Self-assessment

Abstract

An 11-year-old male presents to the emergency department with a 5-day history of a full body papular rash. The patient's mother reports lethargy, intermittent fever across a similar time period, and one episode of emesis the day prior. The patient awoke this morning with pain from the rash on the lateral left upper thigh and has taken paracetamol which helped control the pain. The rash is non-pruritic and consists of blanching lesions of various sizes. Most of the lesions have a target-like appearance. It is bilateral and present on the trunk, buttocks, arms, and legs. The lesions have grown with time but their location is fixed. The patient has a temperature of 38.9°C, a respiratory rate of 28/min and SpO2 of 95%. His other observations are within the normal range for his age. The tonsils and oropharynx are erythematous on examination but there is no pus or suggestion of quinsy. The patient has never had a similar experience and there is not notable medical history in the family. Bloods are taken including creatinine, CRP, FBC and clotting: the only abnormality is a raised neutrophil count of 9.14 x 109/L. The patient is discharged to return for review in 2 days. 2 days later the patient presents pale, lethargic, and with a capillary refill time of 3 seconds. He is awake and oriented but the rash is still present and he is intermittently shivering. He has vomited overnight, has been taking in little fluid, and has a frontal headache. His observations are as follows: