CASE 80
On a hot summer day, a 23-year-old man was brought to the emergency department 3 days after the onset of fever, severe headache, and muscle pain. He was also experiencing nausea, vomiting, and abdominal pain. A fine, spotted rash was seen on his extremities and trunk; the patient said the rash had appeared earlier that day.
PHYSICAL EXAMINATION
LABORATORY STUDIES
Diagnostic Work-Up
Table 80-1 lists the likely causes of illness (differential diagnosis). A presumptive diagnosis based on clinical findings, physical examination, and a reliable patient history is important for aggressive management of a patient with these symptoms. Lumbar puncture can be performed if the patient does not have papilledema or lateralizing neurologic findings. Investigational approach may include
TABLE 80-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Fever and a rash may be signs of serious illness, particularly in a young adult. In the United States, meningo-coccemia and RMSF should be considered because they are life threatening and prompt therapy must be instituted. Typical viral exanthems are not common in adults, and aseptic meningitis usually is not associated with a rash. Dengue fever and typhoid fever are associated with a specific travel history, although both can be seen in the United States. Scarlet fever does not usually have a petechial rash.
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