Diagnosis and Management for 6-Year-Old Female with Intermittent Fever and Oral Lesions
This is most likely Herpangina or Hand-Foot-Mouth Disease (viral pharyngitis/stomatitis), and treatment should focus on supportive care with antipyretics and oral analgesics, not antibiotics. 1
Clinical Assessment
The presentation of intermittent fever (5 days, nocturnal pattern) with multiple oral ulcers ("singaw") extending to the tongue in a 6-year-old strongly suggests viral pharyngitis/stomatitis, most commonly caused by enteroviruses (Coxsackievirus A causing herpangina or hand-foot-mouth disease). 2
Key diagnostic considerations:
- Viral etiology is most likely given the age (5-15 years peak for viral pharyngitis), fever pattern, and characteristic oral lesions 2
- The absence of tonsillar exudates, anterior cervical lymphadenitis, or sudden-onset severe sore throat makes Group A Streptococcal (GAS) pharyngitis less likely 2
- Viral causes include enteroviruses, herpesviruses, adenovirus, and other respiratory viruses 2, 3
Requested Laboratory Tests
CBC and Urinalysis are appropriate to:
- Rule out bacterial infection (would show elevated WBC with neutrophil predominance) 2
- Assess for lymphocytosis (typical in viral infections) 2
- Exclude urinary tract infection as alternative fever source 1
Common pitfall: Ordering throat culture or rapid strep test without clinical features suggestive of GAS pharyngitis leads to overtreatment of viral carriers. 2
Medical Assessment/Diagnosis
Diagnosis: Acute Viral Pharyngitis/Stomatitis (likely Herpangina), rule out Hand-Foot-Mouth Disease
Clinical reasoning: 6-year-old female with 5-day history of intermittent nocturnal fever and multiple oral ulcerations consistent with viral etiology. No features suggesting bacterial pharyngitis (no tonsillar exudates, no anterior cervical lymphadenopathy, gradual onset). 2, 1
Treatment Plan and Recommendations
Medications (PhilHealth Konsulta Formulary-compliant, <300 pesos):
Paracetamol 250mg/5mL syrup
Oral rehydration solution (ORS) sachets
No antibiotics indicated - this is a viral infection and antibiotics provide no benefit while increasing adverse effects and resistance. 2, 3, 4
Non-pharmacologic Management:
- Soft, bland diet (avoid acidic, spicy, or hot foods) 1
- Cold fluids and ice chips for oral pain relief 1
- Rest until fever resolves 2, 1
Red Flags for Re-evaluation:
- Fever persisting >7 days or worsening after initial improvement 2, 1
- Development of respiratory distress, severe dehydration, or altered consciousness 2, 1
- Inability to maintain oral intake 2, 1
- Development of tonsillar exudates or severe throat pain (consider bacterial superinfection) 2
Medical Certificate
This certifies that patient has been seen and examined today with the diagnosis of: Acute Viral Pharyngitis/Stomatitis (Herpangina) and recommendation of: Home rest with supportive care, adequate hydration, and antipyretics as needed. May return to school once fever-free for 24 hours without antipyretics and able to eat/drink comfortably. This medical certificate is issued upon the request of the patient for school absence/return to school clearance.
Note: Patient is NOT fit to return to school until fever-free for 24 hours and able to maintain oral intake, to prevent transmission to other children. 1, 5
Patient/Parent Education
Explanation of condition: Your child has a viral infection affecting the mouth and throat, most likely caused by a common childhood virus called Coxsackievirus (herpangina). This causes painful sores in the mouth and fever that typically occurs at night. This is NOT a bacterial infection and does not require antibiotics. The illness is self-limiting and will resolve on its own within 5-7 days. The fever pattern (nocturnal) is typical for viral infections. Focus on keeping your child comfortable with fever control and maintaining hydration. The oral sores will heal without scarring. 2, 1, 5