H&P #1

IDENTIFYING DATA:

  • Date & Time: July 3, 2023
  • Full Name: S. F.
  • DOB: 6/20/19
  • Location: Dr. Hurwitz Pediatric Outpatient Office
  • Source of information: father / self
  • Reliability: reliable

CHIEF COMPLAINT: fever and rash x 4 days

HISTORY OF PRESENT ILLNESS:

S. F. is a 4 year old male with no PMHx who presents to the pediatric outpatient clinic accompanied by father who reports worsening rash and fever x 4 days. Symptoms began 4 days ago with rhinorrhea and fever, Tmax 101.4 relieved with OTC Tylenol. Patients mother noticed red rash 2 days ago on hands and later spread to feet. As per father, rash has worsened and more lesions have appeared over the 2 days. States patient has been mildly itching the rash. Parents noticed lesions in patient’s mouth this morning. Patient has been eating normally and is not complaining of serious oral pain. Father has applied OTC hydrocortisone to patient’s rash areas and reports mild improvement in itching. Father states the patient is currently attending day camp at camp fun but has no known sick contacts. Patient has not had exposure to any new products on body. Denies chills, anorexia, sore throat, ear pain, N/V/D, constipation, abdominal pain.

MEDICAL HISTORY:

Medications:

  • Hydrocortisone 1% PRN
  • Tylenol 160mg/5mL PRN

Medical History:

  • No past medical history

Surgical History:

  • No past surgical history

Immunization Hx:

  • Vaccinations UTD

Allergies:

  • No known drug, food or environmental allergies

 

Family History:

  • Mother: age 28, alive and well, no past medical history
  • Father: age 29, alive and well, no past medical history
  • 1 brother: age 6, alive and well, no past medical history
  • Maternal grandparents: alive and well, hx of HTN in maternal grandfather
  • Paternal grandparents: alive and well, no known medical history
  • Denies known family history of cancer or MI.

Social History:

  • Lives with mother, father and brother in 3 bedroom home in Kew Garden Hills
  • No smokers in home, no pets
  • Safety: patient uses booster seat and safety belt while in car; home equipped with smoke and carbon monoxide detectors
  • Attends summer day camp at camp fun
  • Schooling: Patient will be attending pre-K in fall
  • Social: patient attends frequent play dates and socializes daily at camp
  • Home situation: father denies stressors at home for patient
  • Travel: denies recent travel
  • Exercise: daily exercise at camp, frequent visits to park.
  • Sleep: average 8-9 hours of sleep per night
  • Diet: home cooked meals cooked by mother; follows kosher diet; balanced diet – vegetables, carbohydrates and protein; limited amounts of candy and sweets provided

Development/Milestones:

  • Able to dress himself
  • Able to walk downstairs alone
  • Able to catch and throw a ball overhand
  • Able to sing songs
  • Able to recite alphabet
  • Able to draw shapes
  • Knows address and mother phone number

Birth History:

  • Birth weight: 7 lbs 14 oz
  • Birth Hospital: Northshore LIJ Hospital
  • NSVD, no complications during pregnancy or delivery

REVIEW OF SYSTEMS

  • General: + Fever. Denies weight loss, changes in appetite, weakness, fatigue, chills.
  • Skin, hair, nails: + Rash w/ associated pruritus. Denies discolorations, abnormal pigmentations.
  • Head: Denies headaches, dizziness or head trauma.
  • Eyes: Denies eye pain or pruritus.
  • Ears: Denies pain, discharge, tinnitus.
  • Nose/sinuses: Denies discharge, congestion, and epistaxis.
  • Mouth/throat: +Mouth ulcerations. Denies bleeding gums, sore throat, voice changes.
  • Neck: Denies swelling or decreased range of motion.
  • Pulmonary system: Denies shortness of breath, cough, wheezing.
  • Cardiovascular system: Denies chest pain.
  • Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stools, nausea, vomiting.
  • Genitourinary system: Denies dysuria, urinary frequency, oliguria.
  • Nervous: Denies loss of strength.
  • Musculoskeletal system: Denies muscle/joint pain or redness. .
  • Hematological system: Denies easy bruising or bleeding.
  • Endocrine system: Denies heat or cold intolerance or excessive sweating.

PHYSCIAL:

General: Appears stated age. Good development and well groomed. Appears well nourished and in no acute distress.

Vitals:

  • Pulse: 98 beats/min, regular
  • Respiratory Rate: 20 breaths/min, unlabored
  • Temp: 99.3 F (oral)
  • Wt: 36.25 lbs (53rd percentile)
  • Ht: 40.5” (56th percentile)

Skin: + Vesicular rash w/ blisters scattered on palms of B/L hands and soles of B/L feet. No masses, scarring or bruising noted. Skin warm and nonicteric.

Head: Head normocephalic, atraumatic.

Hair: Average quantity. No lice or seborrhea noted.

Nails: No spooning or clubbing of nails.

Head: Head normocephalic, atraumatic.

Eyes: Symmetrical OU. Sclera white. Conjunctiva pink. PERRLA OU. EOMI with no nystagmus.

Ears: Symmetrical, no swelling or lesions to external ear. No discharge or foreign bodies present AU. TM pearly grey with light reflex in good position AU.

Nose: Nares patent bilaterally. No discharge or foreign bodies noted.

Mouth/Pharynx: +Vesicles on buccal mucosa. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema present. Uvula midline. Tonsils grade 2 with no exudates or erythema present. Pharynx non-erythematous.

Neck: Trachea midline. Neck supple; non-tender to palpation. No cervical adenopathy noted. FROM.

Thyroid: Non-tender; no palpable masses or nodules; no thyromegaly.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted.

Abdomen: Abdomen flat and symmetric, no masses, ecchymosis or striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. Tympanic throughout. No splenomegaly.

Musculoskeletal: No soft tissue swelling. FROM in upper and lower extremities.

DIFFERENTIAL DIAGNOSIS:

  • Hand foot and mouth disease: Patient is in the common age range for coxsackies infection. Possible exposure in crowded day camp. Blisters present on hands and feet along with oral vesicles present.
  • Varicella: Patient is fully vaccinated for varicella. Rash is usually vesicular. Less likely b/c rash typically begins on trunk and spreads to extremities.
  • Atopic dermatitis: Commonly peaks before age 5. Usually a pruritic, can form blisters. Uncommon to present with fever unless infected.
  • Contact dermatitis: Pruritic rash. No known contact with new products or other potential triggers.

ASSESSMENT:

4 year old male with no PMHx presents for fever and rash x 4 days. Patient is hemodynamically stable. Exam reveals vesicular rash on B/L hands and soles of feet and vesicles on buccal mucosa. Presentation is consistent with hand foot and mouth disease.

PLAN:

#Hand foot and mouth disease

  • Continue with Tylenol PRN for fever or pain
  • Oral rehydration: keep patient well hydrated w/ plenty of fluids, if trouble eating or drinking consider pedialyte
  • Keep patient home from day camp and isolate from brother if possible
  • Close monitoring of patient for worsening symptoms or signs of dehydration

Patient Education:

  • HFMD is a common self limited viral illness caused by coxsackievirus A that is very contagious. Patient should be kept home from camp and kept away from others.
  • Practice good hang hygiene
  • Toys should be washed and sanitized along with surfaces in the home
  • Avoid close contact such as kissing, hugging, sharing cups and utensils
  • Avoid oily or spicy foods that can irritate and cause worsened pain of mouth ulcers
  • Individuals should quarantine until they are fever free for 24 hours and all blisters are completely healed, which typically takes 7 – 10 days

Return precautions: please return to office or call if

  • Symptoms do not improve or worsen after 10 days
  • Fever lasting longer than 3 days
  • Producing less urine
  • Not drinking enough water/becoming dehydrated