Chief complaint: Rash
History of Present Illness:
JC is a 12 month old male with no significant past medical history who present to the pediatricians office with a rash. His mother states the rash started yesterday. She states the rash was on the neck, but now is covering his trunk also. She states he had fever which started 4 days ago and his temperature ranged from 100.8 – 103 degrees Fahrenheit, which she has been giving him Tylenol for, max temperature 103 degrees Fahrenheit. He also had nasal discharge and a cough for 4 days now. She admits he has been a little irritable and fatigued. She denies changes in appetite, shortness of breath, recent sick contact, changes in diet or detergent.
DDx:
Roseola
Rubella
Rubeola
Erythema infectiousum
Scarlet fever
Past Medical History: No medical conditions
Past Surgical History: None
Immunizations: up to date
Allergies: No known allergies
Medications: Tylenol 160mg/5mL oral liquid x 6mL Q4-6H
Family History:
Father: 29 years old alive and well
Mother: 26 years old alive and well
Sister: 5 years old alive and well
Sister: 3 years old alive and well
Social history: Stays home with mother and sister. Oldest sister attends school.
Mother: stay at home mom
Father: Accountant
Smoking: mother denies any smoking in the household
Diet: Child eats a balanced diet.
Review of Systems:
General: Mother denies night sweats.
Skin, hair, nails: mother denies changes in texture, excessive dryness, sweating, moles, itching, changes in hair distribution.
Head: Mother denies recent head trauma
Eyes: Mother denies watery eyes. Never had an eye exam.
Ears: Mother states he doesn’t seem to have any issues with hearing.
Nose/sinuses: Mother denies nose bleeds or nasal obstruction.
Mouth/throat: Mother denies bleeding gums, sore tongue, sore throat, mouth ulcers.
Neck: Mother denies neck stiffness or swelling
Pulmonary system: Mother admits to a few episodes of coughing up mucous. She denies wheezing, or coughing up blood.
Cardiovascular system: Mother denies fainting.
Gastrointestinal: Mother denies vomiting, diarrhea, constipation or blood in stool.
Genitourinary system: Mother denies urinary frequency or polyuria.
Nervous: Mother states the child takes a few steps at a time, waves hello and says a few words. Mother denies seizures.
Musculoskeletal system: Mother denies muscle/joint swelling or deformity.
Peripheral vascular system: Mother denies swelling of the extremities or changes in skin color.
Hematological system: Mother denies easy bruising, bleeding, or anemia.
Endocrine system: Mother states no recent increase in drinking, eating or urinating.
Physical exam:
Vitals:
Pulse: 120 beats per minute regular
Respiratory rate: 34 breaths per minute, unlabored
Temperature: 99.1 degrees Fahrenheit (tympanic)
Height: 21 inches
Weight: 30 lbs
Head Circumference: 45 cm
General: Child appears active. Nicely nourished.
Skin: Warm and moist, macular rash on neck and trunk.
Hair: Average quantity, evenly distributed.
Nails: No clubbing, splinter hemorrhages, divots. Capillary refill < 2 seconds throughout.
Head: Normocephalic, atraumatic
Eyes: Symmetrical OU, conjunctiva clear, sclera white.
Ears: Symmetrical. No masses, lesion or trauma. Tympanic membrane pearly gray AD, not visible AS due to cerumen.
Nose: Mild nasal discharge noted.
Mouth and pharynx: Mucosa pink, no ulcers noted.
Neck: No palpable lymph nodes.
Lungs: Clear in all lung fields, no adventitious lung sounds noted.
Heart: regular rate and rhythm. S1 and S2 present, no murmurs noted.
Abdomen: non-distended, soft
Extremities: Active range of motion of all extremities.
Assessment:
JC is a 12 month old male with no significant past medical history, who presents with recent fever, cough, rhinorrhea and a rash on his neck and trunk. Suggestive of Roseola.
Plan:
Mother counselled Roseola is a virus, the rash may spread before it gets better, but it will go away. The child is no longer contagious. Mother encouraged to hydrate the child. Follow up if symptoms don’t resolve within a few days.
