M.D., 3 years old from,was admitted for the first time in a hospital on june 18, 2007.
Chief complaint: fever and rashes
History of present illness:
Condition started 5 days prior to admission as sudden onset of fever, temperature range= 38-38.5C. Patient was given Paracetamol 5 ml every 4 hours which afforded temporary relief. Decrease in the appetite was noted. Parents did not seek consult because of financial difficulty. The morning prior to admission, temperature was noted to be 39C and parents noted rashes on the face which gradually spread.
(+) cough
(+) soft watery stool 1-2 episodes/day
(-) vomiting
Past history:
Prenatal: Mother is G2P2002. Had prenatal check up at the health center. No meternal illness incurred during the entire gestation. Took multivitamins regularly.
Natal: patient was delivered at home assisted by a midwife. Good spontaneous crying was noted right after delivery. BR= 2/2
Postnatal: Patient was breastfed since birth up to 6 months old. Solid food was introduced at 5 moths old. Developmental milestones – unremarkable.
Immunization status: complete primary immunization done at the health center.
P.E: examined a conscious, febrile patient with the following vital signs
HR= 100/min RR=25/min Temp= 39C
Weight= 13Kg
Skin: (+) maculopapular rashes from the face down to the upper chest
HEENT: (+) “redness” of the eyes, (-) eye discharge, (+) watery nasal discharge, (-) tonsillopharyngeal congestion
Neck: supple
C/L” equal chest expansion, harsh breath sounds
CVS: regular rate and rhythm
Abd: flat, soft, normoactive bowel sounds
GUT: grossly male
Ext: (-) rashes, good pulses
Questions:
1. What is your impression?
2. Make a formulation
3. Give at least 3 differential diagnosis
4. Discuss the case
2007-06-22
19:44:47
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8 answers
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asked by
Mike
3