This is a prescription of a young child, 14 years of age who had a low-grade fever with no other symptoms for the past two weeks. The fever occasionally spikes at night but has never been documented. The fever was not associated with other symptoms like body aches, cough, night sweats, flu, rhinorrhea, urinary or bowel complaints. The patient was advised the following medicines along with some investigations. When the patient did not improve, she visited us for a second opinion. Before that, she consulted her primary physician again and further investigations were advised.

Let's evaluate the prescription and help out this young child with fever

The following medicines and investigations were prescribed by her physician:

1. Orelox (cefpodoxime) 100 mg twice daily
2. Leflox (levofloxacin ) 500 mg once daily after breakfast
3. Ruling (Omeprazole ) 40 mg once daily before breakfast
4. Surbex-Z ( multivitamins and minerals) once after breakfast
5. Vermox (Mebendazole) 500 mg once stat

Investigations Advised by the physician:

1. Blood Cp
2. Blood Cultures
3. Serum Iron and TIBC

She was advised to revisit after one week and keep a record of her temperature.

What is wrong in this prescription - General Observations:

1. The name of the doctor and the patient were written over the prescription. For moral reasons, part of the prescription where the name of the doctor and the patient were written has been hidden. The date was mentioned too.
2. Diagnosis of the patient or any symptoms and signs for which the medicines were prescribed is not mentioned over the prescription. The diagnosis of PUO (pyrexia or fever of unknown origin) has been mentioned but crossed.
3. The strength of the tablets is mentioned.
4. The duration of the treatment is not mentioned but the patient has been asked to revisit after one week.
5. The signature of the doctor is there at the end of the prescription but a valid stamp of the doctor is not visible. Since the signature may not be a valid one, the doctor should stamp his prescription.

What are the patient queries ...

1. What am I suffering from?
2. Why am I given so many medications?
3. Should I take all the medicines prescribed by my doctor?
4. For how long should I take them?
5. What side-effects I may experience with my medicines?
6. When Should I feel better after I start taking these medicines?
7. What if my symptoms get worse and I don’t feel better?

Let's answer this child's queries:

The first question - What am I suffering from?

Since details of the symptoms are not mentioned on the prescription and neither are any investigations suggesting any disease, the diagnosis is not clear.

Symptoms other than fever which may point to any diagnosis need to be reported. Patients who have a fever with no symptoms may be suffering from the following diseases:

1. Malaria ( Fever is intermittent, high grade with shivering and chills. The patient may note a yellow skin and sclera, mild headache and nausea).
2. Typhoid Fever (Patients may have a continuous fever with abdominal pain, constipation or diarrhea with a mild headache, cough, nausea, and vomiting)
3. Viral Fevers (usually these patients have flu, cough, body aches, and a rash)
4. Brucellosis (manifested by enlarged lymph nodes, hepatosplenomegaly, and lower backache)
5. Other infections like urinary tract infections, chest infections, and throat infections)

Why so many Medicines and should I take all these medicines?

Two of the medicines you have been prescribed are antibiotics. Orelox is a third-generation cephalosporin (Cefpodoxime Proxetil) used to treat a variety of infections like sinusitis, bronchitis, ear, throat and chest infections.

Leflox (levofloxacin) is a very broad-spectrum antibiotic from the quinolones group. It is used to treat a variety of chest, throat, sinuses, kidneys, bladder, gut and pelvic infections. It should be used with caution in young children.

A combination of Orelox (Cefpodoxime Proxetil) and Leflox (levofloxacin) may be indicated as empiric therapy in very sick patients with pneumonia or chest infections and septicemia.

Since both the antibiotics have a very broad spectrum of activity against many organisms, the combination should be avoided in less toxic patients.

One of the medicine is Ruling that contains omeprazole is for heartburn. Since the patient is a young child, both omeprazole and levofloxacin should be avoided. Even if the patient did complain of heartburn, simple antacids should be given.

The last two medicines are multivitamin (surbex z) and Vermox (mebendazole) to treat worms infestations. These two drugs have nothing to do with the patient's complaints.

Young children should be advised to take fruits and a healthy diet instead of multivitamin tablets. Similarly, worms infestations?? I don't know why the physician has prescribed Vermox?

It would be best to monitor and record the temperature first. The source of the infection should be identified by the relevant clinical examination and investigations.

If empirically treated, I would only give one of the antibiotics like Orelox for 5 to 7 days and paracetamol as and when required.

What are the side effects of these medicines?

Orelox should be used with caution in patients with penicillin allergy. The patients may develop a rash, diarrhea, nausea, and genital fungal infections.

Levofloxacin may cause nausea, distaste, sleep disturbances, neurological problems, heart problems like QT prolongation, muscle pain, and tendon rupture, liver toxicity, secondary infections, photosensitivity, and disturbed sugars.

Ruling may cause a headache, diarrhea, and skin rash. Long term use has been associated with stomach cancers, fractures, and low magnesium levels.

Mebendazole may cause abdominal pain, liver toxicity, and bone marrow suppression.

When should I start feeling better and what if I am not getting better?

Antibiotics take 48 to 72 hours to be effective. Since you are being given antibiotics without knowing the source, the medicines may or may not work.

If they are effective, you should start feeling better in 2 to 3 days time. Otherwise, your condition may remain static or you may get worse.

If your condition deteriorates, it is better to visit a nearby hospital for a checkup or maybe get admitted for investigations and diagnosis.

Since diagnosis is half the treatment, I would strongly suggest some of the following tests if you do not get better:

1. ICT-MP and MP smear (malarial parasite)
2. a chest x-ray
3. urine routine examination
4. blood cultures
5. CRP and a procalcitonin