Download COMPREHESIVE CASE STUDY WEEK #4 2 YEARS OLD FEMALE REASON :RASH (6512) LATEST CASE 2024 and more Exams Health sciences in PDF only on Docsity! lOMoARcPSD|44886145 COMPREHESIVE CASE STUDY WEEK #4 2 YEARS OLD FEMALE REASON :RASH (6512) LATEST CASE 2024- 2025 ACTUAL SCREENSHOT INCLUDING PHYSICAL, ASSESMENT, HISTORY EVERYTHING ABOUT CASE STUDY GRADED A . \ lOMoARcPSD|44886145 Electronic Health Record by Amber Quinn on case History of PresentIllness Category Data enteredby Amber Quinn Reason for Encounter Rash History of present illness A two-year-old female who presented to the clinic by her mother with complaints of a worsening rash that started on the abdomen but has spread to her legs and arms. The mother stated KY developed a cough, runny nose, and fever three days ago and suddenly developed a rash this morning. The mother denies any itching but is unsure if the rash is painful. No interventions were attempted to treat the rash; Tylenol was given for fever, cough, and runny nose. The fever has resolved. The mother denies any vomiting or diarrhea. No appetite change; KY has 4-5 wet diapers and about two stool diapers daily. The mother denies any new changes in soaps, detergents, or lotions—no known allergies. The mother denies any significant past medical history, uncomplicated birth. KY does attend daycare; the contacts. mother denies any sick lOMoARcPSD|44886145 Neurologic Psychiatric Happy and content Physical Exams Category Data enteredby Amber Quinn General Lying on exam table, alert, happy, interacting with mom, vital signs stable, afebrile. Skin Warm and dry. There is a pink maculopapular rash on the abdomen and extremities. Normal skin turgor. HEENT / Neck Eyes: No ptosis erythema or swelling, conjunctivae pink no discharge, sclerae anicteric, orbital area, no edema, redness, tenderness, or lesions noted. Pupils round, reactive to light, 2-3 mm. Ears: Normal- appearing external auditory canals. The tympanic membrane is translucent, non-injected, and pinkish-gray in color. No scarring, discharge, or purulence was noted. Normal landmarks. Normal mobility with insufflation. Nose: No discharge or polyps. No edema or tenderness over the frontal or maxillary sinuses.Nostrils patent. deformities, facial Head: Normocephalic, atraumatic, no features symmetric. Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non-tender. Throat: No hoarseness; oropharynx not injected, clear mucosa, tonsils withoutexudate. Tongue normal color, symmetrical no swelling or ulcerations. Normal gag reflex. Neck: Thyroid firm, an acceptable size for patient gender and age, no nodulespalpated. No visible scars, deformities or other lesions. Trachea midline and freely mobile. No asymmetry or accessory respiratory muscle use with quiet breathing. lOMoARcPSD|44886145 Cardiovascular Normal heart sounds upon auscultation, no gallops, murmurs, clicks or rubs. Chest / Respiratory Chest is symmetrical, AP diameter is normal. The excursion with respiration is symmetrical, and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses or rashes. No adventitious lung sounds heard throughout Abdomen Flat and symmetric with no scars, deformities, striae or lesions. Bowel sounds active in all four quadrants. No pain, tenderness, masses or pulsations. There is no guarding or rebound tenderness. No hepatosplenomegaly. Liver span normal, spleen not palpable. Genitourinary / Rectal Deferred Musculoskeletal / Osteopathic Structural Examination No swelling clubbing, or deformities, no cyanosis, or edema. Neurologic Deferred Psychiatric Alert Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains. Attempt
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History:
Patient Information: 2-year-old female
Reason for Encounter: Rash
Chief Complaint: The patient's parent reports a rash that has developed, seeking medical
evaluation.
History of Present Illness (HPI): The parent noticed a rash on the child's body. Further
questioning would include when the rash started, if it has changed or spread, any associated
symptoms (fever, itching, or discomfort), and any recent exposure to new substances
(detergents, foods, outdoor activities, or illnesses).
Past Medical History: (Need information such as previous medical conditions, allergies,
immunization history, etc.)
Medications: |s the child on any medication?
Family History: (Inquire about family history of dermatological conditions, allergies, or
autoimmune disorders.)
Social History: (Consider daycare attendance, pets at home, or any new changes in the home
environment.)
Allergies: Document any known drug or food allergies.
Physical Exam:
Vitals: (Though not provided in the image, they would be essential.)
General Appearance: The child appears well-developed and well-nourished, without signs of
distress.
Skin: Observe and describe the rash (location, appearance — macular, papular, vesicular,
How can | help her today?
Does she have any other symptoms you would like to discuss?
What treatment has she had for the cough? Is she coughing any sputum?
What treatment has she had for the rash?
On what part of her body did the rash start and where did it spread?
Is her rash painful or itchy?
What treatment has she had for the rash?
Has she been having fevers?
When did the fever start?
How high is the fever?
Is she taking any over the counter medication?
How is her appetite any recent change?
Did she have any other problems two to four days .....?
How many wet diapers does your child have per day?
How many stools diaper does your child have per day?
Does she have any allergies?
Your Findings Case Findings
+ Rash since this morning + Cough for three days
* maculopapular pink rash on abdomen and extremities + Runny nose for three days
* Cough + Fever that started three days ago and resolved yesterday
* Runny nose + Rash that started today on abdomen, spreading to
« fever (103) 3 days ago extremities
« Rash started on abdomen and spread to arms and legs « Irritability
Feedback
The medical problem list or list of pertinent findings you have compiled should include everything that is out of the ordinary
about this patient, even when it is not a "problem’ in the true sense of the word.
The rash that started this morning and is spreading is the chief complaint per Kecia's mother and the most significant active
problem (MSAP) for this case.
The cough and runny nose for the last three days could be a part of a larger picture related to the rash and is therefore related
to the MSAP,
Itis also important to note the fever that started three days ago and resolved the day before as this can guide our differential.
This is therefore related to the MSAP.
Legend: @ Correct X Missed € Extraneous
@ exanthema subitum (HHV-6/roseola)
@ rubella (German measles)
@ measles (rubeola)
@ viral upper respiratory infection (URI)
> human parvovirus 19
C allergic contact dermatitis
C allergy
(C cytomegalovirus infection (CMV)
© arzama
Your Your Your
Differential Diagnosis Lead Graded Alt Graded MNM Graded
exanthema subitum (HHV-6/roseola) © e ° c
human parvovirus 19 ° ° e ce
measles (rubeola) ° ° e c
rubella (German measles) ° © e c
viral upper respiratory infection (URI) O ® e oO
Feedback
Because Kecia has had a cough and runny nose along with a fever that has subsided followed by a rash, roseola is our
leading diagnosis in this case.
Parvovirus B19 which is also known as erythema infectiosum or fifth disease, can present with a fever and cough, but it also
presents with a lacy rash on both cheeks which can then spread to the abdomen and extremities. Kecia's rash did not present
on her cheeks. Therefore, this is a diagnosis we can consider, but is an alternate diagnosis in this case.
Before the era of vaccination, measles and rubella were more common. Both measles and rubella can present with a fever
and cough; however, Kecia does not have koplik spots that are commonly seen in measles or a rash that spread from face
downwards that is commonly seen in rubella. Kecia is also up to date on her vaccinations. Therefore these are alternate
diagnoses in this case.
Kecia does have common signs of an upper respiratory infection, however the presence of a rash appearing after the fever
makes roseola the /eading diagnosis in this case and therefore URI is an alternate diagnosis.
Diagnosis Feedback
Because of the presentation of cold symptoms and a fever that resolves before the rash appears, roseola is the diagnosis in this
case.