Identifying Data:

Age: 6 y/o

Sex: Female

Date & Time of encounter: March 22, 2022  10AM

Location: QHC Pediatric Emergency Department

Race: Hispanic

Source of Information: Mother and self via Spanish interpreter

Reliability: Reliable

Chief Complaint: Rash since this morning

History of Present Illness:

Pt is a 6 y/o female with PMH of congenital hip dysplasia, BIB mother to the ED with complaints of pruritic, erythematous rash to the palms of bilateral hands that began this morning. The rash is not painful and is not located anywhere else. No alleviating or exacerbating factors. Mother also notes some decreased food intake within the last few days but states the pt has been drinking fine and voiding well. She also mentions nasal congestion x1 week. No medications have been given for her symptoms. No sick contacts at home but patient attends school. Pt and mother deny fever, sore throat, mouth pain, abdominal pain, vomiting, diarrhea, ear pain, cough, behavioral changes.

Past Medical History:

Congenital hip dysplasia – followed by ortho. No current pain. Last hip XR in 2021 with no abnormalities

Immunizations – Up to date, including influenza.

Denies recent hospitalizations.

Past Surgical History:
None.

Medications: 

Pediatric multivitamin – 1 chewable tablet daily

Allergies:

Denies any known drug, environmental, or food allergies.

Family History:

Mother with Hx of DVT. Pt has been worked up by hematology who, per mother, stated no abnormalities and no interventions needed.

No family history of eczema or asthma. Otherwise FHx noncontributory.

Social History:

Patient lives with her mother and father. She is in 1^st grade and enjoys going to school. She is doing well in her classes.

Sleep – no complaints. Pt sleeps ~10 hours a night.

Travel – No recent travel

Review of Systems:

General – Denies recent fever, chills, weight loss/gain, fatigue, night sweats, or change in appetite.

Skin/nails – (+)rash. Denies bruising, changes in hair distribution, or wounds.

Head – Denies headache, dizziness, recent head trauma.

Eyes –Denies visual disturbances, itchiness, redness, tearing, or discharge.

Ears –Denies otalgia or discharge. No hearing aid use.

Nose – (+)congestion. Denies sneezing, epistaxis, rhinorrhea.   

Mouth/throat – Denies sore throat, difficulty swallowing, bleeding gums, ulcers, tongue pain, swelling.

Neck – Denies pain, stiffness.

Pulmonary – Denies SOB, DOE, cough, wheezing.

Cardiovascular – Denies chest pain, palpitations.

GI – Denies abdominal pain, vomiting, diarrhea, constipation. No recent changes in BM.

Genitourinary – Denies dark urine, incontinence, dysuria, hematuria, frequency.

Nervous – Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – Denies body aches, back pain, joint pain.

Physical Exam:

Vital signs:      BP (Seated)                  L-arm: 97/60

RR:      18 breaths/min, unlabored                 

Pulse: 91  bpm, regular                     

T:        98 degrees F (oral)

O2 Sat: 99% on room air

Height: 3’ 10” inches        Weight: 50 lbs.       BMI: 16.6 (79^th percentile for age)

General: Pt alert, active, oriented. No acute distress. Well nourished. Looks stated age.

Skin: (+)macular rash to palms of bilateral hands, with blanching erythema. No rash to soles of feet or anywhere else on the body. Skin is warm & moist. No ecchymosis. Nonicteric, no other lesions noted.

Hair:  Good distribution.

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Moderate amount of cerumen in auditory canals bilaterally. No discharge or other foreign bodies in external auditory canals.  Right and left TM pearly white and fully intact with cone of light in good position.

Nose: Symmetrical. No masses, lesions, deformities, trauma, discharge. Nares are patent bilaterally.

Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.

Septum midline without lesions, deformities, injection, perforation.  No foreign bodies.

Sinuses – Nontender to palpation and percussion over the frontal, ethmoid and maxillary sinuses.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, ulcers, vesicles, masses, or scars. No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies. Tonsils are grade I.

Neck – Full ROM. Supple. Non-tender to palpation. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. No cervical adenopathy noted. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRL.
Fundoscopy – Red reflex intact OU.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Respirations unlabored. No use of accessory muscles noted. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated.

Abdomen: Abdomen nontender to palpation, no guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Is able to repeat words and name objects. Speech is of appropriate quantity, rate, volume, flow, and articulation.

Patient behaves appropriately for her age.

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Symmetric and fluid facial movements. No difficulty with BMP speech sounds. Soft palate rises and uvula remains midline with phonation. No hoarseness or nasal quality in voice. No facial droop. No difficulty with LTND speech sounds.

Peripheral Neuro –

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Gait steady with no ataxia.

Meningeal Signs

No nuchal rigidity noted.

Musculoskeletal: No soft tissue swelling/ ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Differential Diagnoses:

• Hand foot mouth disease (enteroviral/coxsackie infection)
• Contact dermatitis
• Impetigo – less likely given location, lack of papules/vesicles or crusting
• Eczema – less likely given location, lack of dryness or cracks, lack of vesicles
• Syphilis (secondary) – rare

Assessment:  6 y/o female with PMHx of congenital hip dysplasia, c/o pruritic rash to bilateral palms since this morning.

Plan:

Likely viral etiology. Education was discussed with mother including high likelihood symptoms will self-resolve in 7-10 days. Mother was advised to give Benadryl if pruritis is bothersome, especially if interfering with sleep. Return precautions (including worsening rash, vomiting, fever >4 days, lethargy, etc) were discussed. Follow up with PCP in 2 days.