Intern Report 8.20

internreport

Case Presentation by Khoa Nguyen, MD

CC: “fever and runny nose”

 

HPI: 9-day-old full term female born via C-section who presents with cough, rhinorrhea, and tactile fever. Patient’s mother stated that the patient had rhinorrhea 3 days ago who then developed a cough the following day. The mother then felt that the patient was warm in the back but did not measure any temperature. The patient was not given any anti-pyretic or antibiotics. There had been green discharges from the eyes. Patient had 2 episodes of non-bloody nonbilious emesis that looked like her feeds. Patient had been sleeping more than normal. On further questioning, the patient’s mother had GBS and Chlamydia with this pregnancy and had HSV during the previous pregnancy.   There were no changes in the number of wet diapers and no changes in PO intake.

 

ROS:

Constitutional: positive for tactile fever

HEENT: positive for rhinorrhea, green discharges from eyes, and congestion

CV: neg

Pulmonary: positive for coughing

GI: positive for 2 episodes of NBNB emesis. No changes in appetite and PO intake.

GU: no change in number of wet diapers

The rest of the ROS were negative

 

PMH/PSH: none

Allergies: NKDA

Immunizations: UTD

Birth history: 39 wks, repeat c-section

Family history: Mother was treated for GBS and chlamydia with this pregnancy

 

Physical Exam:

Vital signs: Temperature 37, HR 160, RR 30, BP 67/41, 98% on RA

General: patient is alert and responsive to touch

HEENT: NC/AT, anterior fontanelle is open, soft, and flat. There is bilateral eye discharge with crusting. No chemosis. Eyelids appear normal. TMs are clear. Oropharynx within normal limits

Neck: supple

CV: RRR, S1 S2, no notable murmurs

Lung: Clear to auscultation bilaterally

GI: soft, nontender, non distended, no masses

MSK: moving all extremities

Skin: no rashes, bruising

Neuro: normal moro, rooting, grasp

 

Questions:

  1. What is the workup for this patient?

A. Patient does not need a workup.

B. Full sepsis workup: LP, CBC, CXR, LP, UA with culture, blood culture, RSV/Flu.

C. UA with culture, CBC, Chest x-ray

D. Rapid Viral antigen testing

 

  1. What is the management?

A. PO challenge and discharge home after reassuring the mother that this is likely a viral infection and that she needs to follow-up with PMD.

B. Ampicillin, ceftriaxone, and acyclovir

C. Ampicillin and acyclovir

D. Ampicillin, cefotaxime, and acyclovir

 

  1. Which of the following is true?

A. Management of pediatric fever is the same throughout all ages.

B. Defervescence after acetaminophen administration has been shown to reliably exclude bacteremia in children of any ages.

C. The absence of fever does not eliminate the possibility of serious bacterial illness.

D. A thorough history and physical exam can exclude a serious bacterial illness in a patient less than 28 days old.

 

Answers:

1. B
2. D
3. C

 

Pediatric patients from 0-28 days of age who present with a fever are at a high risk for bacterial illness. Fever may be the only clinical manifestation of a potentially life-threatening disease. However, in this age group, the absence of fever does NOT eliminate the possibility of serious bacterial illness because more than half of neonates with meningitis are afebrile.

The physical exam in this age group is insensitive to exclude serious bacterial illness.

Here are some of the findings to suggest bacterial meningitis:

Vital signs – apnea, tachypnea, hypothermia, hyperthermia, bradycardia, tachycardia. The absence of fever does not rule out the possibility of serious bacterial illness.
Behavior – listless, restless, irritable, lethargy, change in sleeping pattern
Neurologic – high pitch cry, nystagmus, vacant stare, seizure, altered tone, absence of cry
Dermatologic – cyanosis, petechiae, purpura, livedo reticularis
GI – altered feeding, diarrhea, vomiting, abdominal distention, jaundice

 

B – Although the patient has symptoms to suggest a viral infection, she needs a thorough workup given her age. A change in sleeping pattern, cough, eye discharges, and tactile fever must be taken seriously. Additionally, the patient’s mother has a history of GBS, chlamydia, and HSV which all put the patient at risk of a serious infection. For these reasons, the patient needs a complete sepsis evaluation.
D – The patient should be treated empirically with broad spectrum medications in the ED given her risks of a serious infection. Ceftriaxone should be avoided in patients younger than 28 days because of a hypothetical risk of causing bilirubin encephalopathy since this medication causes bilirubin to be displaced from protein binding sites.
C – Management of pediatric fever depends on the age of the patient. Defervescence of a fever after Tylenol ingestion does not exclude bacteremia in children of any ages.

 

References:

Marx, JA, Hockerberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th edition), Mosby 2013.

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