103.2 fever in 13 year old

•Explain how culture might impact the diagnosis, management, and follow-up care of patients with the musculoskeletal and/or neurologic disorders your colleagues discussed.

•Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives on the below casestudy.

Case Study 3:

HPI: Trevon is an 18-month-old with a 3-day history of upper-respiratory-type symptoms that have progressively worsened over the last 8 hours. Mom states he spiked a fever to 103.2°F this morning and he has become increasingly fussy. He vomited after drinking a cup of juice this afternoon and has refused PO fluids since then.

PE: VS: Temp: 102.5°F;

HEENT: Marked irritability with inconsolable crying, and he cries louder with pupil examination and fights head and neck assessment

ABD: negative abdominal exam

NEURO: You are unable to elicit Kernig’s or Brudzinski’s signs due to patient noncompliance.

1.What additional questions will you ask? 1.What type of medications has the child received; has he been around other sick individuals; has he had recurrent ear infections; has there been recent head trauma; ears, nose or throat symptoms; any GI symptoms; recent surgery; chronic health problems; skin rash; is he in daycare; recent travel; exposure to poisonous plants; exposure to animals; recently vaccinated?

2.Vaccination status would be extremely important, especially if this child has received the Haemophilus Influenzae type B (HiB) vaccine which is the most virulent and accounts for pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis media, purulent pericarditis, etc. in children younger than four (Burns et al., 2017).

2.What additional examinations or diagnostic tests, if any will you conduct?

1.Blood cultures, CBC with diff, CMP, ESR, CRP

2.Lumbar puncture with CSF testing of protein level, glucose concentration, Gram stain, culture, and cell count with differential (Buttaro et al., 2017).

1.What are your differential diagnoses?

1.Reye Syndrome – is encephalopathic process usually related to a viral infection and follows a predictable path starting with severe vomiting that progresses to irrational behavior and if left untreated can lead to death (Burns et al., 2017).

2.Bacterial Meningitis – bacterial meningitis is spread hematogenously predominately by the respiratory tract or contiguous spread from sinusitis, mastoiditis, or otitis media and is most common in children under two; initial symptoms in young children are fever and irritability and can also include photophobia (Buttaro et al., 2017).

3.Salicylate poisoning – salicylates are not recommended for children, but this child may have been exposed to medications that contain them such as aspirin or anti-diarrheal; salicylate poisoning symptoms include fever, tinnitus, nausea, vomiting, respiratory difficulty, agitation, confusion, and restlessness (Barnett & Boyer, 2019). Salicylate poisoning is diagnosed by plasma salicylate concentration and treatment is aimed at reversing the metabolic acidosis caused by salicylates (Barnett & Boyer, 2019).

1.What is your most likely diagnosis and why? 1.Bacterial meningitis – the majority of patients with bacterial meningitis will present with fever and signs of meningeal inflammation such as nausea, vomiting, irritability, anorexia, and photophobia and is usually preceded by an upper respiratory infection (Buttaro et al., 2017).

2.How will you treat this child? 1.Empirical IV antibiotic therapy should be started immediately and usually includes vancomycin 15mg to 20mg/kg every 8 to 12 hours plus a third-generation cephalosporin (cefotaxime 2g every 4 hours or ceftriaxone 2g every 12 hours), and can be narrowed to specific antibiotics once Gram stain and culture findings come back (Buttaro et al., 2017).

2.Dexamethasone 10mg IV every 6 hours for 4 days to minimize damaging inflammation (Buttaro et al, 2017).

3.Supportive: optimization of fluid balance and electrolytes, treatment of headaches, fever, and nausea, airway protection, management of ICP, and seizures (Buttaro et al, 2017).

3.Patient Education, Health Promotion & Anticipatory guidance: 1.Having a child hospitalized can be a very scary experience for parents, they need to understand that this is a serious condition that needs prompt treatment. Providing tools, resources and suggesting strategies are ways the healthcare practitioner can help families navigate stressful times (Hagan, Shaw, & Duncan, 2017).

2.Health Promotion: ◦What immunizations should this child have had? ◦This child should have already received the complete HepB series, rotavirus series, Hib series, PCV13 series, and HepA, three doses of IPV, four doses of DTap, and the 1st dose of MMR and VAR (CDC, 2015)

◦Based on the child’s age, when is the next well visit? ◦Next well visit should be at two years of age (Hagan, Shaw, & Duncan, 2017)

◦At the next well visit, what are the next set of immunizations? ◦Annual Influenza (CDC, 2015)

◦What additional anticipatory guidance should be provided today? ◦Anticipation of return to separation anxiety and managing behavior with consistent limits, recognizing signs of toilet training readiness and parental expectations, and managing forthcoming changes to the family (Hagan, Shaw, & Duncan, 2017).

References

Barnett, K. & Boyer, E. (2019). Salicylate poisoning in children and adolescents. Retrieved from http://uptodate.com.

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

Centers for Disease Control and Prevention. (CDC). (2015). Vaccines & immunizations. Retrieved from http://www.cdc.gov/vaccines/

Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics.