Week 9 Discussion Comment.

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Subjective

CC: “fever ranging from 101 – 104.7 for 7 days”

HPI: 18 month old female comes in with her mother with complaint of this being the 7th day with her running fever. The fevers range from 101 to 104.7. Mom took her to the ER on the 4th day of running a fever. In the ER they drew blood and urine cultures which were negative, CBC, and CMP.

ROS: Mother admits to fever x 7 days. She took her to the ER on the 4th day. Blood and urine cultures resulted negative.

MEDICAL HISTORY: none noted

OBJECTIVE:

Vitals: Temperature: 101.5 degrees Fahrenheit, Heart rate: 120 beats/minute, Respiratory rate: 20 breaths/minute, Blood pressure: 90/40

Physical exam: She has injected conjunctiva, palmar redness, magenta-colored lips, red macula, excoriating rashes in the diaper area

Labs and diagnostic exam: CBC and CMP was ordered in the ER. CRP, ESR, ALT, AST. Laboratory parameters are used for the diagnosis and evaluation of conditions of patients for any inflammatory disease. The severity of inflammation in KD is reflected by inflammatory parameters; thus, laboratory findings are helpful for diagnosing incomplete KD and evaluating patients for early prediction of IVIG non-responsiveness (Lee, Rhim, & Kang, 2015). A high white blood cell count and the presence of anemia and inflammation are signs of Kawasaki disease.

ASSESSMENT

Primary diagnosis: Kawasaki disease Clinical manifestations of KD include prolonged fever,10-11 days, conjunctival injection, oral lesions, polymorphous skin rashes, extremity changes, and cervical lymphadenopathy, all of which comprise diagnostic criteria (Lee, Rhim, & Kang, 2015). Electrocardiogram measure the electrical impulses of your child’s heartbeat. Kawasaki disease can cause heart rhythm problems.

Differential diagnosis: Group A streptococcal Pharyngitis. Fever, headache, rash, and tiny red spots on the area at the back of the roof of the mouth (soft or hard palate). If untreated, strep throat can cause complications, such as kidney inflammation or rheumatic fever. Rheumatic fever can lead to painful and inflamed joints, a specific type of rash, or heart valve damage.

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrosis (TEN) are very serious skin conditions that can happen as a result of illness or as side effects to medications. Unexplained widespread skin pain. A red or purplish rash that spreads. Blisters on your skin and the mucous membranes of the mouth, nose, eyes and genitals. Shedding of skin within days after blisters form.

Treatment: To reduce the risk of complications, it is best to begin treatment for Kawasaki disease as soon as possible to lower fever and inflammation and prevent heart damage. Infusion of an immune protein (gamma globulin) intravenously can lower the risk of coronary artery problems. High doses of aspirin may help treat inflammation. Aspirin can also decrease pain and joint inflammation, as well as reduce the fever. Kawasaki treatment is a rare exception to the rule that says aspirin shouldn’t be given to children. Aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in children recovering from chickenpox or flu. Children should be given aspirin only under the supervision of a doctor. Once the fever goes down, your child may need to take low-dose aspirin for at least six weeks and longer if he or she develops a coronary artery aneurysm. Aspirin helps prevent clotting. Monitoring health of the heart at regular intervals, often at six to eight weeks after the illness began, and then again after six months (Pilania, Bhattarai, & Singh, 2018).

Education: It is important to keep the follow up appts after treatment. First follow up within 2 weeks and repeat EKG. Then again 6 to 8 weeks after their fever first started. Live viral vaccines should be postponed at least 11 months after IVIG, because IVIG can cause the vaccines to be ineffective. Follow a heart healthy diet and lifestyle. Cholesterol levels should be checked every 5 years (Healthy Children, 2020).

ANTICIPATORY GUIDANCE: Follow heart healthy diet. Seek early treatment recurrent fevers and keep follow ups to monitor the heart after treatment.

Discussion #2

The answers to the questions are to be posted in following the SOAP NOTE FORMAT below. You are to include the headings and subheadings below in your answer:

SUBJECTIVE CC: seven-day history of fever ranging from 101 to 104.7 degrees Fahrenheit. HPI: An eighteen-month-old child, well-known to your practice, presents to the ER with a seven-day history of fever ranging from 101 to 104.7 degrees Fahrenheit ROS: Eyes- sclera positive for Injected conjunctiva, lips magenta, red macula, extremities- palmar erythema, groin/genitalia positive for excoriating rash. MEDICAL HISTORY – none, 18 month- old, no other history provided

OBJECTIVE VITALS

Temperature: 101.5 degrees Fahrenheit

Heart rate: 120 beats/minute

Respiratory rate: 20 breaths/minute

Blood pressure: 90/40

PHYSICAL EXAM

• Injected conjunctiva

• Palmar redness

• Magenta-colored lips

• Red macula

• Excoriating rashes in the diaper area

LABS & DIAGNOSTIC RESULTS -urine and blood cultures (negative), CBC and CMP done in ER. Additional testing recommended to include CRP and ESR. CBC and blood cultures to evaluate presence of infection, and oxygenation status, especially to rule out endocarditis that could be related to the condition. CPR (c reactive protein) is elevated in response to inflammation, before ESR does. CRP levels between 0.3 and 3.0 indicate high risk for trauma, infection or inflammatory disease. ESR (erythrocyte sedimentation rate) also shows inflammation severity in symptomatic patients with ongoing disease processes that need further investigation. In an 18 month-old child the ESR should be below 10 (Pagana & Pagana, 2018).

ASSESSMENT PRIMARY DIAGNOSIS – Kawasaki Disease M30.3- a severe and systemic form of vasculitis with persistent fever over 4 days, bilateral injection of conjunctiva, progressive skin rash, oral mucosa swelling ad erythema with rashes on hands and feet. The disease is fatal if left untreated and requires immediate attention to prevent the complication of cardiac damage and coronary artery disease (Tanaka et al, 2020). The patient presented with all of these symptoms to the ER, making this the primary diagnosis.

DIFFERENTIAL DIAGNOSIS

Streptococcal scarlet fever A38.9- Streptococcal infections can manifest with fever and subsequent rash of the body and is the most common infection presenting with fever and rash in children. Group A streptococcus (GAS) pathogen in children presents with symptoms of scarlet fever, tonsillitis, high fever, rheumatic fever, and glomerulonephritis. Penicillin (PCN) is usually used to treat the infection, and erythromycin is used in patients with PCN allergy. Most cases are treated with antibiotics good success and resolution of symptoms (Li et al, 2020).

Viral infection B34.9- viruses can cause several rashes in children. Infections with visible rases include measles, zika, roseola, rubella, hand-foot and mouth or unknown/unclassified infections. Most are self-limiting and require comfort measures and do not progress (Castro & Ramos-e-Silva, 2020).

PLAN TREATMENT- intravenous immunoglobulin (IVIG), intravenous prednisolone (PSL) and in some cases high dose aspirin if indicated for cardiac changes such as aneurysm or coronary artery disease. Careful monitoring of I&O, activity and atherosclerosis is essential. The risk of skin damage is also a factor and needs continued monitoring as part of the care plan (Zhong, 2020).

EDUCATION-Teaching of post treatment care to the parents is essential. Diet full of nutrients and proper rest after treatment is important. The importance of follow up care for prevention of heart disease is the most important teaching goal. Signs of coronary aneurysms or decreased cardiac output such as lethargy, pallor, breathing difficulty, decreased appetite and decreased output should be stressed to be reported to doctor immediately. Careful wound care and rash treatment should be done to prevent skin infection and cellulitis (Tanaka et al, 2020).

ANTICIPATORY GUIDANCE- As the Nurse Practitioner caring for the patient, the next step in this evaluation is to have careful follow up for cardiac complications related to Kawasaki disease and any secondary infections such as pneumonia, cellulitis or endocarditis (Zhong et al, 2020).

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