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A 5 year old patients presents to your office with a 6 day history of fever, bilateral lymphadenopathy, and the findings consistent with the attached picture. Based on this history and physical, what is the next best step in management of this patient?

A. Cold Agglutinin Test
B. Echocardiogram
C. Electrocardiogram
D. Biopsy of lymph node
E. Coronary Angiography
F. Immunofluorescence for ANCA

Face Hair Nose Cheek Head
click image to enlarge
 

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Classic presentation of kawaski vasculitis. 5 year old, adenopathy, a fever of more than 5 days and cracking and fissuring of the tongue.

Well, what complication may kill the patient; coronary artery aneurysm. To monitor aneurysm you need 2D echocardiography, which is most important. We also get EKG, but echo comes first.

Good Q! Classic for step 2 management type of qs where they confuse u between two choices like when to choose EKG or echo.
 

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Could also be TSS or some post-strep sequela; I'll still go for the Echo...
This is classic for kawaski. Answer choices further confirm this.

In scarlet fever (post-strep sequela), u get sandpaper like rash that begins on the trunk and neck, and then spreads to the extremities, sparing the face. The skin may come off in fine scales. Here sore throat is not primary problem and nothing in answer choices about strep.

U also get rash with kawaski, but that is de-squamative and comes with edema of hands and feet.
 

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B) Echocardiogram

This is a classic presentation for Kawasaki DIsease.

(1) erythema of the lips or oral cavity or cracking of the lips
(2) rash on the trunk
(3) swelling or erythema of the hands or feet
(4) red eyes (conjunctival injection)
(5) swollen lymph node in the neck of at least 15 millimeters

Complication: Coronary artery aneurysm

Patients who have had Kawasaki disease should have an echocardiogram initially every few weeks, and then every one or two years to screen for progression of coronary artery aneurysm.
 
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