Case by Nicholas Dimenstein MD MPH, CNH PEM Fellow

20-month-old female presented with fever to 101.7.  Had been discharged from the hospital 6 days ago during which she had required ICU care for distributive shock and respiratory failure. She had received IVIG, ASA, Anakinra, and Infliximab for presumed KD vs MIS-C. Was discharged home on low-dose aspirin w/cardiology follow-up in 2 and 6 weeks. Her initial echo showed diffuse left anterior descending coronary artery dilation.

This was her first fever since discharge. Aside from two episodes of emesis in the setting of crying and medication. , she has no localizing history or exam features, no cough, rhinorrhea, increased WOB, ear pain, abdominal pain, diarrhea, rashes, or altered mental status. No cracked lips, red eyes, large cervical lymph nodes, or swelling of hands or feet. No prior history of AOM or UTI. No known sick contacts. Does not attend daycare.

Past Medical/Surgical/Family/Social History:
Aspirin therapy
No pertinent surgical history.
NKDA.
Vaccines: will be delayed after IVIG, up to date currently

HR 146 bpm, RR 26, BP 100/66, MAP 79. SpO2 99% on RA. T 37.9C rectal temp.

General: Alert, Interactive, Nontoxic, well hydrated in no acute distress.
HEENT: NC/AT, PERRLA, EOMI, MMM, No mucosal changes, No oropharyngeal erythema or exudate. Uvula midline. TM’s clear bilaterally.
Neck: Supple, Trachea Midline, Non-tender to palpation. Full ROM.
CV: RRR, No M/R/G, 2+ distal pulses; warm well perfused extremities, cap refill <2 seconds
RESP: CTAB, Symmetric chest expansion. Normal work of breathing. No wheezing/rales/rhonchi/stridor
ABD: Soft, non-tender, non-distended, normoactive bowel sounds. No palpable hepatosplenomegaly.
SKIN: Normal color and appearance. No concerning abrasions, swelling, bruising, petechiae, or signs or infection.
NEURO:  Alert, no focal deficits, normal mentation.
MSK: Moves all extremities. No tenderness or deformities.
PSYCH: Appropriate; normal mood and affect.

RN updates you that after patient received Motrin, fever improved, is tolerating PO, active and playful in room, and family is eager to go home, if possible.

Your repeat exam is unchanged.

Repeat Vitals: T 36.9, HR 133, RR 27, BP 103/74, MAP 83

Lab results:
CBC: wbc 10.9, h/h 10.5/32.1, platelets 618. ANC 4.83. ESR 41. CRP 0.38. BMP wnl. AST 64, ALT 30.
Bcx: pending. UA neg. Viral panel pending.