identifying data fv 6 months old male roman catholic filipino chief complaint: fever and rashes 6...

IDENTIFYING DATA FV 6 months old Male Roman Catholic Filipino CHIEF COMPLAINT: Fever and rashes 6 months old Fever Rash

History of Present Illness 6 days PTA First dose of measles vaccine 5 days PTA Fever (Tmax 38.8 oC ) Temporarily relieved by paracetamol (Tempra) drops 100 mg/ml 1ml every 4 hours (14mg/kg/dose)

3 days PTA Still with fever Erythematous maculopapular rashes on the back of the ears and forehead 2 days PTA Spread of the maculopapular rashes to the face and neck area Colds watery nasal discharge Non-productive cough Consult at TMC satellite clinic CBC with platelet count (Hgb 119, Hct 0.35, WBC 15.04, Neutrophil 29.1, Lymphocytes 63.3, Platelet 305) Sent home: Ambroxol (dose) and cetirizine (dose)

1 day PTA Progression in severity of the cough Persistence of colds Eye redness and discharge (pagmumuta) Lysis of the fever spread of the maculopapular rashes to the trunk and lower extremities Irritable (increased crying) Day of consult Decrease in oral fluid intake Difficulty of breathing Admission

Temporal Profile

ROS GENERAL: No weight loss, no decrease in activity HEENT: see HPI CARDIOVASCULAR: No palpitations RESPIRATORY: see HPI GASTROINTESTINAL: No vomiting, no diarrhea EXTREMITIES: see HPI 6 months old Fever Maculopapular Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing

PMH No known allergies Previous illness: UTI at 2 mos Given unrecalled dose of cefixime without resolution of infection At 4 mos, change of antibiotic to cefuroxime with unrecalled dose with subsequent resolution 6 months old Fever Maculopapular Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing

Birth History Born full term, via LTCS II, to a 28 year old G3P3 (3003) at Unciano Medical Center Birth weight of 3kg No complications during pregnancy or delivery. 6 months old Fever Maculopapular Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing

Immunization History BCG:1 dose Penta:3 doses OPV:3 doses Hepa B:1 dose Measles: 1 dose Varicella: 1 dose Hib: 1 dose PCV:1 dose 6 months old Fever Rash (Cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Nutritional History Breastfed exclusively until 3 months old Formula feeding (Enfalac) started at 3 months old Weaning at 6 months of age - started on mashed vegetables and Cerelac Normally eats well consuming 2-4 oz per feeding around 6x/day 6 months old Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Developmental History At par with age Motor: able to sit with support Language: imitate sounds, babble incomprehensible syllables Social: stretches arms when he wants to be taken and indicates likes and dislikes with actions 6 months old Fever Rash (Cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Family History No hypertension, diabetes, asthma, allergies, cancer No other family member with similar symptoms 6 months old Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Personal, Social, and Environmental History Lives at home with his parents in Rosario, Pasig 10 people at home (mother, father, 2 older siblings, maternal uncle and his wife, the mothers cousin, and great aunt, nanny, patient) 4-story aparment-type complex; each family has their own room Father: property manager Mother: accounting assistant No smokers in the household 6 months old Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Personal, Social, and Environmental History Financial problems due to the increasing length of the hospital stay and medications Everyone in the household contributes to the hospital expenses (mothers older brother shares a lot) 6 months old Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Stakeholder Analysis StakeholderRoleInterest in Issue Level of Influence FatherPrimary Breadwinner High MotherPrimary Caregiver High Uncle and wifeBreadwinnerModerateHigh NannyCaregiverModerateLow SiblingsHighLow Great auntCaregiverModerateLow Mothers cousin Low

Salient Features SUBJECTIVEOBJECTIVE 6 months old Fever Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior)

Temporal Profile

Physical Examination General Survey: Awake, alert, not in respiratory distress Vital Signs: BP 90/60 mmhg CR 126 bpm RR 31 cpm T 39.9C (febrile) Anthropometric: Wt 7.0 kg(z score > -2) Ht 86 cm(z score < 3) HC: 38cm (z score < -3) AC: 40cm CC: 39cm High grade fever

Physical Examination Skin Pinkish in color (+) Erythematous maculopapular rashes on the face and trunk Soft/supple skin High grade fever Erythematous maculopapular rashes on face and trunk

Physical Examination HEENT Head: No deformities of the head Eyes: Equal, non-sunken almond-shaped eyes; anicteric sclerae, pink conjunctivae, pupils 2-3mm, EBRTL, no discharge/swelling noted, no cataracts Ears: Normal-looking pinnae, patent ear canal with no swelling or discharge Nose: Midline, intact nasal septum, patent nares and no nasal discharge; no alar flaring; no nasal congestion Mouth: Pink, moist lips, tongue and buccal mucosa; no cleft lip/palate High grade fever Erythematous maculopapular rashes on face and trunk No alar flaring, dry lips

Physical Examination Cardiovascular Adynamic precordium; no deformities; good S1/S2; regular rate and rhythm; no heart murmur Pulmonary (+) Intercostal retractions; equal chest expansion; (+) bilateral rales/crackles High grade fever Erythematous maculopapular rashes on face and trunk No alar flaring, dry lips Intercostal retractions Harsh breath sounds Bilateral rales/crackles

Physical Examination Abdomen No masses/lesions; normoactive bowel sounds; soft, non-tender Extremities No edema, no cyanosis, full and equal pulses, CRT

Physical Examination Neurological Exam Appropriate for age Cranial nerves: I: Not tested II: Pupils 2-3 mm bilaterally reactive to light III, IV, and VI: Full range of motion of extraocular muscles VI: (+) Corneal reflex VII: No facial asymmetry VIII: follows sounds IX and X: (+) gag reflex XI: Can shrug shoulders XII: Tongue midline Motor: exhibits spontaneous movement on all extremities Cerebellar: cannot be assessed Reflexes: 2++ on all extremities Sensory: reacts to pain High grade fever Erythematous maculopapular rashes on face and trunk No alar flaring, dry lips Intercostal retractions Harsh breath sounds Bilateral rales/crackles

Salient Features SUBJECTIVEOBJECTIVE 6 months old Fever (5 th day) Rash (cephalocaudal) Cough Colds Conjunctivitis Decrease in oral intake Difficulty of breathing Measles vaccine (6 days prior) High grade fever Erythematous maculopapular rashes on face and trunk No alar flaring No retractions Bilateral rales/crackles

Problem List (?)

Differentials Differential #1: MEASLES Fever Rashes Colds Cough Conjunctivi tis Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Rule InRule Out Presents with: Fever Rash (Cephalocaudal spread) Coryza Cough Conjunctivitis Complication of Pneumonia Measles IgG/IgM results Cannot be totally ruled out Laboratory findings: Diagnosis of measles is mainly clinical and laboratory exams are not routinely ordered. CBC: Slightly decreased hemoglobin, hematocrit, RBC with slightly increased WBC PRESENTER: This will serve as our theoretical discussion. NOTE: Measles Rubeola, Tigdas, an acute viral infection due to measles virus: Genus Morbillivirus, Family Paramyxoviridae. Incubation stage Prodromal stage (3cs, preceded symptoms by Koplik Spots, low-moderate fever) Stage of cephalo-caudal Rash and High fever PRESENTER: This will serve as our theoretical discussion. NOTE: Diagnostic management for measles IgM is detectable for 1mo but is limited in the first 72 hr of the rash illness. IgG antibodies detectable by about a week after rash onset. It is recommended that specimens be drawn on the seventh day after rash onset. Diagnostic is mainly clinical.

Measles Rash

Differentials Differential #2: Varicella Rule InRule Out Presents with: Low grade fever Anorexia Headache Rash (vesicle on an erythematous base, with significant pruritus) dew on a rose petal Emerge in various asynchronous crops Rash lasts 12-21 days Does not present with: Same description of rash (pustule with erythematous base) Trunk to extremities Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: Non-specific CBC findings. May show a decrease in WBC with lymphocytic predominance as found in other viral illnesses. Diagnosis is mainly clinical.

Varicella Rash

Differentials Differential #3: Rubella Rule InRule Out Presents with: Low grade fever Rash Does not present with: Same description of rash Anorexia Maculopapular rash appears on face and neck and spreads to the rest of the body Spares the palms and soles Fades after 3 days Tender posterior acuricular adenopathy Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: Non-specific CBC findings. May show a decrease in WBC with lymphocytic predominance as found in other viral illnesses. Diagnosis is mainly clinical.

Rubella Rash

Differentials Differential #4: Roseola Rule InRule Out Presents with: Fever Diffuse macular or maculopapular rash Does not present with: Presentation of fever Same description of rash Well looking baby Condition improves with appearance of rash Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: Slightly decreased hemoglobin, hematocrit, RBC with slightly increased WBC

Roseola Rash

Differentials Differential #5: Hand Foot & Mouth Disease Rule InRule Out Presents with: Low-grade fever Rash Does not present with: Same description of rash malaise, anorexia, and posterior pharyngeal ulcerations Oral lesions on whole palate/tongue Maculopapular lesions on hands and feet (progresses to vesicles and then ulcerations) Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: Non-specific CBC findings. May show a decrease in WBC with lymphocytic predominance as found in other viral illnesses. Diagnosis is mainly clinical.

Hand, Foot, and Mouth Rash

Differentials Differential #6: Dengue Rule InRule Out Presents with: Fever Defervescence rash (isles of white in a sea of red) Does not present with: Same description of rash Anorexia Abdominal pain Bleeding episodes CBC results decreasing platelet count with hemoconcentration Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: Decrease in WBC, hemoconcentration, and decrease in platelet. Lymphocytic predominance as found in other viral illnesses. May request for Dengue NS1 and Dengue Blot test to confirm diagnosis.

Dengue Rash

Differentials Differential #7: Chikungunya Rule InRule Out Presents with: Fever Rash Conjunctivitis Does not present with: Presentation of rash Anorexia Vomiting Joint pains Fever Rashes Colds Cough Conjunctiviti s Irritability (+) Measles Vaccine Harsh breath sounds Bilateral crackles Laboratory findings: CBC: CBC: Decrease in WBC and slight decrease in platelet. Lymphocytic predominance as found in other viral illnesses.

Chikungunya Rash

Primary Working Impression Rubeola Pneumonia, Severe Generalized inflammation Epithelial cells (skin, conjunctivae, and the mucous membranes of the nasopharynx, bronchi, and intestinal tract) Generalized inflammation Epithelial cells (skin, conjunctivae, and the mucous membranes of the nasopharynx, bronchi, and intestinal tract) Complications Otitis media most common (All ages less than 5 years) Strep, H. influenza, M. catarrhalis Pneumonia Leading cause of mortality H.influenza, Strep May be viral or due to bacterial lung infection Encephalitis From measles virus itself Laryngotracheobronchitis Complications Otitis media most common (All ages less than 5 years) Strep, H. influenza, M. catarrhalis Pneumonia Leading cause of mortality H.influenza, Strep May be viral or due to bacterial lung infection Encephalitis From measles virus itself Laryngotracheobronchitis

Hospital Day 1 SubjectiveObjectiveAssessmentPlan Day 6 of illness crying but consolable, weak looking Fever (39.9C) slightly sunken eyeballs, bilateral conjunctivitis, dry lips bilateral rales and shallow subcostal retractions generalized maculopapular rash Measles Pneumonia CBC with PC Measles IgG and IgM Chest Xray AP Lat IVF: D5LR 350ml to run at 44ml/hour Paracetamol 100mg/ml (Ibuprofen) Salbutamol + Ipratropium (Combivent) neb Cefuroxime 200mg/IV every 8 hours (86 mg/kg/day Stages of Measles Incubation stage Prodromal stage With enanthem Final stage Maculopapular rash High fever Stages of Measles Incubation stage Prodromal stage With enanthem Final stage Maculopapular rash High fever

CBCNormal Values01/15 Hemoglobin137-170119 Hematocrit0.40-0.540.35 RBC Count4.60-6.20 WBC Count4.50-10.0016.04 MCH27-32 MCHC0.32-0.36 MCV80-96 RDW11.5-16.0 Platelets140-440305 Differential Count Neutrophil0.56-0.6629.1 Lymphocyte0.22-0.4063.3 Monocyte0.04-0.06 Eosinophil0.01-0.04 Basophil0.00-0.01 Blast cells Erythrocyte Morphology

Differentials Measles Immunoglobulin G and Immunoglobulin M Laboratory findings: Measles IgG/IgM: IgG (+): past infection IgM: current infection Measles IgM (ELISA)0.541 Measles IgG0.217 1.1 positive

Chest Xray: Interstitial Pneumonia, bilateral

Hospital Day 1 SubjectiveObjectiveAssessmentPlan Day 6 of illness crying but consolable, weak looking Fever (39.9C) slightly sunken eyeballs, bilateral conjunctivitis, dry lips bilateral rales and shallow subcostal retractions generalized maculopapular rash Measles Pneumonia CBC with PC Measles IgG and IgM Chest Xray AP Lat IVF: D5LR 350ml to run at 44ml/hour Paracetamol 100mg/ml (Ibuprofen) Salbutamol + Ipratropium (Combivent) neb Cefuroxime 200mg/IV every 8 hours (86 mg/kg/day Supportive management Antiviral therapy is not effective Prophylactic antimicrobial therapy - not indicated Goals of therapy: Hydration Oxygenation Comfort Supportive management Antiviral therapy is not effective Prophylactic antimicrobial therapy - not indicated Goals of therapy: Hydration Oxygenation Comfort

Recommendations for Vitamin A Treatment of Children with Measles INDICATIONS: Children 6 mo to 2 yr of age hospitalized with measles and its complications (e.g., croup, pneumonia, and diarrhea) Children >6 mo of age with measles who are not already receiving vitamin A supplementation and who have any of the following risk factors: Immunodeficiency Clinical evidence of vitamin A deficiency Impaired intestinal absorption Moderate to severe malnutrition Recent immigration from areas where high mortality rates attributed to measles have been observed From the American Academy of Pediatrics, Committee on Infectious Disease: Vitamin A treatment of measles. Pediatrics

REGIMEN Parenteral and oral formulations of vitamin A are available in the USA. The recommended dosage, administered as a capsule, is: Single dose of 200,000 IU orally for children 1 yr of age (100,000 IU for children 6 mo to 1 yr of age) The dose should be repeated the next day and again 4 wk later for children with ophthalmologic evidence of vitamin A deficiency From the American Academy of Pediatrics, Committee on Infectious Disease: Vitamin A treatment of measles. Pediatrics

Hospital Day 2 SubjectiveObjectiveAssessmentPlan Day 7 of illness Irritable Cough Soft stools x2 Tachypneic 60s-80s Tachycardic 145-204 bpm O2 sat 90-91% 96% after O2 support Hyperemic conjunctiva, hyperemic posterior pharyngeal walls bilateral rales and shallow subcostal retractions generalized maculopapular rash Measles Pneumonia Paracetamol, Cefuroxime, Shifted Salbutamol + Ipratropium (Combivent) neb to NSS neb q2hrs Zinc drops BID O2 support via facemask at 5 lpm 10-15 lpm Advised PICU admission, family refused due to financial limitations OGT inserted

Hospital Day 3 SubjectiveObjectiveAssessmentPlan Day 8 of illness Febrile episodes able to tolerate oral feeding every 2-3 hours Adequate urine output and bowel movement Tachypneic episodes noted; no desaturations Hyperemic conjunctiva, hyperemic posterior pharyngeal walls bilateral rales and shallow subcostal retractions generalized maculopapular rash Measles Pneumonia Paracetamol, Cefuroxime NSS neb q2hrs Zinc drops BID O2 support via facemask nasal cannula at 3 lpm OGT removed IVF at maintenance +10% rate

Hospital Day 4 SubjectiveObjectiveAssessmentPlan Day 9 of illness Febrile episodes + chills able to tolerate oral feeding every 2-3 hours Adequate urine output and bowel movement Tachypneic episodes noted; no desaturations Hyperemic conjunctiva, hyperemic posterior pharyngeal walls bilateral rales and shallow subcostal retractions generalized maculopapular rash Measles Pneumonia Referred to Infectious Disease Cefuroxime shifted to Piperacillin-Tazobactam 500mg/IV every 6 hours (258 mg/kg/day) Paracetamol Shifted Salbutamol + Ipratropium (Combivent) neb to NSS neb q2hrs Zinc drops BID O2 support via facemask nasal cannula at 3 lpm OGT removed IVF at maintenance +10% rate

CBCNormal Values01/1501/17 Hemoglobin137-170119100 Hematocrit0.40-0.540.350.33 RBC Count4.60-6.204.21 WBC Count4.50-10.0016.0411.20 MCH27-3224 MCHC0.32-0.360.31 MCV80-9677 RDW11.5-16.014.9 Platelets140-440305325 Differential Count Neutrophil0.56-0.6629.10.56 Lymphocyte0.22-0.4063.30.36 Monocyte0.04-0.060.08 Eosinophil0.01-0.040.00 Basophil0.00-0.010.00 Blast cells0.23 Erythrocyte Morphology Laboratory findings: Slightly decreased hemoglobin, hematocrit, RBC with slightly increased WBC (predominance of lymphocyte)

Chest Xray: Interval progression of bilateral pneumonia

WHAT IS THIS PICTURE?

Case Definition Clinical case definition Any person in whom a clinician suspects measles infection Any person with fever, maculopapular rash, cough, coryza, conjunctivitis Laboratory criteria for diagnosis 4x increase in antibody titer, isolation of measles virus, or presence of IgM antibodies

What is considered an outbreak? DOH: 1 case, suspected or confirmed, in a community where there was no case in the past 1 case per 2 weeks for 2 consecutive weeks WHO Number of cases observed is greater than the number normally expected in the same geographic area for the same period of time

Outbreak Timeline (Metro Manila) 25 cases 2012 179 cases Dec 10 2013 760cases Jan 11 2014 DOH Declared Outbreak Jan 4, 2014 21 barangays In 9 cities 716% increase 416 % increase DOH statistics Only 6% of the reported Cases are confirmed

Philippines YearConfirmed measles cases Incidence (per 1 million) Deaths due to measles 20088749.88 2009149016.610 2010638868.234 2011655569.128 2012149915.55 2013172417.9721 Source: WHO. Country Profile-Measles Elimination.

DOH National Epidemiology Center Jan 1 Dec 14, 2014 1,724 cases and 21 deaths Majority came from Metro Manila (744 cases) 13/17 regions of the Philippines have measles case increase 2013 (NCR) 416 confirmed cases 1568 % increase! 2012 (NCR) 25 confirmed cases Las Pinas (78), Manila (72), Muntinlupa (65), Caloocan (45), Paranaque (32), Malabon (31) Urbanized, congested area High mobility of the residents Supposedly good EPI coverage

Source: WHO. Country Profile-Measles Elimination.

Population at Risk Children under age 5 years old Higher percentage of death due to measles complication 158,000 people died from measles in 2011 Pregnant women Immunocompromised

MCV2 routine coverage: the level of coverage by the second dose of the measles-containing vaccine, as reported in the annual WHO/UNICEF Joint Reporting Form on Immunization.

Goals Herd Immunity Vaccination coverage of no less than 95% The Iligtas sa Tigdas ang Pinas program in 2011 only covered 84% of the population (15,649,907) MR vaccine 16% (~3million) were unvaccinated or in 2 years since at 84% coverage, 6 million were unvaccinated Measles Free by 2017 (WHO) 1 case per 1 million population

Vaccination Measles At 9 months At 6 months during outbreaks Maternal antibodies may have dwindled already MMR 2 doses 1 dose 90% immunity Booster at 12-18 (15) months 2 doses almost 100% immunity At 4-6 years of age Some children who have been vaccinated still got infected 2-3% may not develop antibodies Some parents refuse vaccination Religious belief Transfer of residence

Government Response Vaccination It will take a couple of weeks before they develop immunity Mass Immunization Campaign that aims to cover children

identifying data fv 6 months old male roman catholic filipino chief complaint: fever and rashes 6...

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