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Join date : 2013-12-26

PostSubject: AMC Clinical exam preparation   Sat Dec 28, 2013 1:31 pm

amc clinical exam

Your next patient in general practice is an 8 year old boy, Grant, brought in by his mother, Jane, because he developed a red rash about 3 days ago which started in his face and a day later it spread over his trunk, arms and legs. It started off with small red spots which then later seemed to flow into each other. The rash is not itchy.

• Take a history
• Examine the patient
• Explain the most likely diagnosis, differential diagnoses and your management plan to the mother

HOPC: Grant complained about a runny nose, cough, red eyes about 5 or 6 days ago which his mother thought was just a common cold. He seemed to have a temperature as well and felt generally quite miserable. Then he developed a rash 3 days ago which started on the face and then spread across his trunk, arms and legs. The rash had red flat areas covered with small, raised bumps, all flowing into each other. It was not itchy.

PHx.: normal pregnancy, delivery and development, has had all his immunizations, never been seriously sick or in hospital, no operations, NKA.

SHx.: lives with parents and 2 siblings, no problems.

FHx.: unremarkable

Examination: Grant looks miserable with a runny nose and conjunctivitis with a generalised macula-papular rash, confluent – provide the provided picture!
His vital signs are normal except for a temperature of 38,3.
He has some small red spots with white centres on his buccal mucosa (KOPLIK SPOTS).

Measles is a highly contagious (droplets), viral infection that is most common among children. It is characterized by onset of fever, cough, coryza, conjunctivitis, followed after 2 days by an enanthem (Koplik's spots) on the buccal or labial mucosa, and a day or 2 later a macular-papular rash usually appears on the face first and then spreads over trunk, arms and legs. It can be a fatal disease and lso complicated by ear infections, pneumonia, encephalitis, acute thrombocytopaenic purpura etc.
During pregnancy the exposure to measles may trigger miscarriage or premature delivery.
Vaccination is highly effective.

• FBE is unnecessary but may show leukopenia with a relative lymphocytosis
• Laboratory identification by blood test for presence of measles IgM antibody or by viral culture or PCR of throat swabs, blood, nasopharyngeal swabs, or urine samples can identify measles for reporting purposes to the health
However, the diagnosis is usually clinical and needs to be reported even before the test results are obtained.

• Atypical measles syndrome
• Pneumonia (in 5% of patients, the most common cause of lethal outcome)
• Bacterial superinfection (otitis media, pneumonia)
• Acute thrombocytopenic purpura
• Encephalitis
• Subacute sclerosing panencephalitis

Differential diagnosis:
• Rubella (recognizable prodrome is absent, fever and other constitutional symptoms are absent or less severe, postauricular and suboccipital lymph nodes are enlarged (and usually tender), and duration is short).
• scarlet fever
• drug rashes (eg, from phenobarbital or sulfonamides, a drug rash often resembles the measles rash, but a prodrome is absent, there is no cephalocaudal progression or cough, and there is usually a history of recent drug exposure.)
• serum sickness
• roseola infantum
• infectious mononucleosis
• erythema infectiosum
• echovirus and coxsackievirus

Treatment is supportive with bed-rest, lukewarm sponging to reduce the fever as well as panadol or ibuprofen, fluid replacement, possible humidified or vaporized air to ease the cough.
Calamine lotion can help to ease rare itch and soothe the skin.
Measles is a notifiable disease!

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