Case StudyKristen Deep, FNP-SNUR 670Intermediate Family Clinical

Patient D.C. was seen during family practice

clinical rotation. He is five years old. He came into health center for episodic visit.

History of present illness D.C. presented to the health center 9/10/13. His mother states that

he had fever of 102°-103° since 9/8/13. On day 1, fever was alleviated when dose of Tylenol was given, but would spike again when he was due for his next dose. On day 2, fever went down to 100° when dose of Tylenol was given. Pt. was slightly lethargic, had runny nose, and dry cough as the day progressed, so mom brought him to ER in the early evening. She states that they did a rapid strep test, but it was negative. Mom had not heard from ER regarding overnight throat culture results. Urine dip was negative, and culture results were unavailable. She brought him into health center today because she noticed a rash on his chest, stomach, and arms during the middle of the night. Mom states that rash has progressed to legs this morning. Pt. also started complaining of a sore throat this morning. Last dose of Tylenol was 40 minutes prior to this visit. There has been no travel outside the state or country. No one else in the home is sick.

Past Medical History Healthy 5 year old boy. He just started kindergarten last

week. Goes to daycare before and after school four days a week

One case of strep when he was four years old. 1-2 ear infections per year since he was two years old.

No chronic illness, injuries, or accidents. No hospitalizations. All immunizations are up to date. He has not had a flu

vaccination this year because they are not available at office yet.

Last physical exam was 5/2013. NKA/NKDA No current medications.

Family HistoryMother, age 31, alive and well.Father, age 31, alive and well. Brother, age 3, alive and well.Sister, age 7-several UTI’s from age 8 months to 1 ½ years old. Negative for vesicoureteral reflux. U/S was WNL. Maternal grandparents, alive and well. Paternal grandmother- hyperlipidemia, hypothyroidism.Paternal grandfather-HTN (newly diagnosed)Other family history unremarkable. -No family hx of heart disease, diabetes, stroke, or cancer.

Review of Systems General Health-good Skin-mom noticed rash to trunk, arms, and legs. Began during the middle

of the night. Described as smooth, with no bumps felt. Head-No headaches, dizziness, or syncope. Eyes-No discharge, eye pain, inflammation, redness. Ears-No hearing loss or difficulty. No earaches, discharge, tinnitus. Nose-Clear nasal discharge for 2 days. No sinus pain, epistaxis, or allergies. Mouth and throat-Sore throat since awakening this morning. No dysphagia,

hoarseness, other mouth pain. Has tonsils. Neck-No neck pain, swollen glands. Respiratory-Dry cough for two days. Lives in a non-smoking home. No pets. Cardiovascular-No chest pain, palpitations. No history of murmurs. GI-Decrease in appetite since the day fever developed. Able to tolerate

fluids and has been keeping hydrated. No constipation or diarrhea. GU-No dysuria, frequency, urgency, hesitancy, or straining. No pain in

flank, groin, or suprapubic region. Urine has been clear, yellow with no foul odor. No blood reported in urine.

Differential Diagnoses Viral exanthem Measles Rubella Infectious Mononucleosis Roseola Kawasaki disease Severe sunburn Toxic Shock Syndrome Drug rash Dermatitis

Physical Exam BP-102/62, HR-98 bpm, Temp-102.2°orally. RR-20/min. Weight 20kg, Height-42” Skin- Generalized fine, red papules noted to neck, trunk, arms, and legs

bilaterally. Rash blanches when pressed. Has a “sandpaper” quality to it. No open lesions noted.

Eyes-PERRLA, no discharge or crusting. Ears-TM’s intact, pearly gray, without perforation bilaterally. Landmarks visible. Nose-Nares patent. Mucosa red with clear drainage noted. No frontal/maxillary

sinus tenderness. Mouth/Throat- Mucosa pink. Pharynx red. Tonsils 3+ bilaterally, without

exudate. Uvula rises midline on phonation. Gag reflex present. Neck-Anterior cervical nodes enlarged (L>R). Left node tender to palpation. Lungs-Clear to auscultation bilaterally. Heart-No abnormal pulsations or heaves. S1 and S2 audible. No S3 or S4, or

murmur noted. Abdomen-Soft, non-distended. No masses, tenderness, or hepatosplenomegaly.

Rash

Any Guesses

?

Scarlet Fever Usually a childhood disease

characterized by fever, pharyngitis, and rash caused by group A β-hemolytic Streptococcus pyogenes (GAS)that produces a erythrogenic toxin (Huscher & King, 2013).

Why Scarlet fever? We did not have any information from

ER visit, so after examination of the child, another rapid strep test was completed. This test came back positive. The mother also verbalized that the person who took throat specimen in ER did not get good swab because the child was not being cooperative.

Refining list of diagnoses Exanthem is another name for a rash or skin

eruption. Causes can include infectious pathogens and/or medication reactions. Viral infections are the most common exanthems. The five most common childhood viral exanthems are:

-Measles or rubeola-Rubella-Varicella-Fifth disease-Roseola

(Lam, 2010).

Facts about Scarlet Fever Incubation period:1-7 days Duration of Illness: 4-10 days Rash usually appears on the second day of

illness. Rash first appears in the upper chest and

flexural creases and then spreads rapidly all over the body.

Rash clears at the end of the first week. Also known as Scarlatina.

(Huscher & King, 2013).

EpidemiologyIncidence and Prevalence Fairly common; rare in infancy because of

maternal antitoxin antibodies. Predominant age: 6-10 years old. Males and females both get it in equal

numbers. 5-30% of pediatric sore throats are due to

GAS. <10% of children with streptococcal

pharyngitis develop scarlet fever. (Huscher & King, 2013).

Pathophysiology Erythrogenic toxin produced by phage is

necessary for scarlet fever. A, B, and C types Toxins damage capillaries causing rash and

act as superantigens stimulating cytokine release.

Antibodies to toxins prevent development of rash but do not protect against underlying infection.

(Huscher & King, 2013).

Etiology Site of streptococcal infection is usually

tonsils; may occur with infection of skin, surgical wounds, or uterus (Huscher & King, 2013).

Signs and Symptoms Prodromal phase is 1-2 days

Sore throat Headache Myalgias Malaise Fever > 100.4 Vomiting Abdominal pain Rash Cough

(Huscher & King, 2013).

Assessment FindingsORAL Beefy red tonsils and pharynx with or

without exudate. Petechiae on palate White coating on tongue: White strawberry

tongue appears on days 1-2. This sheds by day 4-5, leaving a red strawberry tongue, which is shiny and red with prominent papillae.

(Huscher & King, 2013).

Strawberry Tongue

Assessment FindingsSKIN Scarlet macules over generalized erythema. Sandpaper-like texture of rash Sunburn with goose bumps. Starts on chest and axillae, then spreads to abdomen

and extremities-prominent in skin folds. Does not appear on palms and soles of feet. Petechiae and increased redness in antecubital and axillary skin folds (Pastia’s lines) can be helpful in making the diagnosis (McKinnon, Jr. & Howard, 2000).

Flushed face with pallor around lips, but red lips. Blanches if pressed.

(Huscher & King, 2013).

Management Plan Amoxicillin 400mg/5ml-Take 2.5tsp daily for 10 days. Tylenol 240mg-give every 4-6 hours as needed, but

not more than 5 times in a 24 hour period. Follow-up throat culture is not needed unless patient

is symptomatic. According to the American Academy of Pediatrics, if rapid strep is negative, then it is good practice to send specimen for culture because rapid strep test can read as a false negative, when there is actually strep present (Gieseker, Roe, MacKenzie, Todd, 2003).

Good hydration.

Education Brief delay in initiating treatment while waiting for throat culture

results does not increase the risk of rheumatic fever (Huscher & King, 2013).

Antibiotics should be taken for the full course(Huscher & King, 2013).

Children should not return to school or daycare until they have been on antibiotics for >24 hours (Huscher & King, 2013).

Can spread from person to person, so avoid contact. Frequent hand washing. Avoid contact with respiratory secretions of infected person (Hollier

& Hensley, 2011). Prophylactic penicillin is not recommended after exposure to scarlet

fever (Hollier & Hensley, 2011). Antibiotics started within 10 days after onset of symptoms effective

in preventing rheumatic fever (Hollier & Hensley).

ReferencesGieseker, K.E., Roe, M.H., MacKenzie, T, & Todd, J.K. (2003). Evaluating the American Academy of Pediatrics diagnostic standard for streptococcus pyogenes pharyngitis: Backup culture versus repeat rapid antigen testing. Pediatrics 111(6), 666-670. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12777583

Huscher, J.C. & King, M.S. (2013). Streptococcal Pharyngitis and Scarlet Fever. In F.J. Domino (21st ed.). The 5-minute clinical consult 2013. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Hollier, A., & Hensley, R. (2011). Clinical guidelines in primary care: A reference and review book. Lafayette, LA: Advanced Practice Education Associates, Inc.

Lam, J.M. (2010). Characterizing viral exanthems. Pediatric Health, 4(6), 623-635. Retrieved from www.medscape.com/viewarticle/734882_6

McKinnon, Jr., H.D. & Howard, T. (2000). Evaluating the febrile patient with a rash. American Family Physician 15(4), 804-816. Retrieved from http://www.aafp.org/afp/2000/0815/p804.html