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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 7 of 9: Adequate investigations?

Yes <incorrectNo

INCORRECT : No lab investigations undertaken despite symptoms suggesting possible invasive bacterial infection.
Further Information

Initial laboratory assessment

The tests below should be done on all suspected cases of MD and children who are suspected of having an invasive bacterial infection:

  • Glucose
  • Full blood count
  • Electrolytes and urea
  • Calcium and magnesium ( metabolic derangements are common in septicaemia and may contribute to myocardial dysfunction)
  • Phosphate
  • Clotting studies
  • Venous blood gas to measure base excess
  • Blood culture
  • Throat swab culture
  • Meningococcal PCR whole blood (EDTA specimen) to send to reference laboratory

Parameter Normal range*
Hb 10.5 to 13.5 g/dL
WCC 5.0 to 15.0 (×109)
Platelets 150 to 450 (×109)
Base Excess 0 to -3 mmol/L
pH 7.35 to 7.45
HCO3 22 to 26 mmol/L
PaO2 10 to 13.5kPa or 75 to 100mmHg
PaCO2 4.6 to 6kPa or 34.5 to 45 mmHg
Glucose 3.6-5.2 mmol/L
Urea 2.5 to 6.0 mmol/L
Creatinine 19 to 43 mmol/L
Na 133 to 146 mmol/L
K+ 3.5 to 5.5mmol/l
Mg++ 0.66 to 1.0 mmol/L
Total Calcium 2.17 to 2.44 mmol/L
PO4 1.60-2.90 mmol/l
INR 1
PT 9.9 to 12.5 seconds
APTT 26.0 to 38.0 seconds
TT 9.2 to 15.0 seconds
Fibrinogen 1.7 to 4.0 g/L

*Please note that normal ranges for many variables can differ among hospitals.

Blood gas reports measurement of base excess (BE), which, when negative indicates that there is a base deficit (acidosis).


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