Admission 20/01

Chief Complaint FEVER, THROAT PAIN History of Present Illness 5 years old boy presented with: 1) Fever X 5 days, intermittent, TMAX 39 oral, responding to paracetamol, no sweats/chills 2) URTI s/s X 3 days, nasal congestion, mild wet cough 3) Moderate throat pain, associated with dysphagia and occasional drooling, no dysphonia 4) Vomiting X 2 days, 2 times per day, not projectile, no blood/bile, no diarrhea or abdominal pain. 5) Mild dehydration, sunken eyes, slightly dry mouth, not lethargic, no decrease in UOP Associated with mild headache and neck pain, no dysuria or rash. Positive contact with sick persons: granfather has cough/ URTI. No recent travel. Patient went to NMC hospital 4 days ago and to a PHC 1 day ago. Was treated as pharyngitis and took two doses of oral augmentin with no improvement. In ER: - given 1 dose of ondansetron - given 10mg/kg bolus of normal saline - rapid strep test done > negative PAST MEDICAL HISTORY - Recurrent URTI/ tonsillitis every 3 months - ? Adenoid hypertrophy - snoring at night, mouth breathing only with URTI - No previous admissions or surgeries FAMILY HISTORY - negative Review of Systems General: fever, no sweats/chills, lethargy Respiratory: no tachypnea, wet cough, no cyanosis/apnea Cardiology: tachycardia Immunology: no recurrent major infections ENT: multiple episodes of pharyngitis every year Current medications: (Selected). Inpatient Medications Ordered cefTRIAXone: 700 mg, Inj, IV, BID, Routine, 20/6/2013 20:00:00 UAE, 10 day(s), 35 mL/hr, infuse over 30 min(s), 17.5 mL clindamycin parenteral: 190 mg, Inj, IV, q6hr, Routine, 20/6/2013 18:53:00 UAE, 10 day(s) paracetamol parenteral: 280 mg, IV, q8hr, PRN, Pain, Routine, 20/6/2013 18:59:00 UAE, 3 day(s)

Physical Examination VS/Measurements Vital Signs 20/6/2013 17:45 UAE Temperature Axillary 37.9 degC HI Peripheral Pulse Rate 126 bpm HI Respiratory Rate 26 br/min Systolic Blood Pressure 111 mmHg Diastolic Blood Pressure 73 mmHg Oxygen Saturation 100 % Mean Arterial Pressure, Non-Invasive 86 mmHg General: Mild distress. Developmental milestones: 4 - 5 years. Eye: Conjuctival injection (because he is currently febrile, otherwise none), PERRL HENT: Tympanic membranes are clear, Normal hearing, Dry oral mucosa, nasal congestion, strawberry, pharyngeal erythema with enlarged tonsils (no exudate). Neck: limitation of movement of the head Enlargment of the submandibular nodes bilaterally with tenderness on palpation. On cleft sided cervical LN measuring 1x1 cm non tender noticed ,other multiple small cervical LN are palpable.. Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion. Cardiovascular: Regular rhythm, No murmur, Normal peripheral perfusion, tachycardia. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Musculoskeletal No swelling. No deformity. Erythema of palms and soles. Integumentary: Warm, Dry, pinpoint maculopapular rash discretely present only over upper half of anterior chest. Neurologic: Alert. Psychiatric: Cooperative. Health Maintenance Immunization schedule: UTD . Medical Decision Making 20/6/2013 16:51 UAE Rapid Strep A POC Negative 20/6/2013 15:25 UAE Sodium Lvl 137 mmol/L Potassium Lvl 5.0 mmol/L Chloride Lvl 104 mmol/L CO2 22 mmol/L Creatinine 41 micromol/L LOW WBC 18.3 x10^9/L HI Hgb 113 g/L LOW MCV 67 fL LOW MCH 22.0 pg LOW Neutro Auto % 73.2 % Neutro Auto # 13.40 x10^9/L HI Lymph Auto % 18.0 % LOW Lymph Auto # 3.30 x10^9/L C Reactive Prot 183 mg/L HI Interpretation: 1) CBC > mild leucocytosis, normocytic normochromic anemia 2) LYTES > mild prerenal azotemia most likely due to dehydration 3) CRP > markedly elevated 4) MICROBIOLOGY > blood and throat cultures pending .

Radiology results CT HEAD & NECK 20/06 CT Neck shows retropharangeal abcess measuring about 48 mm in cranio-caudal extention with measured AP dimention to about 6 mm. There are multiple enlarged LN in the anterolateral aspect of upper neck bilateraly with measured AP diameter to about 12 mm. Evident hypertrophied adenoid tissue seen. Impression and Plan 5 years old boy addmitted as a case of tonsillitis with retropharengeal abcsess for observation and IV antibiotics. Rapid STREP test is negative. Child has submandibular LN, conjunctival injection, strawberry tongue, palmar eythema, and h/o fever X 4 days, rash is present but not sandpaper-like DDX: scarlet fever kawasaki disease other viral exanthem Incidental finding of microcytic hypochromic anemia ?iron deficiency, for workup and management as outpatient. Incidental finding of adenoid hypertrophy on CT, child sometimes snores and breathes with mouth open. PLAN Intake IV Fluids at maintainence + 3% dehydration Encouraged oral intake Investigations CT shows retropharyngeal abcess To follow throat and blood cultures Urinalysis and culture to check for infection/sterile pyuria Do iron profile as outpatient Medications start on IV ceftriaxone and clindamycin (confirmed with ID on call) IV Paracetamol PRN xylometazoline nasal spray X 3 days mometasone nasal spray Monitoring Shift to pediatric medical ward Place on telemetry Vitals q3 hourly Intake and output Consults Pediatric infectious disease Dr. Ghassan contacted about antibiotics and Possibility of kawaski ,As per Dr Ghaasan patient has other manifestation of kawasaki but doesn't have fever so kawasaki is possibility but we need to observe fever and to order LFT ,ESR for him

ENT Dr. Omid :currently no indication for surgical intervention. keep close eye on breathing deterioration and possibility of the abscess progriating further downwards. continue aggressive conservative management. Pediatric infectious disease Dr. Ghassan contacted about antibiotics ENT Dr. Omid > to manage conservatively as long as there is no upper airway comprosmise ENT CONSULT Subjective child admitted under peds with history of fever, throat pain, drooling for 5 days. recent antibiotics given in a private hospital did not help. status: rigtht TM is injected, left TM is intact, congested nose with clear discharge, inflammed tonsils and pharynx, no signs of peritonsillar abscess, epiglottis is normal, posterior pharyngeal wall is not buldging. bilateral painful enlarged neck nodes. currently afebrile, drools and holds neck anteriorly and head tilting and rotation seems to be painful. no signs of nuchal rigidity. CT neck: retropharyngeal abscess formation with minimal anterio-posterior diameter, although the abscess seems to be extending all the way to the level of laryngeal inlet. multipl enlarge neck nodes bilaterally, enlarged adenoids. right sphenoid sinus is opacified. opinion: acute tonsillo-pharyngitis acute nasopharyngitis adenoid hypertrophy acute cervical lymphadenitis Retropharyngeal abscess plan: currently no indication for surgical intervention. keep close eye on breathing deterioration and possiblity of the abscess progriating further downwards. continue aggressive conservative management.

Day 1 hospital 21 /06

developed rash over the chest wall. he was later noticed to have cracked lips and NO FEVER CONTINUES TO LOOK TIRED LFT ESR ASO ORDERED ID CONSULTED > MAYBE KAWASAKI, DO FURTHER LABS LATERAL NECK XR TO SEE UPPER AIRWAY > NORMAL ID CONSULT: If the patient shows no clinical improvment and /or re spikes fever ,while continuing antibiotics consider treatment for Kawsaki ( IVIG plus Asperin ) please call ID on call with any clinical changes. SPIKED FEVER AT 22:30 38.2 BLOOD CULTURE NEGATIVE THROAT CULTURE NEGATIVE URINE CULTURE NEGATIVE

Day 2hospital 22 /06

Both rash and Palmar erythema are better today

Patient has Retropharyngeal abcess ,and retropharyngeal abcess could be part of kawaski disease presentation For his clinical condition it not worse but there no improvment has limitation of movment still has Mild DOB and looks sick His ESR abd CRP are high. to repeat his inflammatory markers (ESR, CRP, Ferritin, ALT/AST) and reassess this evening.. KEPT ON IVF AT MAITAINENCE - Was tachycardic despite there was no fever. - fading erythematous rash appeared on his CHEST Mucositis: strwaberry tounge, cracked swollen lips Bil non purulent conjugtivits with limbus sparing. Swollen erythematous palms. ESR is rising Fever : at times pt. was afebrile. - Based on what mentioned above, pt was started on: IVIG 2g/kg once Aspirin 100mg/kg Q 6HOURLY

Day 3 hospital 23 /06

- Pt. average HR is settling today morning was 87-90 bpm - Spiked fever today 38.6 CARDIO CONSULTED FOR ECHO

Day 4 hospital 24 /06

- Clindamycin and ceftrixone Day 5 Ent: much improved, no more drooling, neck nodes seem to be getting smaller and less tender. accepting food better and starting to play accordinfg to the mother - Dr.Palani radiologest advised NOT to repeat imging if pt. is stable with no new complaint. Radiating the pt. without deterioration will compromise his thyroid esp. he had Neck Xray and CT neck bit during this admission.

Day 5 hospital 25 /06

SHIFTED TO ORAL CLINDAMYCIN - Repeat CBC, CRP, and ESR Medications: decrease dose of aspirin to 81mg OD PO - monitor pt. for 24 hrs after the changes in medication > if stable withut new complain. to be discharged tomorrow. Complete Pediatric Echo (2D + M-mode, Doppler & Color Flow Mapping) (CPT 93303+93320+93325) Findings:

1. Completely normal cardiac structure, function, and dimensions. EF 72% 2. Normal coronary arteries Coronary artery Z-scores: LCA 2.7mm (Z: 0.2) LAD 2.1mm (Z: 0.02) RCA 2.1mm (Z: 0.0.02) Orders 1. No restrictions to exercise 2. No need for I.E. prophylaxis 3. Medications: Continue Aspirin 81mg PO OD until next echo 4. FU echo on 18/8/2013 (scheduled).