MORNING REPORT

September 9, 2013

4 YEAR OLD NATIVE AMERICAN MALE PRESENTS TO OUTSIDE ED FOR FEVER

-The patient developed tactile fever 3 days prior to presentation.

-The following day he had increasing fever and was less active. Mother also noted that he had decrease ROM in neck, manipulating his whole trunk to look at family members when talking to them.
-The following day was much the same, but his under eyes seemed sunken with eyes "bugging out" and mother noticed that he began yelling at siblings when they would turn on lights 2/2 to sensitivity. -Mother had difficulty getting fever down with Tylenol and cool baths, so presented to ED. He was diagnosed with likely viral illness and discharge to home. -The following day he was hard to arouse and unable to keep any fluids down. She represented to ED

PHYSICAL EXAM
VITAL SIGNS: Temp 36.2-38.6 P 96-128 RR19-32 BP92-116/48-64 SaO2 96-100% on RA Weight 19.3Kg

GENERAL: Irritable, crying wincing and yelling with being moved/exam HEENT: NC/AT, appears EOMI but exam difficult, PERRL , conjunctivae mildly injected , sclerae nonicteric, TMs clear, MMM, geographic tongue , NP clear, OP w/o exudates. NECK: Supple, Currently has good ROM to expected terminal angles, no adenopathy. LUNGS: CTAB, no increased WOB, good aeration, no adventitious sounds. CV: RRR, no M/R/G, nl perfusion and pulses. ABD: Soft, ND, no HSM, nl BS, no masses. It is unclear if abdomen is tender. Cries that belly hurt in multiple portions of exam. Later denies pain. GU: Nl external genitalia, nl Tanner stage for age. BACK: No CVA tenderness. EXTREMITIES: No C/C/E. L . second toe and right great toe with healing, somewhat deep lacerations. Taken through ROM of all major joints without pain. Long splinter-like lesion in one nail bed. SKIN: nits and live lice visualized in hair . Multiple scars noted. Mulluscum type lesions on glabella and nasal bridge. Bases of feet with 1-2mm dark, slightly raised spots. NEURO: Very difficult exam. irritable, unable to interact appropriately. EOMI, PERL. hearing, vision and gag intact. No focal deficits noted. DTR's appropriate in bilateral biceps and patellar tendons. Normal tone. Upper extremities move equally, but unable to get compliance with LE testing. Unable to visualize gait.

UPDATE
Patient was found to be bacteremic with MSSA

CBC: WBC = 4.4; differential 29% Band forms, 44% Neutrophils, 19% Lymphocytes, 0% Monocytes, 0% Eosinophils; Hgb = 10.9, Hct = 31.6, Platelet = 50.
Complete Metabolic Panel: Na = 137, K = 3.4, Cl = 106, CO2 = 22, BUN = 7, Cr = 0.39, Glucose = 126, Ca = 9, Protein = 4.9, Albumin = 2.2, Bilirubin = 0.3, Alk. Phos. = 137, ALT = 64, AST = 36

CSF: WBC: 56 with a differential of 89% Neutrophils, 11% Lymphocytes, and 9% Monocytes; RBC: 82; Protein: 100; Glucose: 58; Gram Stain negative.
Enterovirus Serum PCR: negative HSV Serum PCR: negative ECHO negative, Spinal imaging negative, Brain imaging with punctate infarcts, abdominal imaging with splenomegaly MSSA did not clear; Developed murmur

PEDIATRIC ENDOCARDITIS
MSSA is an odd candidate for Meningitis

If there is MSSA in the Blood, assume endocarditis, or another focus

Start Nafcillin Get an ECHO Daily Blood cultures If ECHO negative, start searching for another focus. Dont forget to get another ECHO, when blood if blood doesnt clear