Where you are:
You are an FY2 working in a GP clinic.Who the patient is:
Lippy Harrison, the mother of Robin Harrison aged 3 years old, has come to the clinic as her son is not feeling well.What you must do:
Take focused history, address the patient’s concerns and discuss the plan of management accordingly.
Doctor: Hello my name is doctor (name)… Can I get your full name please? can I confirm your little one’s full name and date of birth as well… How can I help?
Patient: My child is unwell (fever and rash all over the body since yesterday)
2 complaints explore both
Dr: Can you please tell me what happened? Open Qs then ODIPARA
Pt: He was fine 3 days ago until he got a fever. Onset/Duration
Dr: Did you measure his temperature? Fever
Pt: No doctor.
Dr: What did you do to bring it down?
Pt: We went to the GP and he gave her Calpol and referred us to the hospital.
Dr: Does he have any cough? Sputum?
Pt : No
Dr: You mentioned he has rash as well?
Pt: Yes.
Dr: When did you notice it? Onset/duration
Pt: 3 days ago.
Dr: Where on his body did it start? Site
Pt: On his chest.
Dr: Did you notice its size or shape?
Pt: They were red spots.
Dr: Did they change afterwards? (Progression/any change)
Pt: They spread all over and some became blisters.
Dr: Do they emit any discharge? Bleeding?
Pt: No.
Dr: Is there any itching?
Pt: Yes.
Dr: Is he crying? (Painful)
Pt: Yes, a lot.
Dr: Have you noticed if he is shying away from light or cries while moving his neck?
Meningitis
Pt: No.
Dr: Have you noticed any difficulty in breathing? Anaphylaxis
Pt: No.
Dr: Any vomiting?
Pt: No.
Dangerous Sx and Dehydration Sx:
Dr: Do you feel that his mouth is dry?
Pt: No.
Dr: Does he have any problems with his wee? Has he been weeing normally today?
Pt: He’s been weeing fine.
Dr: Have you noticed any tummy pain or change in his poo?
Pt: No.
Dr: Any diarrhoea?
Pt: No.
P2+MAFTOSA
Dr: Has this ever happened before?
Pr: No, this is the first time.
Dr: Has he been diagnosed with any medical condition in the past?
Pt: No.
Dr: Is he taking any medications including OTC or supplements?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Any previous hospital stays or surgeries?
Pt: No.
CONTACT
Dr: Has anyone in your family been diagnosed with any medical condition or developed
similar Sx?
Pt: No.
Dr: Who looks after him?
Pt: I do.
Dr: May I ask who lives with you at home?
Pt: Just his father and sister.
Dr: By any chance are you pregnant?
Pt: No.
BIRDDD
Dr: How was Colton’s birth?
Pt: It was a normal vaginal delivery.
Dr: Was he born full-term?
Pt: Yes.
Dr: How much was his birth weight?
Pt: I can’t remember but it was normal.
Dr: Are you happy with his red book?
Pt: Yes.
Dr: Is he up to date with all his jabs?
Pt: Yes.
Dr: Has he received any recent jabs?
Pt: No.
Dr: Is he feeding well? Diet
Pt: Yes/Not much
Dr: Since when?
Pt: Since his fever.
On Examination
• Observation
• Rash
• Check signs meningism
- Chickenpox starts with red spots. They can appear anywhere on the body and might spread or stay in a small area.
- The spots fill with fluid and become blisters. The blisters may burst.
- The spots scab over. New spots might appear while others are becoming blisters or forming a scab.
Management:
Diagnosis:
From what you have told me and from my examinations as well (Explain briefly positive findings) I am suspecting your child has Chickenpox. It’s a type of viral infection with caused by a virus called varicella that as you mentioned starts with red spots that can appear anywhere on the body and might spread or stay in a small area. The spots fillwith fluid and become blisters. The blisters may burst. The spots scab over. New spots might appear while others are becoming blisters or forming a scab. It may take a few
weeks 1-3 to develop Sx after infection.
Senior
Symptomatic
- Medications:
− Paracetamol to help with pain, fever and discomfort.
− A soothing cream (emollient) may help the itch. Calamine lotion is the most
popular one.
− Sedating antihistamine (liquid medicine) may help with sleep if itch is a problem.
This can be used in children over 1 year old. Give a dose at bedtime.
Chlorphenamine (Piriton®) is the one most commonly used.
− Extra treatment such as acyclovir is given for children have a higher risk of
developing complications from chickenpox (such as heart , lung disease , taking
steroids or less than 1 month ).
DO
− Drink plenty of fluids (try ice lollies if your child is not drinking) to avoid dehydration.
− Put socks on your child’s hands at night to stop them scratching their spots and cut
your child’s nails.
− Bathe in cool water and pat the skin dry (do not rub).
− Dress him in loose clothes.
DON’T
− Do not use ibuprofen unless advised to do so by a doctor, as it may cause serious
skin infections.
− DO NOT GIVE ASPIRIN TO CHILDREN UNDER 16
− Do not be around pregnant women, newborn babies and people with a
weakened immune system, as chickenpox can be dangerous for them.
Safety netting
You’ll need to stay away from school, nursery or work until all the spots have crusted
over. This is usually 5 days after the spots appear. Chickenpox is infectious from 2 days
before the spots appear, until they have all crusted over – usually 5 days after they first
appear.
Although serious complications are rare, it is best to be watchful. See us if your child
develops any worrying symptoms that you are unsure about such as:
− Breathing problems.
− Weakness such as a child becoming wobbly on his/her feet.
− Drowsiness.
− Fits.
− Pains or headaches which become worse despite paracetamol.
− Being unable to take fluids, due to a severe rash in the mouth.
Follow up after a 1 week
The following groups, should see a doctor urgently if they have been in contact with chickenpox or have symptoms of chickenpox:
− Children (babies) less than 1 month old.
− Children with a poor immune system. For example, children with
leukemia, immune diseases or HIV/AIDS.
− Children taking certain medication such as steroids, immune-suppressing medication, or chemotherapy.
− Children with severe heart or lung disease.
− Children with a severe skin condition.
4 POINT RECAP:
- EXPLORE FEVER AND RASH
- EXCLUDE DANGEROUS SX OF MENINGITIS AND ANAPHYLAXIS
- CONTACT AND PREGNANCY
- TTT SUPPORTIVE+ ADVICE (AVOID SCHOOL)