PRE SCHOOL CHILD

PRESENTING WITH FEVER AND

COUGH
BY
SUCHINTHA TILAKARATNE
HARSHA WIMALARATHNA
History
Miss Radha Gimhani
5 years old (Date of Birth: 28
nd
April
1999)
No 73, Sri Nanda Mawatha, Madinnagoda,
Rajagiriya.
Date of admission: 10
th
November 2004
8:30 am
PLAN
History
Examination
Summary
Problems Identified
Management & Discussion

History
Presenting complaint

Fever for 9 days
Cough for 6 days
Difficulty of breathing for one day

History of presenting complaint
Apparently well on 30 /10/2004
Day 1 ( 31/10/2004)
Fever
Not documented
No chills and rigors
Intermittent fever responding to paracetamol
Measures taken
Tepid sponging
Paracetamol tablet (250mg) 6 hourly
Fever temporarily subsided


History
Day 2 ( 01/11/2004)
intermittent fever responding to paracetamol






History
Day 3 ( 02/11/2004)
Intermittent fever responding to paracetamol
Cough
Dry/non productive
Worst at night
sleep not disturbed
Treatment LRH OPD.
Amoxycillin 1 capsule (250mg) tds 3 days
Paracetamol tablet (250mg) qds 3 days
Vitamin C tablet


British Thoracic Society
Indicators for admission to hospital in older children:

oxygen saturation <92%, cyanosis;

respiratory rate >50 breaths/min;

difficulty in breathing;

grunting;

signs of dehydration;

family not able to provide appropriate observation or supervision.

History
Day 4,5
Fever and cough continued despite
treatment
Day 6 (05/11/2004)
Treatment LRH OPD - full blood count done
Sent home with medication
Amoxycillin 1 capsule (250mg) tds 3 days
Paracetamol tablet (250mg) qds 3 days
Vitamin c tablet


Full blood count

WBC 5400 /L (6000- 15000)
DC Neutrophils 73% (3942/ L)
Lymphocytes 25% (1350 / L)
Monocytes 2% (108 / L)
PCV 32%
Platelet count 152000/ L)

History
Day 7 & 8
Fever and cough continued despite
treatment
On day 8 evening she developed difficulty
of breathing

Day 9 (10/11/2004 8.30 am)
Increase in cough and fever
Admitted to Ward 1
On admission fever 102 F
Difficulty of breathing present
No sputum
No chest pain


History
History
No history of sore throat
No chest pain
No wheezing
No urinary symptoms
Bowel habits normal
No vomiting
Loss of appetite present through out the
illness




History
No skin rashes or bleeding manifestations
No recent contact history of fever
No visits to malarial areas
No neck pain or fits
No headache
No earache
History
D9 (at ward)
Paracetamol given
Tepid sponging done
Blood taken for investigations
X ray taken
Drugs given by needle
Cough,fever persistant

History
D10
Chest exercises started
D11
Nebulization started
D13
X ray taken
History
D14
Blood taken for a test
Chest exercises stopped
Scan done

D16
Blood sent for an out side investigation

History
D18(morning)
Scan done

D18(evening)
Child active
Improved appetite
Cough and fever present
Well between fever episodes

Past medical history
No significant past medical history
No history of recurrent chest infections
or wheezing


Birth history

unplanned pregnancy, Uncomplicated
Normal vaginal delivery
Birth weight 2. 75 kg
No post natal complications
Exclusive breast feeding up to 4 months


Immunization
Development age appropriate
Immunization up to date
All EPI vaccines given at appropriate ages
JE 3 doses given
Hib not given


CHDR
CHDR
Feeding history
On adult diet

Early morning full cream milk (2 tea spoons) with 2 biscuits
Mid morning Samaposha, noodles, rice 1-2 cups
Lunch rice, fish,vegetables
Evening tea with 2 biscuits
Night rice with fish and vegetables
Before sleep - full cream milk (2 tea spoons) with Sustegen


Family history
Non consanguinous marrriage
No family history of asthma, chronic
cough

37yr
38yr

6yr 6yr

5yr
Social history
Father

Electrician
39 years old
Education A/L
Working in Dubai for past 3 years
Income Rs. 25000 per month
Occasional alcoholic
Smokes 2 3 cigarettes per day

Mother
Housewife
37 years old
Education O/L
Contraceptives OCP

Social history
Elder brothers
6 years old
Schooling grade one


Grand parents
Healthy
Capable of looking after children


Gimhani
Attending nursery school km from home




Social history
Housing
Fully completed single story house
Toilet water sealed squatting type, attach to the
house
Pipe borne water
Water boiled before drinking
Bed room
Good ventilation, neatly maintained
Social history
Pre school
Around 20 children in the class
Well ventilated
No recent outbreak of fever or cough in the class



Pre school
Examination (On admission)
General examination
Weight 15.5kg ( Between 3
rd
10
th
centiles)
Height 112cm ( Between 50
th
75
th
centiles)
Ill looking
Dyspneic at rest
Hydration adequate
Temperature 102 F
No pallor
Good oral hygiene,throat not inflamed
No dental caries
Bilateral cervical lymphadenopathy present
Discrete,mobile,non tender lymphnodes
no skin rashes
BCG scar present

Examination
Respiratory system
RR 38/min (normal 30/min)
Nasal flaring present
No chest wall deformities
Intercostal recession present
Trachea central
Apex beat not shifted
Dullness on right lower zone
Bronchial breathing on right lower zone
Air entry decreased on right lower zone
No pleural rub

Examination
Cardiovascular system
Pulse rate 92 beats /min (80 -120)
Regular good volume
Blood Pressure 90/60 mmHg
Dual rhythm. No murmurs
Examination
Abdomen
Not distended
Soft
Non tender
No hepatomegaly
Examination
Nervous system
No neck stiffness
Kernigs sign negative

Summary
5yrs old Gimhani presenting with
fever for 9 days, dry cough for 6 days
and difficulty of breathing for one day
On examination fever 102 F, mild
dyspnea and cervical lymphadenopathy
Dullness on right lower zone with
bronchial breathing and decreased air
entry

Problems identified
Lower respiratory tract infection
Loss of preschool activities
Anxiety of the mother
Absence of father
Lack of proper spacing between
children
Diagnosis Pneumonia
Cough and fever
Difficulty of breathing

Increased respiratory
rate
Nasal flaring
Intercostal recessions
Dull to percussion
Decreased air entry
Bronchial breathing


MANAGEMENT AND DISCUSSUON
day 9 (D
1
)


ACUTE MANAGEMENT
TEPID SPONGING
Paracetamol 250mg 6 hourly


DAY1 DAY2 DAY3 DAY4 DAY5 DAY7 DAY8
98
99
100
101
102
103
104
0 5 10 15 20 25 30 35
FEVER PATTERN


D
1
D
2
D
3
D
4
D
5
D
6
D
7
D
8
D
9

IV penicillin

IV Gentamicin

IV Cefotaxime

IV Clarithromycin
MANAGEMENT AND DISCUSSION
Subsequent management (D
1
)
bed in the acute side
QHT
Paracetamol 250mg (10 15 mg/kg) 6 hourly
Salbutamol 2mg 8 hourly
Chart RR 2 hourly

MANAGEMENT AND DISCUSSION
INVESTIGATIONS (D
1
)
WBC/DC
ESR
CXR (URGENT)
Mycoplasma antibodies


Sputum culture & ABST
Blood culture
Viral studies

MANAGEMENT AND DISCUSSION
WBC/DC

WBC 6700/L (6000- 15000)
DC Neutrophils 72%
Lymphocytes 20%
Monocytes 6%
PCV 40%
Platelet count 200000/ L)
Hb 10.1 g/dL (10.5 14 g/dL)
ESR 68mm 1
st
hour
CXR(D
1
)

MANAGEMENT AND DISCUSSION
D
1 afternoon
C. Penicillin 1.5 million units 6 hourly after ST
ST negative

D
1 5 pm
Fever and dry cough present
No vomiting
MANAGEMENT AND DISCUSSION
D
2 (11/11/2004)
Fever spikes present Ex- RR - 40/min
Dry cough present signs of consolidation
Hydration adequate No signs of effusion

Mx Chest physiotherapy

MANAGEMENT AND DISCUSSION
D
3 (12/11/2004)
Fever spikes Ex-RR- 48/min
Dry cough signs of consolidation
SOB & intercostal recession
no effusion

Hydration adequate
No chest pain
Mx IV Gentamicin 37 mg 8 hourly 3-5 mg/kg/day
MANAGEMENT AND DISCUSSION
Ototoxicity
Peak / trough blood levels
MRI

Why not done?

MANAGEMENT AND DISCUSSION
D
3 7.30pm
Fever spikes PR 150/min(80- 120)
Increased cough BP 90/70 mmHg
SOB O2 saturation 95%
Intercostal recessions
Mx
Nebulize- salbutamol 5mg with normal saline 4
hourly
MANAGEMENT AND DISCUSSION
D
4 (13/11/2004)
Fever spikes Ex-RR- 44/min
Dry cough signs of consolidation
SOB & intercostal recession
no effusion

Hydration adequate
No chest pain

MANAGEMENT AND DISCUSSION
D
5 (14/11/2004)
Fever spikes
Dry cough
Signs of consolidation
Mx- CXR
IV cefotaxime 250 mg 8 hourly
MANAGEMENT AND DISCUSSION
D
6 (15/11/2004)
No improvement in the clinical state

Mx
Blood culture
Stop physiotherapy
USS (right lower lobe consolidation with a small pleural effusion)

MANAGEMENT AND DISCUSSION
D
7 (16/11/2004)
No improvement in the clinical state
Mx
Blood for mycoplasma antibodies (private sector)
Inward cold agglutination test positive
IV Clarithromycin125mg/5% dextrose 100cc/12 hr
(125mg/12hr)
Omit Gentamicin and C. Penicillin
Hb- 9.5 g/dL
MANAGEMENT AND DISCUSSION
Inward cold agglutination test
o 1ml of blood
o Anticoagulated bottle
o Cooling 4
0
C
o 3-4 minutes
o Check for agglutination of RBC
nonspecific test
MANAGEMENT AND DISCUSSION
Serum bilirubin- total \direct\ indirect
Blood picture
Blood for cold agglutinin titres (1:32)
Coombs test
MANAGEMENT AND DISCUSSION
D
8(17/11/2004)
No significant clinical improvement
signs of consolidation
Blood culture negative
Mx
Start chest physiotherapy
MANAGEMENT AND DISCUSSION
D
9(18/11/2004)
Fever spikes present
Appetite improving
No sleep disturbances
Signs of consolidation present


USS (right lower lobe consolidation with a small pleural effusion,
no evidence of empyema)


MANAGEMENT AND DISCUSSION
D
9(18/11/2004)

Traced the mycoplasma antibody test in
MRI
Report - Significant titer suggestive of recent
mycoplasma infection
Mycoplasma
Further management
IV clarithromicin
CXR
Problems identified
Lower respiratory tract infection
Loss of preschool activities
Anxiety of the mother
Absence of father
Lack of proper spacing between
children
THANK YOU