FM&PH – Feverish child in the community

·       In module Family Medicine and Public Health

·       Luca is a 4-year-old boy, who has been brought to his GP with an episode of fever.  His mother is keen for him to have antibiotics.

·     MAIN CASE

Guidance and Resources – Feverish child in the community 

Case Introduction – Feverish child in the community 

Further Case Information – Feverish child in the community 

Background Science – Feverish child in the community   

Case Conclusion – Feverish child in the community 

Formative Assessment – Feverish child in the community 

CASE COMPONENT

Guidance and Resources – Feverish child in the community MED 35

In case FM&PH – Feverish child in the community

Reference materials and Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

Recommended essential Readings/Resources

· HealthAwareness/EducationalContent/vaccination/Pages/vaccination1.

· WHO cold chain

· NHS Choices: Why vaccinate your kids?

· Short video produced by Public Health England to address parental concern about vaccines and their child’s immune system.

· NICE Guideline: ‘Traffic Light Table’

· Acute Sore Throat (See Murtagh) see chapter 73

Additional Reading/Resources

· Chapter 1 The Green Book: Immunity and How Vaccination Works

·  Vaccine Safety and Adverse Reactions

· GMC 0-18 years: Guidance for all doctors

· Prescribing Handbook 1 and Prescribing Handbook 2 (iBook links)

· NICE Guideline: Fever in the under 5s, assessment and initial management

· Personal Child Health Record also known as ‘The Red Book’

What you have already covered related to this case

· UHSM Adult Antimicrobial Guide (App) – Select ‘University Hospital South Manchester’ from the list of hospital trusts

· Infectious diseases (eBook)

· You have already come across some of the issues relating to vaccinations and it is a good idea to refresh your memory relating to the issues around vaccinations.

· You have also come across the previous case of measles.

CASE COMPONENT

Case Introduction – Feverish child in the community MED 35

In case FM&PH – Feverish child in the community

Luca has just turned 4 years old. His mother, Sofia, has brought him to an emergency GP appointment with Dr Walsh. Sofia tells her that he has ‘a cold again’. His symptoms started 3 days ago with a cough, and for the past 2 days he has been complaining of a cough. He has had a temperature which started last night. Luca ‘always seems to be chesty’ and Sofia wants some antibiotics for Luca so that he gets better quicker and can go back to nursery.

He has been well in himself, playing and eating and drinking, and passing urine as normal. He has not had any stridor, shortness of breath, drooling or difficulty swallowing. He is chatty in the consultation, and does not appear to have any features to suggest immediate admission is required (including audible stridor, difficulty breathing or altered consciousness).

From the medical record, Dr Walsh sees that Luca is not up to date with his routine childhood immunisations.

Have a look at  KSA Childhood Immunisation Schedule. This is constantly updated so always best to check on-line for most up-to-date version.

What are the benefits of population vaccination programmes?

Adapted from: http://www.nhs.uk/Conditions/vaccinations/Pages/reasons-to-have-your-child-vaccinated.aspx

Not all children are up-to-date with their vaccinations.

Reasons parents may not have arranged vaccination could include:

IN PRACTICE:

Spend time with a practice nurse when giving immunisations. What does he/she tell the parents? How does she/he give the vaccination? What questions does she/he ask before administration of the vaccine?

Sofia reports that for the past three months, Luca has been snotty and unwell about once a month. This has coincided with him starting nursery. She has always brought him to the GP for an emergency appointment, like this appointment today, but has been told that the infection is viral each time and Sofia feels that she has been ‘fobbed off’. She is very concerned today as Luca has a raised temperature for the first time. She has wanted antibiotics each time, but never asked the GP, until now.

What is a normal temperature?

·          33.5ºC - 34.5ºC

·          34.5ºC - 35.5ºC

·          35.5ºC - 36.5ºC

·          36.5ºC - 37.5ºC

·          37.5ºC - 38.5ºC

IN PRACTICE:

See how the GP assesses children. What is asked in the history? What examinations are done? What features does the GP consider increase the chance of an infection being bacterial vs. viral? How does the GP communicate to a parent about viral illnesses and the use of antibiotics?

CASE COMPONENT

Further Case Information – Feverish child in the community 

In case FM&PH – Feverish child in the community

Before Dr Walsh discusses management with Sofia, she needs to make a careful assessment, as with any child, and particularly for a child with a history of fever. This involves ‘triadic consulting’ skills, which is where there is a history from a third party.

Accurate assessment of a child with fever is essential.

NICE have produced a guideline to help with the assessment of a child with fever, which helps the healthcare professional in the community assess risk, and if the child needs immediate treatment, or to be assessed in hospital and how urgently. This is often referred to as the ‘Traffic Light System’. The NICE guidelines are crucial reading here.

There are also specific symptoms and signs which indicate serious diseases and should always be considered.

Consider the following diseases, and drag and drop each of the symptoms to the corresponding disease which the sing or symptom can indicate

Dr Walsh takes a more thorough history, to enquire about any additional symptoms which Sofia has not yet mentioned, and specifically those which could indicate a serious condition as outlined in the table above.

She asks her about fevers specifically, and Sofia says that usually the temperature is around 37 degrees at home, but last night for the first time it was over 37.5, at 37.8. She feels that this definitely means that Luca needs antibiotics.

Dr Walsh also finds out through the consultation that Luca is Sofia’s only child and she is single parent, age 21, living in a one bedroom flat with Luca. She came to the UK five years ago from Lithuania, and has struggled to make ends meet. She is now working part time (3 days a week) and she can’t afford to take any more time off her work as a waitress in order to look after Luca when he is ill. This is partly why she wants antibiotics this time.

Sofia smokes 12 cigarettes per day, and has done so since she was 17.

Dr Walsh asks more about the cough, and if Sofia has noticed Luca seeming short of breath, which he has not. She also outlines what signs to look for in terms of increased work of breathing for future, and checks that Sofia has not seen any of these signs.

What signs should Sofia be looking out for which might indicate increased work of breathing?

You should try to see as many clinical signs in children as you can on your GP placements, and also during your Acute Illness block next year as assessment of children will form part of your Foundation Doctor work and training.

Dr Walsh has been looking at Luca during the consultation so far, and has noticed that he is alert and interested in his surroundings. He has not been drooling and there are no features in the history which alert Dr Walsh to epiglottitis.

What features might suggest epiglottitis?

Why is it important that Dr Walsh considers epiglottis before examining Luca’s throat?

Dr Walsh examines Luca and notes the following:

· Red cheeks

· Snotty nose

· No photophobia

· No drooling

· Red enlarged tonsils but no exudates

· No neck stiffness

· No enlarged lymph glands

· Temperature is 37.7°C

· Respiratory rate is 24 breaths/minute, sat 99%, no increased work of breathing, chest is clear

· Heart rate is 100 beats/minute, heart sounds normal

· Warm, pink peripheries

· Capillary refill normal

· No rashes on full exposure

· Alert and smiling

· Abdomen soft, non-tender, normal bowel sounds

For children, it is important to consider a full examination and documentation of key findings, and including key negative findings.

What is the most likely diagnosis based on the history of sore throat, cough, coryzal symptoms and one episode of fever, and in combination with the examination findings above?

·          Pneumonia

Pneumonia is not the most likely diagnosis. Although there is a history of cough, there is no increased work of breathing or Tachypnoea. The chest is clear with normal saturations. Heart rate is also normal. Another diagnosis  is therefore more likely.

·          Meningococcal septicaemia

.This is not the most likely diagnosis given the lack of symptoms which are consistent with this diagnosis (see table above), lack of supporting signs on examination (see table above) and normal physiological parameters (review the traffic light system above to check). However, it is always important to consider diagnoses that you wouldn’t want to miss.

·          Tonsillitis/Pharyngitis

.

Correct answer.

This is a likely diagnosis given the history of sore throat, enlarged tonsils and fever. The physiological papameters put Luca in the low risk group, and so can  at this stage be managed in the community and with his mum,  without further specialist assessment.

Dr Walsh outlines to Sofia that she thinks that Luca has a throat infection. Sofia smiles and says ‘Great, I knew it. What antibiotic does Luca need?’

Does Luca require antibiotics?

The GP might also consider antibiotics in certain other situations, including immunocompromise, systemic upset or valvular heart disease. A peritonsillar abscess or cellulitis on examination would require immediate admission.

What is the Centor Criteria?

What is Luca’s Centor Criteria score?

·                1

·          2

·          3

·          4

What is the normal capillary refill time for a child of 2 years?

·          <1 second

·          <2 seconds

·          <3 seconds

·          <4 seconds

What age do children in the KSA currently get their first Meningococcal C vaccination?

 12 weeks

 12 months

 2 years

 12 years

 16 years

What serious underlying pathology would the following alert the GP to consider?

Non-blanching rash, particularly with 1 or more of the following:

•    an ill-looking child
•    lesions larger than 2 mm in diameter (purpura)
•    capillary refill time of ≥3 seconds
•    neck stiffness

·          Bacterial meningitis

·          Kawasaki disease

·          Meningococcal septicaemia

·          Pneumonia