Transcript No Slide Title

Chapter 6
Fever
Case I
Case study: Baby Jone
Baby Jone is a 6 month old boy, brought to hospital with a two
day history of fever, lethargy and decreased feeding
What are the stages in the management
of Jone?
Stages in the management of a sick child
(Ref. Chart 1, p. xxii)
1.
Triage
2.
Emergency treatment
3.
History and examination
4.
Laboratory investigations, if required
5.
Main diagnosis and other diagnoses
6.
Treatment
7.
Supportive care
8.
Monitoring
9.
Discharge planning
10.
Follow-up
What emergency (danger) and priority (important)
signs do you notice from the picture?
Temperature: 39.7ºC, 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
What emergency treatment does Jone
need?
Emergency treatment
• Airway management?
• Oxygen?
• Intravenous fluids?
• Anticonvulsants?
• Immediate investigations?
□ Blood sugar
(Ref. Chart 2 p. 5-6)
Emergency treatment (continued)
Because of tachycardia, poor perfusion and cold
extremities insert intravenous drip and give 20 ml/kg
– Ringer’s lactate or normal saline solution
(Ref. Chart 7, p. 13)
Give emergency treatment until the
patient is stable
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: 39.7ºC, 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)
Additional questions on history
• Duration of fever
• Feeding pattern / vomiting
• Conscious state – irritable / lethargic
• Immunization history
• Infectious contacts
• Malaria endemic area
Further examination based on
differential diagnoses
• Look for signs of serious bacterial infection:
– Chest indrawing
– Rash / skin sepsis
– Stiff neck / fontanelle normal or bulging
– Ear-Nose-Throat examination
What investigations would you like
to do to make your diagnosis ?
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
□ Discuss expected findings from investigations
Full Blood examination
Haemoglobin:
119 gm/l (125 – 205)
Platelets:
45 x 109/l (150 – 400)
WCC:
23.4 x 109/l (5.0 – 19.5)
Neutrophils:
12.78 x 109/l (1.0 – 9.0)
Lymphocytes:
6.06 x 109/l (2.5 – 9.0)
Monocytes:
4.81 x 109/l (0.2 – 1.2)
Blood sugar: 3.9 mmol/l (3.0 – 8.0)
Malaria RDT: negative
Suprapubic aspirate
Urine
Protein / Glucose :
nil
Nitrate / Leucocyte esterase :
3+
Blood:
1+
Microscopy:
Red Blood Cells:
20 x 106/l n(<13)
Leucocytes:
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 / sepsis
How would you treat Jone?
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
What supportive care and monitoring
are required?
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
• Encourage regular breastfeeding
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
• Watch for progression or resolution of petechial
rash
Summary
• Infant with systemic infection due to urinary tract
infection
• Symptoms and signs often non-specific
• Importance of good history and examination,
screening investigations
• Management of early shock, antibiotics, ongoing
fluids
• Frequent monitoring
• Follow-up