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CASE HISTORY
2 hours later - ED doctor's assessment:
Presenting complaint: right hand swollen and painful, hand painful for 4 hours, no history of trauma.
Has been in contact with chickenpox 5 days ago.
On examination: temp 40.1 (55 minutes after Calpol and Brufen).
Small blanching spots on body.
ENT / ABDO clear.
No photophobia.
Diagnosis: probable early chicken pox. Child sent home with anti-pyretics. Child of 5 years attends Emergency Department with sudden onset fever and painful right hand.
ED Triage assessment:
1)? Injury soft tissue
2) unwell, pyrexia.
Sudden onset pain in right hand. No history of trauma, she is reluctant to have it touched. She is also generally unwell. Spots erupting on arm and back. Last had Calpol 2.5 hours ago.
Observation taken: temp 39.9
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QUESTIONS ON CASE 1
 
Q 6 of 9: Persistently abnormal signs/symptoms?
Yes  No
CORRECT
: Symptoms that were assessed were persistently abnormal: unwell child, unremitting fever, severe isolated limb pain, rash.
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Further Information
Symptoms of septicaemia
- Fever
- Many children become suddenly ill with a fever: the classic picture is of a disease of rapid onset. However, some children develop septicaemia after a simple viral illness. In these cases the symptoms may be initially trivial and last for some time and then suddenly become more serious with a high fever and other symptoms of sepsis.
- A history of a fever in a child presenting afebrile is important.
- Not all children with meningococcal disease (or other serious bacterial infection) have fever17. A fever that subsides after antipyretics cannot be dismissed as viral in origin.
- Hypothermia, especially in infants, may also indicate serious infection 18
- Rigors Children with septicaemia often have rigors19.
Occasionally the shaking, if very severe may be mistaken for fitting, but
children having rigors will remain conscious.
- Aches They usually experience very bad muscle aches and
joint aches making them restless and miserable.
- Limb pain Isolated severe limb pain in the absence of
any other physical signs in that limb is a well-established phenomenon in
MD20
7.
The pain can be very severe and children have been mistakenly put into plaster
to treat presumed fractures.
- Gastrointestinal symptoms vomiting, nausea and poor appetite
(poor feeding in babies) are common in septicaemia. Abdominal pain and diarrhoea
(leading to faecal incontinence in some cases) are less common but well documented21.
This can create confusion with gastro intestinal infections.
- Weakness This can become profound.
- Rash Ask about any new rashes or marks on the child’s
skin that the parents may have noticed. Note that parents may not realise
that the petechiae or purpura or 'bruises' on the child’s skin are a rash
as they associate the word ‘rash’ more with a pink ‘measles-like’
rash. They may use other words to describe the rash, for example bruise, spot,
freckle, blister, stain or mark on the skin – like chocolate, etc.
- Urine output Ask whether the child has passed urine or
had a wet nappy recently. Oliguria is one of the early signs of shock
- Cold hands and feet, mottled skin As septicaemia advances,
cold hands and feet and mottled skin are signs of circulatory compromise that
parents notice.
- Signs of circulatory compromise - complications of septicaemia
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