1. Chapter 6 Fever Case I

2. 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

3. What are the stages in the management of Jone?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment, if required
History and examination
Laboratory investigations, if required
Differential diagnoses
Main diagnosis
Treatment
Supportive care
Monitoring
Plan discharge
Follow-up, if required

5. 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

6. 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

7. What emergency treatment does Jone need?

8. Emergency treatment □ Blood sugar Airway management? Oxygen?
Intravenous fluids?
Anticonvulsants?
Immediate investigations?
□ Blood sugar
(Ref. Chart 2 p. 5-6)

9. 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)

10. Give emergency treatment until the patient is stable

11. 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.

12. 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

13. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p. 151)

14. Additional questions on history
Duration of fever
Feeding pattern / vomiting
Conscious state – irritable / lethargic
Immunization history
Infectious contacts
Malaria endemic area

15. 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

16. What investigations would you like to do to make your diagnosis ?

17. Investigations □ Discuss expected findings from 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

18. Full Blood examination
Haemoglobin: 119 gm/l (125 – 205)
Platelets: x 109/l (150 – 400)
WCC: x 109/l (5.0 – 19.5)
Neutrophils: x 109/l (1.0 – 9.0)
Lymphocytes: 6.06 x 109/l (2.5 – 9.0)
Monocytes: x 109/l (0.2 – 1.2)
Blood sugar: 3.9 mmol/l (3.0 – 8.0)
Malaria RDT: negative

19. Suprapubic aspirate

20. Urine Protein / Glucose : nil Nitrate / Leucocyte esterase : 3+
Blood:
Microscopy:
Red Blood Cells: 20 x 106/l n(<13)
Leucocytes: x 106/l

21. 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/Urosepsis

22. How would you treat Jone?

23. 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

24. What supportive care and monitoring are required?

25. Supportive Care Fever management (Ref. p. 305)
Nutritional management (Ref )
Fluid management (Ref. p. 304)
Give initially IV fluids because of signs of shock, but then reduce the rate
Encourage regular breastfeeding

26. 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)

27. 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

28. 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