全科医学临床诊疗思维研究——小儿发热伴皮疹

本文报道全科医生接诊一例发热伴皮疹患儿时，从全科医学视角出发，采用约翰?莫塔教授的临床安全策略--临床5问思维法：（1）哪些常见疾病会引起发热伴皮疹？（2）哪些重要疾病不能忽视？（3）是否有潜在的常被掩盖的疾病？（4）有哪些容易被遗漏的病因？（5）家属是不是有什么话还没有说？结合病史、查体和辅助检查综合分析，确诊川崎病。本案例的启示：（1）发热伴淋巴结肿大，血常规提示细菌性感染，应用抗生素后效果欠佳，要考虑到川崎病的可能；（2）小儿发热性疾病，如果是用药后出现皮疹，不能简单归结为药物过敏，也要警惕川崎病；（3）眼结膜充血、口唇干红、口腔黏膜充血、杨梅舌等川崎病面容与急性热病容有些相似，在询问病史及查体时注意甄别。同时给予患儿家属心理疏导，体现以人为中心和以家庭为单位的全科医学理念。

Clinical Diagnostic and Therapeutic Approaches in Primary Care Practice:a Case Study of an Infant with Fever and Rash

We reported an infant with fever with rash encountered by a general practitioner.The diagnostic procedure was carried out from a general practice approach with John Murtagh's safe diagnostic strategy-a method of five clinical questions was adopted：（1）What common diseases may manifest cause fever with rash？（2）What serious disorders must not be missed？（3）Could the patient have a masquerading illness？（4）What conditions are often missed？（5）Is the patient's family member trying to say something？Besides detailed consultation，careful physical examination and auxiliary examination were also carried out，and the infant was eventually diagnosed with Kawasaki disease.The implications of this case are:（1）Kawasaki disease may be considered if the infant has fever with lymphadenopathy，and bacterial infection suggested by routine blood test as well as poor responses to antibiotic therapy.（2）Infantile febrile disease with rash following medication should not be simply attributed to drug allergy，which may be alerted to the possibility of Kawasaki disease.（3）Attention should be paid to distinguish facial manifestations，such as conjunctival hyperemia，erythema and cracking of lips，erythema of oral mucosa and “strawberry” tongue of Kawasaki disease from those of acute febrile disease during asking medical history and conducting physical examination.At the same time，psychological counseling should be given to the family members of the infant，based on the view of individual-centered and family-based general practice.