History
Identifying Data:
Full Name: Mr. M
Address: Jamaica, NY
Date of Birth: October 26, 2013
Date & Time: March 27, 2022 (12:00 pm)
Location: Dr. Niascio Arana, Queens, NY
Religion: Unknown
Source of Information: Father
Reliability: Reliable
Source of Referral: None
Mode of Transport: Accompanied by father and older brother
Chief Complaint: “My son had a fever and rash” x 3 days.
History of Present Illness:
9 years old Hispanic male with no past medical history presented with father to the clinic with a complaint of fever and rash. Father states the patient had a fever (oral Tmax 103 degrees fahrenheit) 3 days ago. He took the patient to urgent care and was prescribed Tylenol and Ibuprofen. Fever has been subsiding with Tylenol and the last dose of 10ml was yesterday morning. Reports he has been checking the fever every few hours and is now within the normal range. This morning he noted that the patient woke up with an erythematous rash on his back that is non pruritic. States the rash was lighter and located mainly on the lower back but is now spreading up towards patients neck. Reports associated decreased appetite and increased shortness of breath. Denies allergies, rhinorrhea, ear pain, diarrhea, vomiting, sore throat, headaches, sick contacts, recent travel, chest pain, cough, night sweats, recent change in detergent, trying new foods or medications or weight changes.
Past Medical History:
Denies other illnesses
Immunizations – Up to date
Past Surgical History:
Denies past surgeries and blood transfusions
Medications:
None
Allergies:
No known drug or food allergies
Family History:
Mother – 34 years of age, healthy
Father – 36 years of age, healthy
Siblings – Sister 5 years old, healthy
Social History:
Mr. M is in 4th grade who lives with his parents, grandparents and younger sister in a house. Father states he is doing great in school and actively participates in school activities.
Habits – Watch cartoons and play video games.
Diet – Home cooked food and occasionally fast food.
Exercise – Goes to soccer practice three times per week.
Safety measures – Admits to wearing a seat belt.
Travel – Denies recent travels.
Review of Systems:
General – States fever, generalized weakness. loss of appetite. Denies weight gain/loss, or night sweats.
Skin, hair, nails – States rash on the trunk, scapular area and neck . Denies excessive dryness or sweating, moles, or discoloration.
Head – Denies headaches, vertigo, unconsciousness or head trauma.
Eyes – Denies use of glasses/contacts, visual disturbances, or photophobia. Last eye exam – 1 year ago.
Ears – Denies pain, discharge, or tinnitus.
Nose/sinuses – Denies discharge, obstruction or epistaxis.
Mouth/throat –. Denies sore throat bleeding gums, sore tongue, mouth ulcers, voice changes. Last dental exam – 2022.
Neck – States rash on neck. Denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary system –Reports increased shortness of breath. Denies cough, wheezing, hemoptysis, or cyanosis.
Cardiovascular system – Denies chest pain, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal system – States decreased appetite. Has regular bowel movements daily. Denies intolerance to specific foods, nausea, vomiting, dysphagia, unusual flatulence, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system – Denies polyuria, nocturia, oliguria, or dysuria.
Sexual history – Not asked
Nervous – Denies seizures, headache, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system – Denies any pain or tenderness. Right sided dominance.
Peripheral vascular system – Denies color changes, coldness or trophic changes or varicose veins.
Hematological system – Denies bruising, blood transfusion, anemia, bleeding and lymph node enlargement.
Endocrine system – Denies polydipsia, polyphagia, heat/cold intolerance, or excessive sweating.
Psychiatric – Denies depression/sadness, anxiety, OCD, ADHD, ODD or ever seeing a mental health professional.
Physical
General: Neatly groomed, well nourished, well oriented, not in respiratory distress, appears as his stated age.
Vital Signs:
BP: 105/74, Right arm, seated
RR: 20/min unlabored HR: 85, regular
T: 99.9 degrees F (oral) O2 Sat: 98% Room air
Weight: 31 kg. Height: 53 inches BMI: 17.4 (74th percentile)
Skin: Pink maculopapular rash on trunk and neck that is blanchable. Warm & moist, good turgor, no lesions, no tattoos, and no moles noted.
Nails: No koilonychia, no splinter hemorrhages, no paronychia, no lesions and capillary refill <2 seconds.
Hair: No seborrhea, no lice.
Head: Normocephalic, atraumatic, non tender to palpation.
Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white.
Nose: Erythematous nasal mucosa. Symmetrical, no polyps, no masses, lesions, deformities, trauma or discharge. No discharge noted. Septum midline without lesions, deformities, perforation. No evidence of foreign bodies.
Sinuses: Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses.
Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink; Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU; Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Lips: Pink, moist; no cyanosis or lesions.
Teeth: Good dentition, no discoloration
Gingivae: Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Oropharynx: Erythematous but well hydrated; no exudate; masses; lesions; foreign bodies. Tonsils are red and swollen but no exudate. No deviation of uvula.
Neck: Cervical lymph nodes swollen but non tender. Trachea midline. No masses; lesions; scars; pulsations noted. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid: Non-tender; no palpable masses; no thyromegaly.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxical respirations or use of accessory muscles noted.
Lungs – No consolidated to auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.
Heart: Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs.
Abdominal: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Genitalia: Not performed
Rectal: Not performed
Mental status exam:
Intact judgment, insight, and cognitive function. Oriented to time, place, and person. Intact memory and attention for recent/remote events. Intact language and speech. No depression, anxiety, or agitation.
Cranial Nerve exam:
CN I: Nare patency is intact bilaterally.
CN II: Visual fields full OU by confrontation, PERRLA. EOMS intact with no nystagmus. Visual acuity 20/20 OU, uncorrected. Red reflex present.
CN III, IV, VI: EOMS intact with no nystagmus. Pupils reactive to direct light, consensual light and accommodation. Unremarkable convergence present. No ptosis.
CN V: Face sensation intact bilaterally to light touch.
CN VII: Facial expressions are symmetrical and intact.
CN VIII: Auditory acuity intact to whispered voice AU.
CN IX and X: Uvula midline with elevation of soft palate, gag reflex intact.
CN XI: Full ROM at neck.
CN XII: Tongue midline without fasciculations.
Assessment
9 year old male with no past medical history presented to the clinic with a complaint of fever and rash. As per father, fever has subsided since yesterday but has a new onset of rash on the trunk and neck. On physical exam patient with a maculopapular rash on the trunk and neck, swollen cervical lymph nodes and tonsils.
Differential Diagnosis
Roseola: Patient presented with a maculopapular rash on trunk progressing to neck after fever subsided which are typical signs and symptoms of roseola.
Strep Pharyngitis: Patient presented with fever, but no cough or sore throat. He was found to have swollen tonsils and cervical lymph nodes. Centor criteria is 4.
Mononucleosis: Patient presented with fever, lymphadenopathy but less likely as no petechiae on hard palate, muscle aches, hepatosplenomegaly, or headaches.
Pneumonia: Patient has increased shortness of breath but less likely because lungs are clear to auscultation and there is no mucus production.
Assessment:
Patient with rash secondary to Roseola vs Strep Pharyngitis
Plan
- Given the Centor criteria is 4 Strep culture ordered to rule out strep pharyngitis. Throat swab was obtained and Genmark was sent. Will not order antibiotics at this time as clinical presentation consistent with Roseola
- Prescribed Children’s Tylenol if incase fever recurs
- Increased fluid intake and pedialyte to prevent dehydration
- Patient Education: Educated patient on how this is likely a viral exanthem. The presentation is consistent with roseola. I explained the rash may progress to the face as well. Roseola is a viral illness and hence is self limiting and will resolve on its own. Encourages increased handwashing and hygiene to prevent the spread of the viral pathogens. Culture was ordered to rule out strep. If positive, will prescribe antibiotics but at this time supportive treatment is required.
Return precautions – Go to ED if symptoms are worsening, difficulty breathing, seizures or if new symptoms appear.
