) (p 90 %) (p>95 %)
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PHYSICAL EXAMINATION
SKIN

Flushed & dry

Rashes
Appearance

: maculopapular, over erythematous base : neck, chest, back, UE & LE : antecubital area

Location

Pastias lines

(-) periungual peeling of fingers and toes cyanosis, ecchymoses,

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Pastias line

Pinpoint petechiae in the flexures produce a linear purpuric pattern

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PHYSICAL EXAMINATION
SKIN

Flushed & dry

Rashes
Appearance

: maculopapular, over erythematous base : neck, chest, back, UE & LE : antecubital area

Location

Pastias lines

(-) periungual peeling of fingers and toes cyanosis, ecchymoses,

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PATIENT

R. C.

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PATIENT

R. C.

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PATIENT

R. C.

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PATIENT

R. C.

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PATIENT

R. C.

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PATIENT

R. C.
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PHYSICAL EXAMINATION
HEENT

Conjunctivae : Hyperemic
Lips Tongue Tonsils Lymph Node : Dry : hyperemic w/ prominent papillae : Gr 3, hyperemic w/o exudate : 1 x 1 cm, Submandibular, soft, palpable

Anicteric sclerae Pupils equally reactive to light Oral mucosa is pink with no lesions or ulcers

Uvula midline
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PATIENT

R. C.

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PHYSICAL EXAMINATION
CARDIOVASCULAR

Adynamic precordium PMI 5th ICS LMCL (-) Heave/ thrill Distinct S1 & S2 Murmur

Grade 3, blowing, pansystolic Lower left sternal border

RESPIRATORY

Symmetrical chest expansion (-) retractions Clear breath sounds (-) rales / wheezes
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PHYSICAL EXAMINATION
ABDOMEN

Flabby (-) surgical scars Normoactive bowel sounds Tympanitic (-) organomegaly , tenderness

EXTREMITIES

Full and equal pulses (-) edema, cyanosis, limitation of movement

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PHYSICAL EXAMINATION
RECTAL EXAM

(-) hemorrhoids, skin tags good sphincter tone with intact rectal vault (-) rectal tenderness (-) mass, blood or fecal material on the glove of examining finger

GENITALIA

uncircumcised descended testes (-) discharge, lesions Tanner Stage 1

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NEURO EXAM
Cerebral

Awake, coherent, oriented to 3 spheres

Cranial Nerves
I II, III III,IV,VI V VII VIII IX, X XI XII : : : : : : : : : intact Pupils 3-4mm equally & briskly reactive to light primary gaze midline, full EOMS, (-) nystagmus (+) corneal reflex, intact V1-V3 no facial asymmetry gross hearing is intact uvula midline, good gag good shoulder shrug tongue is midline
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NEURO EXAM
Cerebellar : (-) dysmetria, dysdiadochokinesia

Motor
DTR Sensory Meningeals

: 5/5 in all extremities

: ++ in all extremities : No sensory deficit in all extremities : (-) nuchal rigidity, kernig & brudzinski sign

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SALIENT FEATURES
3 Day
Fever Throat pain Epig pain HA

2 Day

Rashes

10 / M

PE

Fever Generalized rashes Hyperemic tongue Hyperemic tonsils Submandibular LN Murmur

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ADMITTING DIAGNOSIS

Viral Exanthem

T/C Scarlet Fever Congenital heart disease (VSD) not in

failure

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SALIENT FEATURES
PATIENT Age 10 yrs old Sex Male

Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines
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10 / M

Rash

Infectious

Non-infectious

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DIFFERENTIAL DIAGNOSIS

Viral Exanthem

t/c Scarlet Fever

r/o Rubeola r/o Coxsackie A

r/o Kawasaki Disease

r/o Toxic Shock Syndrome
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Six Exanthems of Childhood

1st 2nd 3rd 4th 5th 6th

Rubeola Scarlet Fever Rubella Dukes Disease Erythema Infectiosum Roseola Infantum

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Six Exanthems of Childhood

1st 2nd 3rd 4th 5th 6th

Rubeola Scarlet Fever Rubella Dukes Disease Erythema Infectiosum Roseola Infantum

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Differential Diagnosis
Viral Exanthem
PATIENT Rubeola Age 10 yrs old Sex Male

Fever
Hx Headache

Sore throat
Ab pain

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Rash
TPC PE Submand LN Strawberry tongue Sandpaper rash

Pastias lines

Rubeola
Prodrome: fever, cough,

conjunctivitis, coryza

Rash

: hairline, post-auricular, face, neck, trunk : confluent on the 3rd day

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Differential Diagnosis
VIRAL EXANTHEM PATIENT Rubeola Age 10 yrs old Sex Male

Coxsackie

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Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

Differential Diagnosis
PATIENT Age 10 yrs old Sex Male Kawasaki
(1.4x)

Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

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Kawasaki
Prolonged fever 4/5 principal features

oral mucosa : strawberry tongue, pharyn Hands/feet

: edema conj injection : hyperemia Rash : erythematous, polymorphic Cervical LN : > 1.5 cm in diameter.

R/O all other etiologies

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Differential Diagnosis
PATIENT Age Sex 10 yrs old Male Kawasaki Rare

Toxic shock syndrome Rare Rare

Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

> 1.5

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Toxic Shock Syndrome

Major criteria (3)

acute fever > 38.8 C, hypotension rash (erythroderma with desquamation)

Minor criteria (3)

mucus membrane inflammation (strawberry tongue) vomiting or diarrhea liver abnormalities renal abnormalities neurologic abnormalities muscle abnormalities thrombocytopenia
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Differential Diagnosis
PATIENT Age Sex 10 yrs old Male Kawasaki Rare

Toxic shock syndrome Rare Rare

Scarlet Fever

Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

> 1.5

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Differential Diagnosis
Viral Exan PATIENT Rubeola Age Sex 10 yrs old Male

Kawasaki Cox

TSS Rare Rare

Scarlet Fever

Rare
> 1.5

Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

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Differential Diagnosis
Viral Exan PATIENT Rubeola Age Sex 10 yrs old Male

Kawasaki TSS Cox

Scarlet Fever

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Fever
Hx Headache Sore throat Ab pain Rash TPC PE Submand LN Strawberry tongue Sandpaper rash Pastias lines

COURSE IN THE WARDS

Upon Admission
S/O
o Fever o Throat pain o Epig pain o Headache oSubmandibular LAD oRash : generalized oTongue : hyperemic oTonsils : hyperemic, Gr 3 oPastias lines oMurmur : Gr 3 LICS

A
Viral exanthem r/o Scarlet fever r/o Dengue fever

P
Diet : for age IVF : PLRS (3 cc/kg/hr) Labs : CBC CXR ASO Dengue Duo : Pen G 5M u q6 Hydroxyzine Paracetamol

Tx

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Admission RBC 3.65

Hemoglobin
Hematocrit WBC Segmenters Stabs Lymphocytes Monocytes Eosinophils

107
0.31 11.8 0.52 0.17 0.24 0.05

DENGUE DUO Dengue IgM- Negative Dengue IgG- Negative

ASO :712 CXR :Normal

(0-200 IU/ mL)

Platelet

208
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COURSE IN THE WARDS

Upon Admission
S/O
o Fever o Throat pain o Epig pain o Headache oSubmandibular LAD oRash : generalized oTongue : hyperemic oTonsils : hyperemic, Gr 3 oPastias lines oMurmur : Gr 3 LICS

A
Viral exanthem r/o Scarlet fever r/o Dengue fever

P
Diet : for age IVF : PLRS (3 cc/kg/hr) Labs : CBC CXR ASO Dengue Duo : Pen G 5M u q6 Hydroxyzine Paracetamol

Tx

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Upon Admission
S/O
Fever Throat pain Rash : generalized Tonsils : hyperemic, Gr 3

COURSE IN THE WARDS

A
Viral exanthem r/o Scarlet fever r/o Dengue fever

P
Infectious Disease Specialist Imp : ATP; Scarlet Fever Labs : Blood GS/ CS Throat swab CS Tx : Cont. meds

Murmur : Gr 2 Pansystolic 5th LICS

Pediatric Cardiologist Imp : VSD Labs : ECG 2D Echo Tx : No further intervention

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ECG: Normal

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COURSE IN THE WARDS

1st Hospital Day
S/O
Epig pain: persistent Fever
Strawberry tongue Submandibular LAD Tonsils : hyperemic Rash : generalized Murmur : gr 2 pansystolic 5th LICS

A
Scarlet Fever VSD

P
IVF : D5NM (3.7 cc/kg/hr) Tx :Omeprazole Cont. prev meds

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COURSE IN THE WARDS

2nd Hospital Day
S/O
Active, comfortable, good appetite Fever
Tongue/ Tonsils: hyperemia Submandibular LAD Desquamation of rashes Murmur 5th LiCS

A
Scarlet Fever

P
Tx: IVF: D5NM 1L x 70cc/ hr Prev meds continued
Day 2 of Pen G

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COURSE IN THE WARDS

3rd Hospital Day
S/O
Active, comfortable, good appetite
Fever Pruritus - back and Upper Ext Tongue/ Tonsils : hyperemia Submandibular LAD Desquamation of rashes Murmur 4th LICS

A
Scarlet Fever

P
IVF : D5NM 1L x 70cc/ hr
Labs: Rpt CBC Blood C/S result Tx :Pen G 1 M u q6

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Admission RBC Hemoglobin Hematocrit WBC Differential 3.65 107 0.31 11.8

3rd HD 3.67 111 32 10.8

Normal Values
4 5 x 10 (12) / L 120- 150 0.37- 0.45 5 10 x 10 (9) / L

Segmenters
Stabs Lymphocytes Monocytes Eosinophils Platelet

0.52
0.17 0.24 0.05

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1 47 1 4

0.55- 0.65
1. 0.05 0.25- 0.40 1. 0.06

208

262

150 400 x 10(9) /L

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COURSE IN THE WARDS

4th and 5th Hospital Day
S/O
Active, comfortable, good appetite

A
Scarlet Fever

P
IVF: D5NM 1L x 65cc/ hr

Afebrile
Tongue/ Tonsils : Non hyperemic Desquamation of rashes Murmur 5th LICS

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Throat swab CS

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COURSE IN THE WARDS

6th Hospital Day
S/O
Active, comfortable, good appetite

A
Scarlet Fever VSD

P
Blood CS : (-)
IVF: Consumed Tx : Clarithromycin
(250 mg/tab BID PO)

Afebrile

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PATIENT

R. C.

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PATIENT

R. C.
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PATIENT

R. C.

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PATIENT

R. C.

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COURSE IN THE WARDS

7th Hospital Day
S/O A
SENT HOME

P
HOME MEDICATION: Clarithromycin 250 mg/tab 1 tab BID 6 more days

FINAL DIAGNOSIS

Scarlet fever VSD

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FINAL DIAGNOSIS

Scarlet Fever
Congenital Heart Disease

Ventricular Septal Defect

Perimembranous type
not in failure

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