case presenLaLlon

22/10/2010
nor azlmah blnLl azharl
nurul wahldah blnLl muhd abd wahld
Mohd alzaL b abd azlz
emographlc deLalls
name Alml nur Aflqah 8/n S800233446
aLe of 8lrLh 21/4/2010 Age 3 monLh
Cender glrl LLhnlc group Malay
aLe Llme of admlsslon 12 CcLober 2010
aLe of clerklng 13 CcLober2010
Ward of admlsslon Ward 8C PosplLal Sg 8uloh
Address amansara damal
lnformanL moLher
8ellablllLy Cood
9resenLlng complalnL
W AdmlL on 12/10/2010 due Lo fever 2 days prlor
Lo admlsslon
PlsLory of presenLlng lllness
W She was currenLly well unLll she had been feverlsh 2 days
prlor Lo admlsslon lever was hlgh grade lL also assoclaLed
wlLh rash
W A small pln polnL maculapapula rashes sLarLed Lo appear
under paLlenL's chln on Lhe same day she goL fever
W Several hour laLer her face aL Lhe [aw area become
lnflamed redness swollen warm and Lender lL swolen had
been sLarLed Lo be dlsLrlbuLes from Lhe chln up Lo behlnd
ears bllaLerally
W 1hen some maculapapula rashes on Lhe upper chesL and
submenLal area sLarLed Lo growLh and lncrease ln slze
PlsLory of presenLlng
lllness(conLlnue)
W 1he rashes became veslcle llke sLrucLure and glve mlx blood
and pus dlscharged
W 1here were no hlsLory of lnsecL blLlng or Lrauma no pasL
hlsLory of Lhe same lllness
W 9arenL gave Lhe chlld syrup paraceLamol and Leplng
sponglng also done Lo rellef her fever
W 1he rashes and fever also assoclaLed wlLh cough and
runnlng nose 2 days prlor Lo admlsslon
W She ls very lrrlLable and had eplsode of sleeplng
dlsLurbance
W Cn admlsslon she recelve 3 supposlLory and syrup
pasaceLamol Lo conLrol her LemperaLure
W AnLlbloLlc also glven
SysLemlc revlew
W CA8lCvASCuLA8 S?S1LM
no profuse sweaLlng no syncope no shorLness of breaLh no orLhopnoea no leg
swelllng
W 8LS9l8A1C8? S?S1LM
she had b|ocked nose no shorLness of breaLh and no addlLlonal sound durlng
breaLhlng
W CAS18Cln1LS1lnAL S?S1LM
Iom|t no change ln appeLlLe no consLlpaLlon no dlarrhea no dysphagla no dyspepsla
no maleana
W CLnl1Cu8lnA8? S?S1LM
no change ln urlne appearance no hemaLurla normal volume of urlne and no dysurla
W MuSCuLCSkLLL1AL S?S1LM
Pe became less acLlve durlng Lhe fever leLhargy and Llredness no sLlffnes no [olnL
swelllng
W Skln
no bleedlng no brulslng
W LA8 nCSL An 1P8CA1
no sore LhroaL no nasal blockage
Medlcal and surglcal hlsLory
W She had no medlcal hlsLory
W And also no surglcal procedure had be done Lo
her
W rug hlsLory
no drug hlsLory
W Allergy hlsLory
no allergy hlsLory
W 8lrLh hlsLory
She was dellvered vla normal vaglnal dellvery Per welghL
was 333kg and dellvery process was unevenLful
W neonaLal hlsLory
no [aundlce aL blrLh
no nlCu admlsslon
W leedlng hlsLory
She was breasLfed unLll 3 monLh old
Weanlng aL 2 monLh old
ConLlnue wlLh seml solld food (nesLum) aL 3
monLh old
W lmmunlzaLlon hlsLory
up Lo her age
LaLesL was dlphLerlaLeLanusacellular
perLussls(1a9) for 2
nd
dose
W evelopmenLal hlsLory
9ull Lo slL no head lag and slL wlLh sLralghL back
8eaches for ob[ecL and play wlLh Loys
MouLhlng
Summary her developmenL ls correspond Lo her age
W lamlly hlsLory
MoLher and faLher are well and healLh
She ls younger of 2 slbllngs
no famlly hlsLory of Lhe same lllness dlabeLes melllLus
and hyperLenslon
W PlsLory of conLacL
1here are hlsLory of fever of Lhe chlldren aL Lhe baby
slLLer house
W Soclal and envlronmenLal hlsLory
8oLh of parenLs work as clerk 1hey llve ln flaL
house aL amansara amal
1helr chlld wlll be Laken care by baby slLLer
1here are no any Lravelllng slnce she was born
W LffecL of lllness on Lhe paLlenL and famlly
She was very uncomforLable
8oLh parenL need Lo Lake leave Lo Lake care of
Lhelr chlldren
summary
W Alml nur Aflqah 3monLh old Malay glrl
admlLLed on 12/10/2010 due Lo fever for 2
days ln duraLlon assoclaLed wlLh
eryLhomaLous lnflammaLlon and rashes of Lhe
[aw area and upper anLerlor chesL Per fever
was subslde aL 2
nd
days of admlsslon she was
glven syrup paraceLamol and anLlbloLlcs
durlng admlsslon
9hyslcal examlnaLlon
(general examlnaLlon)
she was sleeplng on Lhe bed She was uncomforLable durlng
sleep whlch ls someLlmes wlll awake from sleep and cry 1here was
her moLher beslde her and comforL her She was noL [aundlce noL
anemlc and her hydraLlon sLaLus was adequaLe lonLanel around 03
cm and noL bulge
1here are eryLhomaLous swelllng of Lhe [aw area and some
maculapapula rashes aL Lhe [aw area and anLerlor upper chesL 1he
swollen was Lender and warm 1he rashes was blanch ln pressure
and well demarcaLed border
1he rashes dld noL lnfecL Lhe neck area Per hand was warm
plnk and noL pallor no clubblng and abnormallLy hand feaLures
1here was a small ulcer on her mlddle flnger Loe buL no fungal
lnfecLlon no plLLlng edema
9hyslcal examlnaLlon
(general examlnaLlon)
W vlLal slgn
1emperaLure 363'C
9ulse raLe 129 beaL/mln (regular rhyLhm and
normal volume)
8esplraLory raLe 39 breaLh / mln
8lood pressure 84/41
W AnLhropomeLry
WelghL 10 percenLlle
PelghL 1023 percenLlle
Pead clrcumference 1023 percenLlle
9hyslcal examlnaLlon
(general examlnaLlon)
W LxamlnaLlon of back
no rash
normal splne and no sacral edema
W LxamlnaLlon of lymph nodes
Can'L palpaLe node aL Lhe swelllng area because of Lender Lo
Louch
Axllla nodes noL palpable
CcclplLal noL palpable
lngulnal noL palpable
W evelopmenLal assessmenL
Per developmenLal mllesLone correspond Lo her age
9hyslcal examlnaLlon
(sysLemlc examlnaLlon)
W fd|ovfscu|f exfm|nft|on
lospectloo Lhe paLlenL was well noL ln shorLness of breaLh no
cenLral cyanosls no sweaLlng no flnger clubblng no perlpheral
edema no chesL wall deformlLy no surglcal scars no precordlal
bulge no vlslble or dllaLed velns
9fpftloo flngers and Loes were warm and plnk 1he caplllary
reflll Llme was less Lhan Lwo seconds 1he femoral and brachlal
pulses had good sLrengLh and volume 1he pulses on boLh sldes
are symmeLrlcal 1here was no brachlofemoral delay 1he apex
beaL was found ln Lhe 3
Lh
lnLercosLals space ln Lhe mldclavlcular
llne 1here was no palpable heave or Lhrlll aL Lhe precordlum
sctftloo 1sL and 2nd hearL sound can be heard aL all four
areas of mlLral Lrlcuspld lefL sLernal border and aorLlc areas no
addlLlonal hearL sound
W lmptessloo no abnormal flndlngs
9hyslcal examlnaLlon
(sysLemlc examlnaLlon)
W esp|fto sstem exfm|nft|on
W lnspecLlon Pe was noL appear wlLh slgns of resplraLory dlsLress
1he chesL was noL hyperlnflaLed and Lhe chesL moved symmeLrlcally
wlLh lnsplraLlon no clubblng and no surglcal scar
W 9alpaLlon Lrachea was aL Lhe cenLre Lhe movemenL of chesL
expanslon was symmeLrlcal on boLh sldes Apex beaL was felL aL Lhe
3
Lh
lnLercosLals space ln Lhe mldclavlcular llne
W 9ercusslon 9ercusslon from Lhe fronL and back were resonance on
boLh sldes for upper mlddle and lower area of Lhe lung 1here ls
normal llver and cardlac dullness
W AusculLaLlon alr enLry was good and veslcular breaLh sounds were
heard on boLh slde of Lhe lungs 1here are no addlLlonal sound were
heard
W lmpresslon no abnormallLy flndlng
9hyslcal examlnaLlon
(sysLemlc examlnaLlon)
W bdom|nf| exfm|nft|on
lnspecLlon 1he abdomen was noL dlsLend symmeLrlcal ln shape and
move wlLh resplraLlon no swelllngs no umblllcal or lngulnal hernlas
Per umblllcus was cenLrally locaLed and lnverLed no scar no vlslble
dllaLed velns and no vlslble perlsLalsls
9alpaLlon Cn llghL palpaLlon Lhe abdomen ls sofL no Lenderness or
mass Cn deep palpaLlon Lhere was no any abdomlnal mass Lhe llver
and spleen were noL palpable 1he kldneys were also noL balloLable
bllaLerally
9ercusslon 1he abdomen was resonance shlfLlng dullness and fluld
Lhrlll were negaLlve
AusculLaLlon normal bowel sound was heard no llver or renal brulL
W lmptessloo Lhere was normal abdomen flndlng
9hyslcal examlnaLlon
(sysLemlc examlnaLlon)
W ,uscu|oske|etf| exfm|nft|on
1here was no muscle weakness no muscle wasLlng or hyperLhrophy and no bony
deformlLles normal movemenLs of [olnLs and no congenlLal dysplasla of hlp [olnL
W lmptessloo Lhere was no muscle weakness
W entf| nevous sstem exfm|nft|on
MenLal sLaLus 1he paLlenL was alerL and consclous noL crylng buL ferLful
Speech and language she Lurn Loward sound source
Cranlal nerves he can maklng smlllng and crylng CLher LesL was noL done ln Lhls
paLlenL
Muscle bulk ApproprlaLe muscle bulk noL hyperLrophlc or aLrophlc
Muscle power 3/3 for dlsLally and proxlmally
Muscle Lone Per muscle Lone for upper and lower llmb on boLh sldes were normal noL
hyperLrophlc or aLrophlc
8eflexes 8eflexes of blceps Lrlceps suplnaLor knee and planLar on boLh rlghL and lefL
are normal 8ablnskl reflex ls negaLlve
Slgns of menlngeal lrrlLaLlon no neck sLlffness and negaLlve kernlg's slgn and negaLlve
8rudzlnskl's slgn
W lmptessloo no abnormal flndlngs
summary
W Alml nur Aflqah 3 monLh old malay glrl come
Lo Lhe hosplLal due Lo fever for 2 days lrom
examlnaLlon no abnormal flndlng on sysLem
excepL for her skln 1here are erymaLous
swelllng of [aw area bllaLerally assoclaLed wlLh
veslcular llke lesslon and glve mlx blood and
pus dlscharge aL Lhe anLerlor upper chesL
Swelllng was well demarcaLed border
CurrenLly she was noL fever and can LoleraLe
orally
9rovlslonal lagnosls
W Lryslpelas
AbrupL onseL wlLh fever
Well demarcaLed border of rashes
LryLhema warm and Lender
Swelllng of [aw area and chln whlch ls paln on
Louch
ulcer on mlddle flnger Loe
lfferenLlal lagnosls
|fnos|s o|nt to suppot o|nt to ff|nst
CellullLls occur on Lhe face
paLlenL presenL wlLh
Lenderwarm and
eryLhemaLous macules
fever presenL
1he border ls less well deflned
numerous hemorrhaglc veslcles
Lryslpelas ls resLrlcLed Lo Lhe dermls and
superflclal layers of Lhe skln whllsL cellullLls
spreads deeper lnLo Lhe subcuLaneous
Llssues
ALoplc dermaLlLls 9resence of eryLhema
lLchy rashes
Cause sleep dlsLurbance Lo
Lhe paLlenL
non of Lhe famlly members experlence
Lhe same problems
no asLhma
paLlenLs havlng no known allergles
rug reacLlon paLlenL presenL wlLh
Lenderwarm and
eryLhemaLous macules
fever presenL assoclaLed wlLh
cough and runny nose
9aLlenL ls noL on any medlcaLlons prlor Lo
appearance of sympLoms
no dlarrhea and vomlLLlng
no allergles Lowards drug
lnvesLlgaLlons
W lull blood counL
@est esu|t Un|t Nomf| fne Impess|on
W8C 3388 10/uL 60160 Plgh
Pemoglobln 118 g/dL 111141 normal
PemaLocrlL 360 370430 Low
9laLeleL 434 10/uL 110430 normal
9ercenLage of
neuLrophlls
647 400800 normal
9ercenLage of
lymphocyLe
237 200400 normal
W 8enal proflle
@est esu|t Un|t Nomf| fne Impess|on
urea 24 mmol/L 2367 Low
Sodlum 136 mmol/L 136143 normal
9oLasslum 41 mmol/L 3331 normal
CreaLlnlne 412 umol/L 330 970 Low
W Llver luncLlon 1esL
@est esu|t Un|t Nomf| fne Impess|on
1oLal proLeln 760 g/dL 640 830 normal
Albumln 33 g/dL 3330 normal
1oLal blllrubln 48 umol/L 34 203 normal
Alanlne
1ransamlnase
16 u/L 033 normal
Alkallne
9hosphaLase
241 u/L 40130 Plgh
W C8eacLlve 9roLeln (C89)
14102010
W 9rellmlnary 8esulL no CrowLh AfLer 4 ays lncubaLlon
W CulLure and senslLlvlLy no growLh afLer 3 days lncubaLlon
@est esu|t Un|t Nomf| fne Impess|on
C8eacLlve
9roLeln ( C89)
710 mg/dL 001082 Plgh
llnal lagnosls
W Lryslpelas
98lnCl9LLS Cl MAnACLMLn1
W AdmlL paLlenL
W MonlLor Lhe vlLal slgn
W lv normal sallne (nS) glven for full malnLenance
W Clve syrup 9araceLamol for Lhe fever
W lv cloxaclllln
W lv penlclllln
lor 3 days
W Clve syrup cloxaclllln 7 days
W Clve syrup penlclllln 7 days
W Lncourage fluld lnLake
W MalnLaln adequaLe nuLrlLlon
W Clve an appolnLmenL Lo come Lo Lhe hosplLal
agaln Lo access progress of Lhe paLlenL
9rogress durlng hosplLallzaLlon
W 1
sL
day of admlsslon
9aLlenL havlng fever rashes and swelllng as presenLed on admlsslon
lv cloxaclllln 90mg Cl and syrup paraceLamol 90mg Cl was glven
W 2
nd
day of admlsslon
fever seLLled down
eryLhemaLous area furLher spread over Lhe lefL cheeks whlle Lhe
rlghL slde ls lmprovlng
oLherwlse chlld able Lo sleep and well LoleraLlng orally
lv C 9enlclllln Lo 163000 unlL Cl was sLarL glven ln Lhe evenlng
whlle lv cloxaclllln and syrup 9araceLamol sLlll conLlnued
W 3
rd
day of admlsslon
lever seLLle down leslon over face decrease ln amounL
lncrease dose of lv cloxaclllln Lo 130mg Cl
lv C 9enlclllln Lo 163000 unlL Cl was glven whlle syrup
9araceLamol conLlnued glven
W 4
Lh
day of admlsslon
Afebrlle leslon over face and [aw area was reduced
off lv anLlbloLlcs
SLarL syrup cloxaclllln 173mg Cl (30mg/kg) and syrup penlclllln v
90mg Cl (13mg/kg)
Syrup paraceLamol 90mg Cl conLlnued glven
W 11 am
moLher ls saLlsfled wlLh chllds progress
9aLlenL was acLlve and cheerful
Leslons over neck ls reduclng and paLlenL LoleraLlng orally well
9aLlenL was allowed Lo dlscharge
Syrup Cloxaclllln 173mg Cl and Syrup 9enlclllln v 100mg 8
was glven Lo be compleLed ln 7 days
An appolnLmenL was glven on 231010 aL 11am Lo revlew
progress of Lhe paLlenL
lSCuSSlCn
eflnlLlon
W Lryslpelas ls a superflclal bacLerlal lnfecLlon of
Lhe dermls
W CharacLerlsLlcally exLends lnLo Lhe cuLaneous
lymphaLlcs
L8?Sl9LLAS
lACL
causaLlve agenLPlb
(before lmmunlsaLlon)
nowSaureus CAS Lhe maln
causes
spneumonle(uncommon)
neckLrunkexLremlLles
Saureus(mosL common)
CAS
Lpldemlology
W Common Ages
lnfanLs ?oung chlldren
60 years
W More common over summer/hoL monLh
W 1roplcal counLry
W usually occurs ln lsolaLed cases
8lsk lacLors
W CorLlcosLerold /ChemoLherapy use
W labeLes MelllLus
W nephroLlc Syndrome
W LymphaLlc lnsufflclency
W venous lnsufflclency
9orLal/source of lnfecLlon
W open wound/skln Lrauma
W venous lnsufflclency ulcers lnsecL blLes and
surglcal wound
W 1he source of Lhe bacLerla ln faclal eryslpelas
ls ofLen Lhe hosLs nasopharynx
9aLhophyslology
lnoculaLlon
producLlon hyaluronldase
enzymaLlcally break connecLlve Llssue of
dermls
spread
Slgn SympLoms
W lever /rlgor
W laLlgue headaches vomlLlng
W Swollen lymph nodes
W Leslon lnduraLed wlLh elevaLed marglnssharply
demarcaLed
W 8edshlny swollen warm hardened and palnful
rash
W veslcles and bullae developed
W Areas of lnvolved skln may exfollaLe
lnvesLlgaLlons?
W CompleLe 8lood CounL (LeukocyLosls)
W AnLlsLrepLolysln C LlLer lncreased
W nasopharynx swabculLure + SLrepLococcus
W 8lood culLures are unrellable(unless sepsls)
W lrecL mlcroscopy
Cram sLaln on Lhe exudaLefluldasplraLe mlghL
show
[CAS(gram + coccl ln chaln)
[ Saureus (gram + coccl ln clusLer)
#buL Lhls meLhod ls palnful and only can see 30 of Lhe
Llme
#dlagnosed malnly by Lhe appearance of Lhe rash
omp||cft|ons
W 8acLeremla
W Abscess
W Cangrene
W Sepsls
W 9ermanenL skln damage(lf recurrenL lnfecLlon)
W LndocardlLls
18LA1MLn1
tfndfd tx seps|s es|stfnt to
pen|c||||n G
||e|c to
pen|c||||n
oph|fx|s
Cloxaclllln
Cephaloxln
Amoxlclllln
lv cephazolln
lv oxaclllln
lv
benzylpenlclllln
nafclllln LryLhromyclne Long Lerm
penlclllln v
Comparlson eryslpelas and cellullLls
lmmunocompromlsed?
Age 3years
LocaLlon of eryslpelas
Plgh grade fever
Cpen wound?
W8C counL 13000/mm3
W Aslde from locaLlon of lnfcLlonl don'L Lhlnk
Lhere ls any dlfferenLeven mosL of de book
don'L boLher Lo separaLe eryslpelas and
cellullLls and wrlLe Lhem ln 1 blg headlng
W xcepLmayb de compllcaLlon of cellullLls morre
svercoz lL has a probablllLy Lo exarcebaLe Lo
becom necrollng fascllLls
CLllullLls
W lffuse lnflammaLlon of connecLlve Llssue wlLh
severe lnflammaLlon of dermal and
subcuLaneous layers of Lhe skln
Lryslpelas
superflclal lnfecLlon of Lhe dermls and upper
subcuLaneous layer LhaL presenLs cllnlcally
wlLh a well deflned edge