Rotation 8
Identification:
Patient’s name: AJ
Age: 11
Gender: M
Race: Hispanic
Location: Queens Hospital Center, Pediatric ER
Date: 10/24/19
Informant: self and mother, both reliable
CC: “rash” x 1 week
HPI:
16 y.o male without PMHx, immunizations up-to-date presents to the ER with generalized body rash x 1 week. Patient described the rash as pruritic, started at the trunk and radiated to the upper and lower extremities, but not to the face, palms and soles, or genital area. The rash was mostly localized to the back of the trunk. Mother admitted to changing the brand of body lotion recently and did not give the patient any OTC medication for symptomatic relief. Denies previous experience of similar rash, recent travel, known food or drug allergies, sick contact, and sexual history/previous hx of STDs. No fever, recent URI symptoms, difficulty breathing, face or tongue swelling, or N/V.
PMH:
Denies PMHx
Past Surgical History:
Denies Surgical Hx
Medications:
Denies medication
Allergies:
No food or environmental allergies
NKDA
Family History:
Family history is not provided.
Social History:
Patient is a high school student. Denies use of illicit drug, alcohol, and tobacco. Denies being sexually active.
ROS:
General: Patient denies recent weight loss or weight gain, loss of appetite, generalized weakness, fatigue, fever, chill or night sweats
Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, or changes in hair condition. Positive: rashes, pruritus
Head: Patient denies headache, vertigo, head trauma, or fracture
Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam
Ears: Patient denies deafness, pain, discharge, tinnitus
Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction
Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam
Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion
Breast: Patient denies lumps, nipple discharge, pain, or last mammogram
Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea
Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur
Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy
Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain. Denies hesitancy, dribbling or last prostate exam
Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness
Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis
Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes
Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement
Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter
Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications
Physical Examination:
General: 16 years old male is alert and cooperative. He is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like his stated age. Well developed.
Vital Signs:
BP (seated): 115/75
HR: 70 BMP, regular
RR: 18 not labored
Temp: 99 F oral
O2 sat: 100% room air
Skin: 5 to 10mm in diameter lesions develop across the trunk and less on the extremities. Lesions occurs on the back tend to align in a typical Christmas tree pattern. The lesions are salmon color, ovoid, raised, with scale at the margin. (Herald Patch)
Hair: Average quantity and distribution
Nails: No clubbing, capillary refill <2 seconds throughout.
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.
Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white with cone of light.
Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation.
Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses
Lips: Pink, dry, no cyanosis or lesions
Mucosa: Light pink, dry, no masses, lesions, or leukoplakia
Palate: Pink, hydrated. Palate intact with no lesions, masses, scars
Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge
Tongue: Pink, no masses, lesions, or deviations noted
Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions
Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. No palatable adenopathy
Thyroid: Nontender, no palpable masses, no thyromegaly.
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored. Nontender to palpation
Lungs: Clear to auscultation bilaterally. No wheezing, crackles, rales
Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.
Abdomen: Flat, symmetrical, no scars, striae, caput medusae or abnormal pulsations. Bowel sounds in all 4 quadrants. No bruits. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally
Male genitalia and hernia: did not perform
Anus, rectum, and prostate: did not perform
Peripheral vascular: The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted
Neurological/Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted
Cranial nerve:
Did not perform
Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations.
Sensory: did not performed
Reflexes: did not performed
Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities
Assessment:
16 y.o M presented with generalized body rash. Clinical presentation is most consistent with pityriasis rosea.
Differential Diagnosis:
- Pityriasis Rosea
- Allergic dermatitis/Eczema
- Tinea versicolor
- Viral exanthems
- HIV/Secondary syphilis
Plan:
- Oral Benadryl for itchiness
- Reassurance that the rash is not contagious and it is benign and self-limited
- F/U PCP
- Return to ED if symptoms worsen