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You are completing an elective at an urban pediatric ambulatory clinic. Your preceptor asks you to see Hanna, a 28 month old female. You introduce yourself to Hanna and her mother, and learn that for the last two days Hanna has been having a runny nose, coughing, and complaining of a sore throat. Over the last two days Hanna has become increasingly fussy and is eating less than she had earlier in the week. You perform a physical exam and find the following:
General appearance: Quiet and shy, does not appear toxic
Vitals: HR: 96 beats/min, BP: 105/66, RR: 23/min, T: 38.4 C
HEENT: Erythematous tonsils, normal tympanic membranes, coryza, rhinorrhea, conjunctivitis
Neck: Tender cervical lymphadenopathy
CVS: Normal S1, S2
Pulmonary: Chest clear to auscultation
Abdo: Soft and non-tender, no masses
Neuro: Screening exam normal
Which of the following are on your differential diagnosis at this point?
Responses:
choose any, all or none
Explanation:
Hanna has presented with nonspecific pharyngitis, rhinorrhea, and cough. This presentation is likely a viral infection, however it could also be the early presentation of a bacterial pharyngitis.
Features of Hanna’s history and physical exam favouring a viral infection include coryza, cough, rhinorrhea and conjunctivitis, however the sore throat, sudden onset, fever and cervical lymphadenopathy also suggest that a bacterial infection, such as Group A Strep could be causing her symptoms.
HSV would not be on the differential diagnosis at this point, as it rarely causes coughing and rhinorrhea, and would also present with vesicles. Thrush would also be excluded from the differential diagnosis, as it would not cause the erythematous tonsils, cough and rhinorrhea seen in Hanna.
Kawasaki's disease is important to think about in a child with a fever, however the fever would need to be present for a minimum of 5 days. In addition, few of the clinical signs seen in Kawasaki's disease are present in Hanna. If the fever continues however, and no other cause can be found, it is important to investigate for Kawasaki's disease.
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