Box 10.

13: Typhoid
vaccines
Vi capsular Typhoid conjugate* Live-attemuated Ty21a
polysaccharide
Dose; route 0.5 mL; SC or IM 0.5 mL; IM Oral; capsule
Site Anterolateral thigh or Anterolateral thigh or deltoid Oral
deltoid
Schedule
National program Not included Not included Not included
LAP 2016 (If conjugate vaccine (Preferred) One dose at Not available; 3 doses in children who can
not available) One 9-12 months; one booster at swallow (>6 years)
dose at 22 years; repeat 2 years
every 3 years
Catch up One dose beyond 2 years One dose, up to 18 years Any age
Adverse reactions Local pain, swelling, Local pain, swelling, redness; Abdominal discomfort, fever
redness; fever fever
Contraindication Anaphylaxis after Anaphylaxis after previous dose Immunodeficiency
previous dose
2-8C; do not freeze 2-8°C 2-8°C
Storage
Ensure gap of 4 weeks between this and any measles containing vaccine
YREXIA OF UNKNOWN ORIGIN
Age: Children<I year may not have localizing
signs because of poor immunological devel-
opment: hence infections may present clini-
cally as fever of unknown origin. Children >6
years of age may have a localized infection
(abscess) or respiratory or genitourinary cause
for fever. Kawasaki disease is more common
in less than 5 years. Autoimmune processes
are common in adolescents.
Sex: Autoimmune causes are likely in older fe-
male children.
Presenting complaint
H / o fever since-
History of present illness:
History must be tailored keeping in mind
the most probable diagnosis in your area.
Example could be infections (Viral: IMN,
HIV; Bacterial: UTI, respiratory, typhoid,
TB; Spirochetes: Leptospira; Protozoa:
Malaria, leishmaniasis; ricketsiae: Serub ty-
phus), collagen vascular or malignancy.
A s k whetherand how the fever was docu-
mented (many mothers attribute normal
head warmth as fever). Note the onset (in-
sidious/acute), duration and progression
low
of fever. In typhoid, fever starts as
increases over
grade and progressively
malaria starts as
many days. In contrast,
high spiking fever. But the typical pattern
in en-
of fever (e.g., step ladder pattern
in all cases
teric fever) may not be present
as the course gets interrupted byy
antipyretics.
fever was of high
Enquire whether the
associated with chills and
grade and was
in malaria, urinary
rigor (characteristically
infection and pneumococcal pneumonia).
 18. DISORDERS OF GIT SYSTEM: CASE SHEET FORMATS 419

Number of spikes of fever per day: Once persistent fever think of infective en-
daily spikes (quotidian) in JIA or tertian/ docarditis.
quartan in malaria. Abdomen: Abdominal pain, vomíting,
Ask whether child was well and playful in constipation: enteric fever/dengue fe-
between periods of fever and is unwell ver/TB abdomen.
only during the period of fever (less Renal: Frequent micturition, dysuria,
UTI.
chances of serious infections). hypogastric pain, flank pain -
oral
H/o rash if any and the day on which rash History of recurrent infection,
appeared helps in diagnosing exanthema- thrush, significant loss of weight-
tous fevers. It can be remembered by the HIV
mneumonic "Very Sick Person Must Take History of joint pain, rash, photo-
autoimmune causes like
Double Tablets" sensitivity
SLE, JIA.
Very-Varicella (day 1) risk factor for
History of pica can be a
Sick Scarlet fever (day 2)
Toxoplasmosis, Toxocara canis.
Person - Pox - small pox (day 3)
Brucello-
History of contact with animals
-

Must Measles (day 4/5)

sis, leptospirosis.
Take Typhus (day 5) Travel to endemic areas -

Malaria, Kala
Double Dengue (day 6)
azar, histoplasmosis.
Tablets Typhoid (day 7)
Transient salmon coloured macular
non- Drug history Anticholinergics: Topical
agents including eye drops
can cause drug
rash recurring with fever spikes
pruritic anti-
fever. Drug fever may follow many
systemic onset JIA.
may indicate biotics.
Ask for h/o associated complaints
as
diabetes
to many organ sys-
Endocrinological causes such as
symptoms referable Addison's dis-
a detailed his- insipidus, thyrotoxicosis,
tems may be present and ease are rare causes.

tory is a must. History suggestive of malignancy

or

Nervous system:
Consider meningitis
familial causes should also be kept in mind.
when there is irritability/drowsiness, Familial causes: Familial dysautonomia,
seizures in an infant
refusal to suck,
hereditary periodic fever syndromes.
orheadache, drowsiness, projectile
child. Cerebral 4. Past history
vomiting, in an older Ho recurrent infections/unusual course/not re
malaria may be a close differential.
like persistent
sponding to regular antibiotics may point
Respiratory symptoms towards immune deficiency.
Pleuritis due to tu-
cough, chest pain: 5. Natal & postnatal
berculosis/pneumonia.
Ear discharge:
(otitis media). Prematurity, LBW, prolonged rupture of mem-
Mastoiditis, meningitis
nasal obstruc- branes, maternal sepsis are high risk factors
Pain, nasal discharge,
consider sinusitis to development of sepsis in a young infant.
tion, headache:
(frontal sinuses do not develop until a 6. Immunization history
child is 7 years old); Sore
throat: IMN. Inquire about all vaccines particularly as for
Neck swellings: TB, lymphoma. BCG, Hib, hepatitis A & B, measles, varicella.
Cardiac: Child with a heart disease 7. Growth and development: Usually normal.
before or after surgery presenting with 8. Nutrition history: As routine.
420 PAEDIATRIC CLINICAL EXAMINATION

AIDS Mouth
Contact with TB, h/o
9 Family history: Look for oral ulcers, dental hygeine
related illnesss in the parents.
gingivitis
10. Socioeconomic history Throat: Bilateral enlarged tonsils,
11.General examination
with/without exudates in IMN
whether toxic;
general
-

Note the appearance enteric fe-

child.
Tongue: Coated tongue
note the sensorium of the
ver
12. Vitals
fe- Strawberry red tongue: Kawasaki dis-
Pulse: Tachycardia ( could be due to
ease, scarlet fever
ver:1° rise in temperature approximately
Oral candidiasis (beyond newborn
increases pulse by 10 beats; dispro- period): Immunosuppression
think oftoxemea).
portionate tachycardia Thyroid enlargement: Thyroiditiss
-

or
seen in den-
Bradycardia is occasionally Graves disease
gue, typhoid, leptospirosis. Lymph nodes
Hypotension may be seen dengue,
in
BP:
Matted lymph nodes: TB. generalized
hess test. Hypotension is possible
perform lymphadenopathy IMN (look for
serious ill-
in the advanced stage of any
epitrochlear nodes too). TB or malig-
ness.
nancy.
RR may increase with fever.
in the Skin
Temperature: Record temperature Rash: Note the distribution (more in
of the child
appropriate manner for the age
face or trunk, where it started first)
at the time of examination.
and type (macular/papular/vesicular).
13. Head to foot examination Fever blisters: pneumococcal, staphy-
Eyes lococcal, streptococcal and
rickettsial
Look for pallor, icterus
Palpebral conjuctivitis: Measles infections.
Bleeding manifestations malignancy.
-

Bulbar conjuctivitis: Kawasaki disease,

Absence of sweating (familial dys-
leptospirosis autonomia/anhidrotic ectodermal dys-
Petechiae: Haemorrhagic fevers, in-
fective endocarditis plasia).
Genitalia: Look for any local inflam-
Phlycten: TB
Proptosis: Thyrotoxicosis, metasta-
mation (often missed in exam).
Limbs: Pain may suggest deep vein
sis, orbital infection
Uveitis: Connective tissue disorders thrombosis, especially in prolonged
Fundus: Look for chorioretinitis/ immobilization ofa fat child.
Bone pain/muscle pain: Note if gen-
choroid tubercles
Lack of tear, absent corneal retlex may eralized or point tenderness (osteo-
indicate familial dys autonomia myelitis abscess).
Nose 14. Systemic examination
Look for pus discharge Proceed to examine relevant system based

Ear on clinical clues from history and general

Discharge: Note the colour; whether examination.
foul smelling or not Most often, a good general examination
Look for sinus tenderness followed by abdominal examination is the
 18. DISORDERS OF GIT SYSTEM: CASE SHEET FORMATS421

one needed. Hepatosplenomegaly is likely Pallor

in IMN. typhoid, malignancy, etc. Coaled tongue
Delirium
Investigations Meningeal signs may be elicitable
Investigations must be tailored depending on the Look for rose spots
ifferential diagnosis. The following is a general Hepatomegaly and/or splenomegaly
Gall bladder may become palpable
uggestion.
Total WBC count (>15,000 is more likely to
have bacterial infection), DC (shift to lefvin- Differential Diagnosis
with fever (p
creased band counts suggest bacterial infec- See causes for hepatosplenomegaly re
tion), Pl. count, ESR/CRP, blood film for ab- 167).
normal cells and malarial parasites
Urine routine, C&S Treatment
followedoral cefixime.
by
Blood C&S Ceftriaxone
to third gen-
Mx, X-ray chest Ciprofloxacin if not responding
.Widal, dengue & leptospira serology eration cephalosporin.
Fever: Paracetamol and tepid sponging.
HIV serology
ANA, rheumatoid factor I V fluids, if necessary.
and enemas must be avoided even
Laxatives
Bone marrow
when there is constipation.
Imaging studies (USS, CT) intervention for perforations.
Immunoglobulin assay Surgical
bacteria in stool for
Individuals excreting the
carriers; those
more than 3 months are
are chronic
Treatment
excreting for more than 1 year
Students are
Treatment depends on the diagnosis. carriers.
"Manual of Pediatric Prac-
encouraged to consult
the same author for treatment details for
tice by Complications
fresh
haemorrhage. Dark stools
individual conditions. or
Intestinal
blood in stool.
distension
Tender distension
TYPHOID FEVER Perforation and peritonitis.
Perforation Tender
and the format for and other signs of
Case sheet format for PUO of abdomen, vomiting
used.
examination of abdomen may be peritonitis.
Prolonged fever Toxic myocarditis.
Headache (mainly because of fever) n e r complications
Other
O
anaemia, encephalo-
complications are anaemia,

Cough is a early symptom (typhoid

common
pathy, pyelonephritis, meningitis,
thrombo-
blad-
bronchitis) cytopenia, jaundice, acute hydrops of gall
pain
Diffuse non-localized abdominal to
der, etc.
(late, due
Diarrhoea (early) or constipation

ileus) Prevention
Abdominal distension(ileus) Safe drinking water
History of water source dark stools Toilet use and safe sewage disposal
History of diarrhoea/constipation; Vaccination
(intestinal haemorrhage)
Hepatosplenomegaly with Fever
Here, infections are the most probable cause.
Viral: Infectious mono nucleosis.
Bacterial:Typhoid fever. Widal test and clot
culture will confirm the diagnosis.
Protozoal: Malaria (history oftravel to en-
demic areas should strengthen the suspi-
cion; blood picture will show the malarial
parasite); kala azar.
Malignancy: Leukaemia, lymphoma.
Collagen vascular diseases like SLE (will have
other manifestations of SLE), systemic onset
JRA.