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Chief Complaint: “Itchiness on hands, feet, and face with canker sores on mouth. Fever and throat pain ”
History of Present Illness: PD is a 4 year-old male. For the last three days the patient has been complaining of “itchiness” of the hands, feet, and face, along with “shallow ulcers inside his mouth” according to the patient’s mother. Patient exhibits a vesicular erythematous rash on the hands and feet. Patient also complains of sore throat (pain 5/10). He had one episode of fever with a maximum temperature of 101 F. Ibuprofen was given one time, and the fever was controlled. Benadryl was also given at home with mild improvement of symptoms noticed.
Past Medical History: No prior medical history.
Past Surgical History: No prior surgical history.
Current Medications: None.
Allergies: No Known Allergies (NKA)
Family History: Mother and father both alive. No family history of diabetes mellitus, cancer, or cardiac/respiratory problems. No siblings.
Social History: Lives with mother and father who were born in Cuba and emigrated to the United States (US) 15 years ago. Born in the United States. No tobacco, alcohol, or illegal substance use in the household. Appropriate support at home.
Health Maintenance: Immunizations up to date. Annual medical checkup. Regular dental visits.
Review of Body Systems (ROS)
General: No weight loss, weakness or loss of appetite. Denies night sweats.
Skin, Hair, and Nails: No hair loss, unusual hair growth unusual hair patter, or nail changes. No birth marks.
Head and Neck: Denies headaches, dizziness, or syncope. Denies neck pain or stiffness. No tenderness of the face.
Eyes: Denies vision changes, blurred or double vision.
Ears, Nose, and Throat: Denies ear pain, tinnitus, or epistaxis. Throat pain (5/10).
Mouth: Denies tooth pain.
Respiratory: Denies cough or shortness of breath. Denies sputum production.
Cardiac: Denies chest pain, or tachycardia.
Gastrointestinal: Denies nausea, vomiting or diarrhea. No abdominal pain.
Endocrine: Denies polyphagia, polydipsia, or polyuria. No weight changes or intolerance to temperature changes.
Genitourinary: Denies dysuria, hesitance, or frequency.
Musculoskeletal: Denies muscular or joint pain, weakness, or tremors.
Hematologic: Denies blood disorders, or prior blood product transfusions. Would accept blood products.
Neurologic: Denies headaches, coordination, sensation, or sensorineural difficulties. Denies seizures.
Mental Health: Denies depression or mood changes. Denies suicidal thoughts. Declares himself to be “a happy person”
Vital Signs: Heart rate (HR) 76 beats per minute (bpm). Blood pressure (BP) (left arm) 109/64, mean arterial pressure (MAP) 79. Temperature (axillary) 98.2 F. Respiratory rate (RR) is 16 respirations per minute. Pain 5/10 (Intermittent, sharp/stabbing throat pain when swallowing).
Weight and Height: ( 50 lbs), 45 inches tall
General Survey: 4 year-old male. Well nourished. Communicates in a manner that is congruent with his developmental stage. Appropriate clothing for season. Appears clean and well groomed. No signs of abuse or neglect.
Mental Status: Calm. No loss of consciousness. AAO x 4, follows commands. Clear communication pattern and thought process.
Skin, Hair, and Nails: Skin pigmentation congruent with patient’s ethnic background, warm and dry. Hair distribution congruent with developmental stage. No cyanosis, clubbing, or tenting. Vesicular pruritic rash on hands, feet, and face with lesions presenting either isolated or in groups. Lesions in various healing stages.
HEENT: Head: Norm-cephalic with bilateral symmetrical structures. No masses felt, or tenderness elicited upon palpation of the scalp. Negative Kerning’s and Brudzinski sign. Neck supple. Trachea appears midline. Cranial nerves II, III, IV, and VI grossly intact. Eyes: Pink conjunctiva and white sclera. No exudate or discharge. Pupils equal (3), round, reactive to light (brisk, 3-4), and accommodating. Extraocular muscles (EOM) intact. No strabismus or nystagmus. Ears, Nose, and Throat: External ear canal intact with no erythema, discharge or cerumen. Tympanic membranes opaque and mildly bulging. Hearing grossly intact. No septum deviation. Swollen middle and lower turbinates’. Mild erythema of the nasal passages. Pharyngeal redness observed. Cobble stoning. No postnasal drip or tonsil exudate.
Mouth: Oral mucosa pink and moist. Round and oval (approximately 2mm to 5 mm) ulcerative lesions found on tongue, gums, and roof of mouth.
Chest and Lungs: Lung sounds clear and equal bilaterally with symmetric chest expansion. Resonance on percussion. Minimal effort. No cough or sputum.
Cardiac: Sinus rhythm. S1 and S2 present on auscultation. No S3 or S4. No heaves, thrills, or rubs.
Gastrointestinal: Flat abdomen, soft and non-tender to palpation. No masses. Bowel sounds active and present in all four quadrants. No hepatomegaly or splenomegaly. No CVA tenderness.
Endocrine: Appropriate weight for developmental stage. No intolerance to temperature changes.
Musculoskeletal: No restrictions of range of movement. Full strength in all four extremities.
Peripheral Vascular: Pulses present in all four extremities (+3). Temperature equally warm on upper and lower extremities. Capillary refill less than 3 seconds.
Neurologic: No coordination, sensation, or sensorineural deficits.
Respond these questions.
“Keep in mind that this is the first time you see this patient in your primary care practice” Give rationale for each answer. references
What is your Diagnosis
What is your differential diagnosis
What diagnostic tests would you order and why?
What education will you provide to your patient and parents?