=====================================================fever

- normal temp: 36.3 -37.3

- df: elevation in core temp >38.3? degree w/out intense physical atvt in nirmal child
-acute fever: last <= 7 days
- chronic fever/FOU: ≥38.3°C for at least 3 weeks duration with a failure to reach a diagnosis after 1 week of inpatient
investigation or 3 outpatient visits

- core temp : oral (>=37.8) , rectal (>=38) (show interior of body)

- shell temp? (axillary (37.2), , groin)…can change w environment …groin not comm->private area
- forehead, ear
<>>>
- neonate-> rectal
- baby…6m: rectal , forehead,ear (but not sensitivity) …not moth
- axillary--> swating, for adult hair…not good (**for adult--> stupid to do at axillary)

**ROS
- cns, cvs, respi, git, renal, msk, skin, ent

=========================================ddx for acute/ chronic ,FOU (fever of unkown region)

ACUTE (<1w) vs CHRONIC/FOU (>3w)
-----generalised inf
- dengue -fogging, fever, rash: maculopapular=blanch, gum bleed/bruising/petechiae…, fluid accum, abd pain/distension,
nausea&vomit, body aches (m, joint)…., throat (inflammed)
-tourniquet test
~dengue viral Ag test (NS1 -non-structural prt 1) - D1-5; IgM serology (>D5) , IgG …; FBC: bicytopenia(wbc,plt), ^Hct ;
coagulation profile -bleeding d.o; baseline LFT, RFT -to detect organ failure/dysf; blood gr crossmatch ; CXR (compliL pulm
edema/effusion)
- leptospirosis - rat, water atvt ~MAT(Microscopic Agglutination Test) & PCR test

- malaria - travel h/o, recurr fever+chills (pattern) ~parasitological test (microscopy or rapid diagnostic test (RDT)) ; - giemsa-stained
peripheral blood smear (thick & thin blood film)

-chikungunya
- TB - (chronic, productive cough, LOW, hemoptysis, SOB); travel h/o ~Tuberculin skin test or interferon- gamma release assay
- measles, ~measles-specific IgM antibody in serum and measles RNA by real-time polymerase chain reaction (RT-PCR)
-chickenpox (varicella) ~PCR from skin lesion (vesicle)
-typhoid ~widal test
-sepsis

- viral inf (EBV, HSV, HIV, adenovirus, CMV ~HIV serology

------localised inf
- CNS : meningitis, encephalitis ~lumbar pucnture
- cvs: IE ,rheumatic carditis -(SOB on exertion, chest pain, palpi) ; congenital HD which is risk factor of IE
- respi: URTI **, LRTI(pneumonia, bronchiolitis, pertussis, croup, TB, COVID-19, influenza) -(……nasal cong, sore throat, cough)
- ent: otitis media, sinusitis, mastoiditis
- git : ? AGE,dysentery,cholera…IBD#, SURGICAL: appendicitis
- renal: UTi ** -(<2y, how wipe genitalia, hygine, PE: check genitalia****dysuria (crying when pee), hematuria..) ~(urinalysis, c&s?)
- MSK: osteomyelitis, septic arthritis , autoimm below#
- hema: leukemia, lymphoma ~peripheral blood smear, BMAT
-skin: impetigo, boil, erysipelas

*- abscess - p/o of abd surgery ; mastoiditis ; sepsis

------autoimm inf
- kawasaki dis - red watery eyes, injected pharynx, red lips, strawberry tongue, rash/swelling of palms and soles, rashes,
lymphadenopathy
- SLE - malar flush, photosensitivity, oral ulcer, joint pain/swelling ~c3,4 low;
- IBD

- JIA (juvenile idiopathic arthritis) - joint pain/swelling, limping gait, rashes

- vasculitis

------malig -:loss of weight,loss of appetite

- leukemia - SOB on exertion, palpitation, easy fatigability, easily fall sick,bleeding/bruising tendencies , lymphadenopathy
- lymphoma -Swollen lymph nodes,weight loss,fatigue
- neuroblastoma
-----miscellaneous
- drug fever - taking drugs that can cause drug-induced fever
Anticonvulsants: carbamazepine, phenytoin
Abx: cephalosporins, erythromycin, isoniazid, penicillin, sulphonamide
NSAIDs: ibuprofen, salicylates
- hyperthyroidism - excessive sweating,heat intolerance,irritable,tremors,diarrhoea
-…
- post -vaccine

---------------------------------------------------------------------+ rash

Secondary lesions
- Due to manipulation, evolutionary process, or complication of primarylesion
- Atrophy: thinning or depression of skin
- Xerosis: pathological dryness
- Ulcer: disruption of skin that extends into dermis and beyond
- Erosion: disruption of skin involving only epidermis
- Excoriation: scratch marks
- Lichenification: thickening of skin
- • Macules and/or papules:
Macules— • red or pink discrete, flat areas that blanch on pressure
Papules— • small, raised lesions that blanch on pressure
• Infections—measles, rubella, human herpes virus 6, and enterovirus ; dengue
• Purpura and/or petechiae: red or purple spots that do not blanch on pressure.
- Infections—meningococcal, enterovirus, Haemophilus influenza, pneumococcal

• Vesicles: small raised lesions that contain clear flfl uid.

- Infections— chickenpox, shingles, herpes simplex virus, and hand, foot, and mouth disease
• Bullae and pustules: large raised lesions containing clear fluid or pus.
- Infections—staphylococcal/streptococcal impetigo and scalded skin

• Desquamation: peeling skin, often of the hands and feet.

- Infections— Kawasaki’s disease and after scarlet fever (post-streptococcal infection)

--------------etio
Infectious
- Measles=rubeola -rash: face,neck,shoulder..Koplik's spots (rubeola)
- Chickenpox -rash: begin on face
- Rubella -rash: forehead
-Rubeola, rubella, chickenpox: spreads inferiorly and to extremities
- Prodrome of URTI - measle, rubella, erythema infectiosum, chickenpox, roseola infantum

- Erythema infectiosum - rash: on cheek (slapped cheek)

- Roseola infantum

- Pityriasis rosea
- Scarlet fever -
- Meningococcemia -nausea, vomiting, neck stiffness, altered behaviour, fitting, petechial rash - meningococcemia
- Typhoid fever

- Dengue fever
- myalgia, arthralgia, headache - Lyme disease, dengue fever
- retroorbital pain, bleeding tendencies, abdominal pain/ distention, reduced urine output - dengue fever
- Lyme disease
• Non-infectious
- Acute rheumatic fever -Erythema marginatum

- Kawasaki disease -maculopapular rash: trunk, perineum; -red watery eyes, injected pharynx, red lips, strawberry tongue,
swollen/rash on palm sole, lymphadenopathy,
-strawberry tongue (Kawasaki disease, Scarlet fever),
 swelling of palms and soles, rashes, lymphadenopathy - Kawasaki dis
- Systemic lupus erythematosus -malar flush, photosensitivity, oral ulcer, joint pain/ swelling - SLE
-Systemic juvenile idiopathic arthritis - joint pain/ swelling, limping gait, rashes - systemic JIA
-Inflammatory bowel disease
-Drug Rash with Eosinophilia and Systemic Symptoms (DRESS syndrome)

------------------------------------------------------------------------------------- + lympha
- infectious
- bacterial: streptococcal pharyngitis, skin inf…
- viral: HIV, EBV, …… measles, rubella, hepatitis
- TB: mycobacterial tuberculosis
- fungal: ..
- protozoal …toxoplasmosis
-…
- malig
- leukemia, lymphoma, Ca of head, neck
- lymphoprolif #
-endo
-addison
-immunologic
- drug rx, …
-miscell
-kawasaki, SLE, lipid storage

====================================h/o, PE
******* fever: SO (onset) C(pattern, degree of fever, recorded value) R A# T (duration, timing: morning..malig, afternoon…, night…TB)
E(^&v factor-->tepid sponging/PCM--> dose/ml) S
- how n where mom took temp from (oral, axillary, rectally, .)

-A(chills, rrigor) (headache) (red eye) (rash) (lymphadenopathy) (ddx)

--continuous; remitting; intermittent; nocturnal**; morning; biphasic; relapsing

------- ddx as above +

- Exposure to wild/domestic animals?-cat scratch fever; History of tick bite (insect bite)
- sick contact / day-care
- travel ho in past 1y - endemic country malaria/TB

******Rash: S(site, start from where to where?) O (onset) C (as above# macule, papule, blanch, painful.., color)RATES P(progression)

O:Timing onset in relation to fever…Very Sick Patients Must Take Double Tablets
Varicella D1 of fever
Scarlet fever-D2 of fever
SmallPoxD3 of fever
MeaslesD4 of fever
TyphusD5 of fever
DengueD6 of fever
Typhoid D7 of fever
---ddx

-Exposure to insects/animals; History of sick contact; Recent travel?

********swelling: S(site) O(onset) C(size(progression**, shape, redness, painful) RA# T E S P(progression)

A**
-RASH?: measle, rubella, kawasaki, lyme , dengue
-URTI sym: measle, rubella
- myalgia, arthralgia , headache -lyme, dengue
-LOA, LOW, fever, night sweat - leukemia, lymphoma
- easy bruising/anemic symp / bleeding tend - leukemia, dengue?
- red watery eyes, injected pharynx, red lips, strawberry tongue, swollen/rash on palm sole, lymphadenopathy. - kawasaki
- malar flush, photosensitivity, oral ulcer, jointpain/swellinh - SLE

- exp to insect/ sick contact/ travel h/o ….

******assess COMPLI:
- dehydration (mentioned above below in PE, but ask in h/o)
-febrile seizure
-bw 3m-6y (& no evidence of Intracranial patho/metabolic derangement )
-# seizure note
-^HR, RR (sepsis..)

--------------------------------------------------PE (fever, rash, lymphadenopathy)

Weight, height, BMI, head circumference ..Nutritional status: well build? Thin build? Obese build?
General
- Vital signs: temperature, pulse, BP, respiratory rate, sp02
- urine color ~uti

- compli: hydration status : alert to time place person/drowsy=>GCS? Ill-looking?; ant fontanelle sunken, sunken eye, dry mouth….,
CRT (chest, finger), pulse, skin turgor , PR, bp(hypo?)

- rash+ shock: toxic shock syndrome, meningococcemia, dengue haemorrhagic fever

- Hands: Janeway lesion, Osler node, clubbing, splinter haemorrhages - IE

**- Any visible rashes - Kawasaki disease (back), SLE, JIA, typhoid fever, Rocky Mountain spotted fever
-rash examina:
Characteristic: Maculopapular rash? (Not bleeding)
- Central (start from head, neck)
 ✓ Viral exanthems: rubeola, rubella, roseola,erythema infectiosum, Lyme disease (erythema migrans -
pathognomonic)
- Peripheral ✓ Erythema multiforme

petechiae, purpura ; petechiae- meningococcemia

Erythema marginatum - acute rheumatic fever
Vescicle/bullae- chickenpox …

General/local?
Blanching? Or not?
Painful?
###
- Any bruising, petechiae, ecchymoses - leukemia

- Eyes: conjunctivitis (Kawasaki disease, leptospirosis, infectiousmononucleosis), conjunctival haemorrhage (IE)

congenital cataract (congenital rubella)

- ENT:
Sinus tenderness - sinusitis

Oral ulcer - IBD, SLE

-Koplik's spots (rubeola), strawberry tongue (Kawasaki disease, Scarlet fever), Forchheimer spots on soft palate
(rubella), mucous membrane involvement
Injected pharynx - infectious mononucleosis, toxoplasmosis, leptospirosis
Strawberry tongue

- neck: Any palpable lymph nodes - infection/ lymphoma

***memorise LN
- size, shape, ; unil/bil; local/generali; location; consistency; tender?; merge w below? …
• CVS examination
- Murmur heard on auscultation - IE, rheumatic fever
- Pericardial rub - pericarditis seen in SLE

• Respiratory system examination

-Reduced chest expansion, recession seen on inspection; increased tactile fremitus and reduced chest expansion on palpation;
dullness on percussion; crepitations, reduced breath sounds/bronchial breath sounds, whispered pectoriloquy on auscultation -
community acquired pneumonia , severe dengue=>fluid accum

• Gl examination
- Hepatomegaly/ splenomegaly - cat scratch disease, infectious mononucleosis(Slenomegaly), IE, malaria(spleno..also hepato),
dengue, leptospirosis leukemia , HIC, CMV, typhoid (spleno)
- Tender liver - liver abscess, hepatitis, cat scratch disease
-rash/excoriation - perineum (kawasaki
-MSK examination
- Joint swelling/ tenderness - joint infection, JIA, SLE, IBD, lyme dis
- Bone tenderness - osteomyelitis, malignancy (primary/secondary)
- CNS: meningococcemia (meningitis) - neck stiffness, Kernig, Brudzinski sign

========================Ix (later find specificlly for each**## list tmr once u went thro all##)
• FBC with differentials
- Anemia: malaria, TB, IE, JIA, SLE, IBD
- Leukopenia: leukemia, SLE, viral infection
- Leucocytosis: bacterial infection, IE, JIA, drug fever
- Thrombocytosis: JIA, Kawasaki disease
- Thrombocytopenia: viral infection, SLE, leptospirosis
-peipheral blood smear- leukemia…
- ESR/CRP
Raised - nonspecific indication of inflammation

• Blood culture and sensitivity - if suspicious of serious bacterial inf

- Urinalysis -uti
- Pyuria and bacteriuria: UTI
- Sterile pyuria: intra-abdominal infection, Kawasaki disease
- Haematuria: IE, leptospirosis, SLE
• Renal profile and serum electrolyte - to check for renal involv

• Liver function test - to checkfor hepatic involv

- skin biopsy (rash)

- stool tests (serology-rapid PCR test?; culture) - if hv loose stool/recent travel

- serology check in the list above***

- dengue, HIV, TB…
- test for connective tissue, immunodeficiency d.o - C3, C4, ANA, anti-dsDNA -SLE

• CXR - pneumonia, TB, lymphoma, mediastinal lymphadenopathy

• X-ray/ CT scan of sinuses and mastoid - sinusitis, mastoiditis
- X-ray bone/joint - osteomyelitis
• USG abdomen - intra-abdominal abscesses of liver, subphrenic space, spleen
-u/s of lymph node
• Echocardiography - IE, kawasaki (aneurysm)
- lumbar pucture (meningits)
- BMAT - leukemia , hema d/o
-FNAC/biopsy - lymph node

-CT- malig

==========Mx ##
- if not srsly ill --> regular review by parents (give instruction)…tepid sponging
- if yes --> Ix , observ , Tx (septic screen required)
- ***any who r srsly unwell --> manage as suspected sepsis
-septic screen: FBC (neutro:lympho); CRP; blood culture; urinalysis/UFEME

• Treatment depends on underlying diagnosis

• Antimicrobial drugs - only given when there is evidence of infection
Empirical antimicrobial therapy is avoided, except when life threatening infections are suspected (malaria, disseminated TB,
typhoid fever)
- Abx: 3rd g cephalosporin..cefotaxime (<1m); ceftriaxone (>1m)
• Antipyretics - PCM or ibuprofin ….given after complete evaluation to control fever

<>>>
-------------antipyretic: 10-15mg/kg, 6hrly d
- IMCI: made by WHO

- <1y below…not good to give PCM (deffinitely don’t give to <6m)

-bcoz liver not so mature (still imature--> will easilly get jaundice,liver toxicicity, liver failure
- 9m, 12m…..only give when fever super high

- instead do tepid sponging (tap water)(not give water to whole body--> chills , rigor)
-heat losing area………fontanelle, forehead,

- if pt>1 y…..give PCM, for 30min do tepid sponging until PCM action work--> for 2h…then if high again, tepid sponging
- for child ..don’t wrap in blanket******* unlike adult
- ***be careful at night--> can get febrile fit ***; look for cyanosis

- if baby<3m hv fever, high grade--> take to hospital*** coz not comm unless something srsly wrong

- ***don’t mix ibuprofin n PCM ***

=====================compli
• Children with FUO have better prognosis than adults
• Outcome depends on underlying diagnosis
• In many cases, fever abates spontaneously without a diagnosis established

------------------------------------------pathog #

<>>>>>>>>>>>>
-------------acute fever
-1 viral (RSV, inflamm dis--> kawasaki…. drugs ) (vaccine but resolve in few h so not categoried)
- fungal not comm in kids

****even give PCM, not releived

- continuous fever …always above 38oC…but temp can flactuate above
- remittent…there r some point, temp go down

- intermittent…some time ok, then fever

- biphasic….dengue**
- take temp every

- CXR - acute: hourly (near nurse counter)

- if less…4 hly or 6hly
--> can dx congenital pneumonia

------acute phase reactant

-crp, esr,\…other additional used in research

------------FUO
-lassic (m.comm)
- other category…coz makes easier for Ix (choosing which one to do..) like immunodef profile

---travel to endemic country/area

---sick contact (day care…
-- feeding--> source of inf, diarrhea, also if any risk of dehydration

-------compli: hallucination n dilirium

===========short cases
- if pt (child with teeth)…and has cardiac lesion--> need prophylaxis Ab (b4, during n after procedure..risk of endocarditis
- Q2: measles (not easy to see the unique sign)
- rubella similar symp…but antenatal rubella is important…..after born, not so dangerous

Viral exanthem ….**** mimic symp of measle, rubella

Arthirtis vs arthralgia

-----seizure
- comm cause--> fever, sore throat

------gastroenteritis --> answer all can la

----in child…brain imature..hypothalamus has diff set for tolerable temperature (THERMOSTAT LEVEL)

- Hb-o2 dissociation curve::: HIGH TEMP, metabolic acidosis, dehydration, 2,3 -dth? (glucose metabolism increase) => so body tissue req more o2 so need ot give o2 mask

====aspirin given==> reye syndrome (fever, fitting, liver enzyme high, low gluocose, ammonia high?, leg edema…, school boy age, GP give aspirin ………NO MORE GIVEN**)