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