Case-based discussions: Module 2 - Fever

Case 2 - Riley

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 2 month old female called Riley who was brought in by her father Steven. He tells you the reason they presented was that 'Riley felt warm this morning'.
• History and examination have not identified a source for the fever.
• Riley was born via repeat elective caesarean with no developmental concerns. She has no medical history and is not on any medications. She has no known drug allergies. 6 week vaccinations were provided. There is no relevant family history. This is Steven and Frank’s second child. There are no smokers in the family. Steven is a painter and Frank is a gardener.
• Her observations as taken by the triage team were as follows:  
  RR: 40   O²: 100%   T: 38.1   HR: 155

Questions to discuss about Riley’s case

• What is your approach to investigating and managing Riley if she was febrile without any toxic features and no features concerning for an SBI?
• What is your approach to investigating and managing Riley if she was febrile with toxic features or features concerning for an SBI?
• What if Riley had clinical features consistent with bronchiolitis? Should you do any other Ix for her fever?

Normal range for vital signs by age

Case 4 - Ashraf

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 6 month old male called Ashraf who was brought in by his mother Aisha.
• They tell you the reason they presented was that 'Ashraf feels warm and has a rash'.
• Your examination shows the rash below. It is not blanching.

• Ashraf was born via emergency caesarean due to failure to progress. There are no developmental concerns. He has no medical history and is not on any medications. He has no known drug allergies. His vaccinations are up to date. There is no relevant family history. This is the family’s third child. There are no smokers in the family.
• His observations as taken by the triage team were as follows:
  RR: 40   O²: 100%   T: 38.9   HR: 155

Questions to discuss about Ashraf’s case

• What is the most concerning differential diagnosis?
• What further information on history would you like to know?
• Would the location of the petechial rash alter your management?
• What would be your investigation and management approach?
• What diagnosis should you consider if Ashraf was a 3 year old with petechial rash (lower limb/buttocks predominance), ankle swelling, and abdominal pain/swelling?

Normal range for vital signs by age

Case 6 - Ivy

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 3 week old female called Ivy who was brought in by her mother Alice. They tell you the reason they presented was that 'Ivy felt warm this morning'.
• Your history and examination did not reveal a source.
• Ivy was a term spontaneous vaginal delivery. There were no perinatal complications. Maternal GBS status is not known. There are no HSV contacts.
• There are no developmental concerns. She has no medical history and is not on any medications. She has no known drug allergies. At birth, Ivy had her hepatitis B vaccination and vitamin K injection. There is no relevant family history. Alice is a single mother. Ivy’s father does not routinely see her. There are no domestic violence concerns. There are no smokers in the family. Alice works in retail and is currently on maternity leave.
• Her observations as taken by the triage team were as follows:
  RR: 50   O²: 100%   T: 38.1   HR: 155
• You proceed with a full septic work-up including FBC, CRP, Chem 20, blood culture, urine M/C/S, lumbar puncture. You commence empiric antibiotics in accordance with the guidelines.

Her investigations are as follows:

• FBC: Normal WCC, Neutrophils.
• Chem 20: Nil abnormalities; serum glucose 4.2.
• CRP: 45.
• Blood culture pending.
• Urine M/C/S: 20/<10/<10 no bacteria seen. Culture pending.
• CSF:
  • WCC: 250 (x10⁶/L) monomorphs 90%, polymorphs 10%.
  • RCC: 200 (x10⁶/L).
  • Protein: 0.8 (g/L) (normal range: <1.0 g/L).
  • Glucose: 3.9 mmol/L (range: 3.3-4.5).

Questions to discuss about Ivy’s case

• What is the diagnosis? Consider if this more likely to be bacterial or viral.
• What are symptoms/signs of meningitis in a child less than 3 months old? What about in older children?
• How do you interpret a traumatic tap (where WCC is able to be provided)?
• What is the normal WCC count in the CSF of a neonate? What about if a child is over 1 month old?
• How would you manage Ivy? Include discussion on fluid management, aciclovir and dexamethasone.

Normal range for vital signs by age