Clipp 23 PDF
Clipp 23 PDF
Case 23
15-YEAR-OLD WITH LETHARGY AND FEVER -
SARAH
Author: Steve Miller, M.D., Columbia University
Learning Objectives
Students will be able to describe:
Rash
Lethargy
Key Findings from History
Tachypnea
Decreased urine output
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Petechial rash
Key Findings from Physical
Tachycardia
Exam
Nuchal rigidity
Hypoglycemia
Poisoning
Diabetic ketoacidosis
Central nervous system tumor
Differential Diagnosis Meningitis
Renal failure
Encephalitis
Pneumonia
Sepsis
Case highlights: The case teaches when and how to triage over the phone, and
what information to gather before advising a patient to be seen in the emergency
department. Once Sarah arrives at the hospital, the case focuses on how to
determine level of consciousness, assess airway, breathing, and circulation, and
determine if a patient is in shock. Students learn how to manage a patient in
shock and how to administer fluids to maintain perfusion. Having determined that
Sarah has meningococcemia, students learn how to treat the disease and how to
break the bad news to her parents. Multimedia features include photographs and
drawings illustrating how to open a childs airway.
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Types: Hypovolemic and septic shock are most common causes of shock in
children.
Skills
Principles of telephone triage: It is highly risky to offer advice over the
telephone to a patient not known to the physician. Even if the physician does
know the patient, caution must be used. Keep these guidelines in mind:
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he contagious, etc.). If the family calls and asks about a new problem or
condition, then the same rules apply as if this was a patient you had never
seen before.
If advice is given, it must be documented.
Always start with the ABCs: It is essential to look first for anything that
reduces oxygen and critical nutrients to cells:
Airway: If patient does not seem to be moving air with breathing, first check the
airway and determine if there is an obstruction. May need to:
Breathing: Observe effort and rate of breathing, how the patients lungs sound,
and if they are well oxygenated:
Circulation
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Exposure and Environment: Expose and examine all parts of the patient, and
keep the patient warm during the evaluation
Make sure the patient and family are comfortable and have support people
with them.
Ask what the patient or parent knows and what their concerns are.
Tell them the diagnosis and what the treatment is without using medical
jargon.
Tell them the prognosis.
Be honest and give some way to offer hope.
If the situation is bleak, give the patient and family short-term goals and
tasks.
Differential diagnosis
Altered mental status or lethargy in a child:
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Studies
Complete blood count (CBC) with differential and platelets, blood/urine
culture,and gram stain: These are needed to rule sepsis in or out as soon as
possible. Also, blood and urine cultures must be obtained before starting
antibiotics.
Management
Initial emergency management of shock
Reference: Behrman RE, Kliegman RM, Jenson HB, Stanton BF. Nelson Textbook
of Pediatrics, 18th Ed. Philadelphia, Pennsylvania. 2007
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Immunization:
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