A 15-month-old boy is brought to the emergency room because of fever and a rash. Six hours earlier he was fine, except for tugging on his ears; another physician diagnosed otitis media and prescribed amoxicillin. During the interim period, the child has developed an erythematous rash on his face, trunk, and extremities. Some of the lesions, which are of variable size, do not blanch on pressure. The child is now very irritable, and he does not interact well with the examiner. Temperature is 39.5°C (103.1°F). He continues to have injected, immobile tympanic membranes, but you are concerned about his change in mental status. Which of the following is the most appropriate next step in the management of this infant?
a. Begin administration of intravenous ampicillin
b. Begin diphenhydramine
c. Discontinue administration of ampicillin and begin trimethoprim with sulfamethoxazole
d. Perform bilateral myringotomies
e. Perform a lumbar puncture
the answer is below…
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently.
The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual’s knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.
All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual’s ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
The correct answer is e; Perform a lumbar puncture.
Unsuspected bacteremia due to Haemophilus influenzae type B (now rare), Neisseria menigitidis, or Streptococcus pneumoniae (decreasing in frequency secondary to vaccination) should be considered before prescribing treatment for otitis media in a young, febrile, toxic-appearing infant. In the young, febrile, and toxic-appearing infant, blood culture should be performed before antibiotic therapy is initiated, and examination of the cerebrospinal fluid is indicated if meningitis is suspected. The classic signs of meningitis are found with increasing reliability in children over the age of 6 months. Nevertheless, a febrile, irritable, inconsolable infant with an altered state of alertness deserves a lumbar puncture even in the absence of meningeal signs. A petechial rash, characteristically associated with meningococcal infection, has been known to occur with other bacterial infections as well. Organisms may be identified on smear of these lesions.
A fever accompanied by inability to flex rather than rotate the neck immediately suggests meningitis (a sign more reliable in children older than 12 to 18 months of age). An indolent clinical course does not rule out bacterial meningitis. A lumbar puncture is of prime diagnostic importance in determining the presence of bacterial meningitis, which requires immediate antibiotic therapy. A delay in treatment can lead to complications such as cerebrovascular thrombosis, obstructive hydrocephalus, cerebritis with seizures or acute increased intracranial pressure, coma, or death. In the described patient, lumbar puncture is warranted because of the change in his clinical status.