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Allergy or infection?

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0.1
So this is an interesting case. Now I guess the two main possibilities here. Is this a viral reaction from an infection or is this an acute allergic reaction? Whatever it is at this point we need to do the basics. We need to do an ABCD approach and get a really good history from mum. We also need to have a look at the rash and put that together with the picture of the observations we may have done. For example, if the child looks poorly, and has a temperature it is more likely to lead us to a diagnosis of a potential infection and a viral rash rather than an allergic reaction.
32.1
Okay then Scarlett, can we just have a little look at you? So your mum says you have come up in a little bit of a rash, has it been itchy? Yes Can you show me whereabouts it is? Okay on your arms? Let’s get some oxygen to her. Yes please, thank you. Can I just have a quick look at your tummy? And your chest? Lovely, not been itchy on your tummy, no? And can I just have a look at your back as well, can you learn forward for me? Thank you.
57.1
Okay, has she had any vomiting since the rash? Yes. How many times has she vomited? Uh, once only. Scarlett, I’m just going to put this on your finger, that okay? Okay Scarlett, we’re gonna be attacking you from both sides now, can I just shine a little light in your mouth to have a look at your tongue? That’s it, stick your tongue out for me, lovely. Say ‘ahh’. You’re being really brave! That’s it, and if you swallow is your throat painful? No. Does it feel like your throat or tongue are tingling? No, okay then. Okay so it looks like she has a bit of a rash, just over her chest and arm, looks like urticaria.
82.8
So let’s just do a few checks on her, check her temperature, her blood sugar and things like that okay? Have you got any pain anywhere Scarlett? No? No pain in your tummy? No. Okay then, alright. Temperature at the moment is 38. Okay, 38, and these are all normal for her legs, they haven’t come up since as well? No? Okay. Lovely, have you got any pain in your head at all? No? Okay. Does it feel like it’s difficult to breathe? No it’s okay, alright. I’ll just get the BM, and then the resp rate as well. Okay, thank you. I’m just gonna have a listen to Scarlett, can you sit forward again for me?
117.8
And I’m just gonna have a listen to your chest. Take a nice big deep breath.
142.7
Okay, so resp rate is 28. Lungs are nice and clear. So we’re just gonna do this one last check on her okay? Sweetheart, what I need to do is just get a little bit of blood from your finger, so you may feel a little scratch okay, it might hurt just a little bit. Alright? Let’s just give your finger a wipe. Nice and brave, just a little scratch now. Well done! Well done, that was really brave! So what’s the blood sugar? BM is 4.9 So we have a temperature of 38, heart rate of about 120, sats are 99 with good equal air entry, BM is 4.9. Resp rate is 28.
184.1
And then it just appears that she has this urticaria rash all over her body. Okay so just to recap what happened today. Mum said, when did she have, I believe it was pasta or something before… how long ago was that again? She had pasta for lunch, she’s had that before, about half past twelve. About thirty minutes ago. What was on the pasta, out of interest? It just a home made - no, I used a pesto sauce. Pesto you say? Yeah… She’s had green pesto before, but this was a red pesto. Obviously pesto has nuts in it and you said she has a severe peanut allergy… Yeah oh God… So that could potentially be what’s causing this.
215.7
Alright, and you say she has been unwell today, you’ve been managing the temperature with Calpol. Her brother’s been unwell hasn’t he? Yeah. So there’s potentially a couple of things going on here. It could viral or an infection. She vomited today as well. Which would explain the rash on her face. So I think it’s probably best we pop her up to the hospital just to get her checked out.
Scarlett appears to not be in any immediate danger, but has 2 potentially significant things going on:
  • An allergic reaction
  • An infection
In both cases there is the potential for rapid deterioration.
If it is an allergic reaction this is not anaphylaxis. Anaphylaxis is better termed anaphylactic shock and this term gives you a bit of a clue as to how a child with this condition will present. They will often complain of abdominal pain, they may vomit, the rash may be accompanied by swelling of the lips, tongue, throat and they may have problems breathing due to bronchospasm. The shock bit is manifest by a fast heart rate and potentially low blood pressure. This is a medical emergency and requires intramuscular adrenaline.
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Emergency and Urgent Care for Children: a Survival Guide

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