A 5-Year-Old Girl With Fever and Cough

Nicholas J. Bennett, MB BChir, PhD

Disclosures

October 11, 2016

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A normally well 5-year-old girl presents with a 2- to 3-week history of fever, cough, and occasional posttussive emesis. She was seen 1 week ago and diagnosed with a viral upper respiratory infection after an unremarkable physical examination. Testing for respiratory viral infections was not performed at that time, and symptomatic care was recommended.

After that visit, the patient improved, and 5 days ago, she was afebrile and well enough to return to school. Two days ago, however, the fever and cough returned worse than before. She is now experiencing pain in her right shoulder. Her mother reports that she "just isn't herself" and has brought her back for reevaluation.

The patient had one episode of vomiting with coughing 2 days ago, with no diarrhea. She has had decreased appetite and activity when febrile. Her fevers have been as high as 104°F at home. Her cough is nonproductive. Her mother has given her acetaminophen two or three times to control the fever, but otherwise she takes no medications.

The patient is a normally healthy child with no significant medical history, and her immunizations are up to date, including a seasonal influenza vaccine last month. She goes to kindergarten and has interacted with several sick contacts. She has no siblings and lives with her parents, who do not smoke. No known contact with people exposed to tuberculosis (TB) and no travel history out of New York State are noted.

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