Subjective
Chief Complaint
K. P. is delivered to the emergency room by her parents with the chief complaint – “fever and rash on her feet during the last four days.”
History of Present Illness
K. P. is a 6-year-old white female whose parents are concerned about her behavioral changes, skin rash, and fever has not gone in several days. The child does not visit school at the moment because she is on her summer vacation, so she spends all her time with her mother. Despite her active style of life, the girl has not demonstrated interest in playing with other kids. The mother admits that her daughter prefers to sleep most of the day and uses her fever as the excuse for this behavior.
Past Medical History
Several cases of flu, with no hospitalization, were treated at home with Ibuprofen (to manage fever) and cool-mist humidifiers (to relieve cough severity).
Past Surgical History
An adenoidectomy at the age of 3
Medications/OTC
Ibuprofen 5 mL twice a day
Allergies
Penicillin
Past Family History
Parents are healthy, with no chronic diseases being recently diagnosed; no other children are in this family. The mother’s parents have hypertension and cardiac disease, and the father’s parents were diagnosed with diabetes five years ago.
Health Maintenance
Routine physical examinations are performed in a local clinic two times a year. Regular dental visits occur three times per year, with no serious problems and interventions.
Social History
The patient goes to a local school and visits drawing classes twice a week. Her mother is a freelancer who spends much time at home. Her father is an office manager, and he works five days a week from 9 am till 6 pm. The family spends much time together on weekends, travels the countryside, and has friendly relationships with neighbors. No addictive habits, abuses, and other negative behaviors are reported.
Objective
Vital Signs
Weight: 44.5 lb; Height: 46.2″; Temperature: 39.5°C; BP: 95/110 mm/Hg; HR: 90bpm; RR: 18.
Physical Exam Findings
Skin: erythema on her right foot and on her right hand
Eyes: red, without discharge
Laboratory Tests
WBC – 18 cells/hpf; platelets – 500,000; protein – 10 g/dl
Diagnostic Testing
Echocardiography is used to check the heart’s condition and detect cardiac complications if any.
Diagnosis/Assessment
Primary Diagnosis
M30.30 – mucocutaneous lymph node syndrome or Kawasaki syndrome: It is proved by such symptoms as fever, rashes on feet and hands, and eyes’ redness, without discharge. The initial stage of Kawasaki disease is characterized by high fever, reduced activity, and fatigue (Hedrich et al., 2018). Being poorly recognized and untreated, the next stages provoke additional health changes like diarrhea, vomiting, and abdominal pain; this progress should be controlled and stopped to predict the development of new cardiac complications.
Differential Diagnosis
B34.1 – enterovirus infection, unspecified: This disease is developed with almost similar symptoms like fever and rash. Still, the patient should meet other criteria like the presence of respiratory symptoms, sore throat, and cough (Weng et al., 2018). This diagnosis is common in children, and parents should remember the moment when the first signs are recognized. Many different viruses provoke this condition, and young age is a risk factor.
A38.9 – scarlet fever, uncomplicated: Children with a rash and fever higher than 101°F are usually tested for this disease and the presence of streptococcus (group A strep) that causes strep throat and the progress of blood infections (Rhim et al., 2019). Still, this condition was severe in the past, and now, it is characterized by a rare phenotype. Therefore, strep infections are treated with antibiotics that do not help in Kawasaki’s case.
N39.0 – urinary tract infection (UTI): Misdiagnosis of Kawasaki disease as UTI is possible in children if no typical features of the former are revealed. The patient should have pyuria and increased C-reactive protein levels, which is common for both diseases (Han & Lee, 2018). Urination frequency changes, bloody urine, and painful urination processes could prove UTI.
Management Plan
Medications
Intravenous immunoglobulins is an urgent pharmacological intervention that should be offered to the child. The necessary dosage is 2 g/kg/KG during the first ten days of fever (Hedrich et al., 2018). Aspirin (30 mg/kg/day) is recommended to prevent the growth of inflammation and reduce fever (Han & Lee, 2018). If no response is observed, acetylic acid could be offered.
Non-Pharmacological Approach
The patient should take a rest during the next week of the treatment process. Kawasaki disease may provoke heart problems; thus, monitoring is expected as a part of non-pharmacological interventions. Percutaneous interventions are necessary to reduce and control the development of rash-related problems.
Follow-up
After the patient is treated, it is expected to appoint the next check in 2 and 8 weeks to observe if there are any heart changes or other immune complications.
Patient Education and Health Promotion
The patient’s education is fundamental during and after the treatment process. Regarding the young age of the patient, a nurse has to communicate with her parents and explain the importance of checking her body for the possible development of new rashes. Self-care strategies like hand hygiene, healthy eating, and physical activities with time should be mentioned. Kawasaki disease challenges blood vessels significantly, and it is expected to understand how to improve the vascular health of a child. Walking programs and cholesterol-rich diets are necessary for a child under regular parental and nursing observations.
References
Han, S. B., & Lee, S. Y. (2018). Differentiating Kawasaki disease from urinary tract infection in febrile children with pyuria and C-reactive protein elevation. Italian Journal of Pediatrics, 44(1). Web.
Hedrich, C. M., Schnabel, A., & Hospach, T. (2018). Kawasaki disease. Frontiers in Pediatrics, 6(198). Web.
Rhim, J. W., Kang, H. M., Han, J. W., & Lee, K. Y. (2019). A presumed etiology of Kawasaki disease based on epidemiological comparison with infectious or immune-mediated diseases. Frontiers in Pediatrics, 7(202). Web.
Weng, K. P., Wei, J. C. C., Hung, Y. M., Huang, S. H., Chien, K. J., Lin, C. C., Huang, S. M., Lin, C. L., & Cheng, M. F. (2018). Enterovirus infection and subsequent risk of Kawasaki disease: A population-based cohort study. The Pediatric Infectious Disease Journal, 37(4), 310-315. Web.