Identifying Data:

Full Name: A.K.

Address: Queens, NY

Age: 4 years old

Race/Nationality: Asian

Date and Time: 9/3/2021 7:00 AM 

Location: QHC Pediatric Emergency Department 

Source of Information: Father and Patient

Source of Referral: Father

Reliability: Reliable 

Mode of Transport: Private vehicle 

Chief Complaint: fever x two days 

History of Present Illness: 

4 y/o M, with no PMHx, who presents complaining of fever x two days. Per father, the patient’s temperature this morning was 101F, and he received Tylenol around 6:40 AM, just prior to arriving in the emergency department. Father reports the patient started to have a rash yesterday, that began on the back of his neck. Father reports the rash has now spread to his torso, face, and upper extremities. Patient states the rash is pruritic. Father states the patient has decreased appetite but is able to tolerate liquids. Patient denies ear pain, cough, coryza, sore throat, difficulty swallowing, difficulty breathing, nausea, vomiting, abdominal pain, change in bowel habits, dysuria, hematuria, or any other symptoms at this time. No sick contacts, no recent travel, no change in diet or change in bathing products. Per father patient is up to date on his vaccinations.

Past Medical History:

• Denies past or present illnesses
• Denies any hospitalizations, transfusions, or injuries. 

Past Surgical History:

• Denies any surgeries in the past.

Family History: 

• Mother: alive and well
• Father: alive and well 

Medications:

• Denies taking any medications.

Allergies:

• No known drug, food or seasonal allergies.  

Immunizations:

• Up to date
• Patient received DTap and polio vaccines two days ago. 
• 2^nd dose MMR up to date
• Patient has not received annual influenza vaccine.

Social history:

• Patient lives at home with mother and father in a nonsmoking household.
• Patient is starting pre-k next week. 
• No recent travel
• Sleep: denies difficulties

Nutrition:

• Patient currently has a decreased appetite but is tolerating liquids. 

Review of Systems: 

General: Admits to fever and decreased appetite. Denies chills, night sweats, fatigue, weakness, weight loss/gain. 

Skin : Admits to rash and pruritus. Denies excessive dryness or sweating.

Head: Denies headache, dizziness or head trauma. 

Eyes: Denies blurry vision, double vision, loss of vision, use of glasses, photophobia or pruritus.

Ears: Denies hearing loss, discharge, tinnitus or ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, loss of smell or obstruction.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers, sore tongue or voice changes.

Neck: Denies neck pain/stiffness, localized swelling/lumps or decreased range of motion. 

Respiratory: Denies cough, shortness of breath, wheezing, sputum production, hemoptysis or cyanosis.

Cardiovascular: Denies chest pain, leg edema, hypertension, syncope, palpitations or known heart murmur.

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, pyrosis, dysphagia, jaundice, change in bowel habits, rectal bleeding or blood in stool.

GU: Denies dysuria, hesitancy, flank pain, frequency, hematuria or urgency. 

MSK: Denies muscle or joint pain, redness or stiffness. 

Peripheral Vascular: Denies coldness or color changes.

Neuro: Denies weakness, dizziness, seizures, lightheadedness, headaches, numbness, or tingling. 

Physical Exam: 

VS: T 101.1 F, BP 95/65 sitting upright right arm, HR 140 bpm, RR 18 unlabored, O2 sat 100% on room air, Ht 88.9 cm, Wt 16.3 kg, BMI 20.6

Gen: Alert and oriented. Well-developed, well-nourished and well-groomed.

Skin: Warm and moist with good skin turgor. Fine, papules with diffuse erythema with sandpaper texture to neck, torso and face.  Area of rash on bilateral upper extremities limited to antecubital fossa. Non-icteric. Capillary refill less than 2 seconds.

Head: Normocephalic, atraumatic. 

Ears: Symmetrical with no lesions or masses externally. Ear canals with no swelling, foreign bodies, or discharge bilaterally. Tympanic membranes normal bilaterally. 

Eyes: Pupils equal, round and reactive. Sclera non-icteric. Red reflex normal bilaterally. 

Mouth/Throat: Uvula midline, mild erythema to posterior oropharynx with minimal exudate. Tongue does not have edematous papillae or erythema. No masses in the oropharynx. Good dentition.

Neck: Trachea midline. Non-tender to palpation. Full range of motion of neck with no pain. No lymphadenopathy.

Cardiovascular: Tachycardia with regular rhythm. S1 and S2 with no murmurs or gallops. Radial pulse 2+ bilaterally.

Respiratory: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing.

Abdomen: Soft, symmetric. Bowel sounds normoactive in all four quadrants. Non-tender to palpation with no masses. No organomegaly. 

Extremities: No edema in bilateral upper or lower extremities. No ulcerations.

Musculoskeletal: No swelling, ecchymosis or deformities to bilateral upper and lower extremities.

Neuro: Alert and oriented. Normal speech and gait.

Differentials: Scarlet fever, roseola, varicella, hand-foot and mouth disease, measles, viral exanthem  

Assessment: 

4 y/o male, with no PMHx, who presents c/o fever x two days and rash x one day. Physical exam reveals erythematous, sandpaper texture rash on face and torso and mild erythema to posterior oropharynx. No other abnormalities noted.

Plan: 

Scarlet Fever

• Started on Amoxicillin 400 mg/5mL – 5 mL by mouth two times a day for 10 days. Please finish entire course of antibiotics.
• Diphenhydramine 12.5 mg/5mL – 5 mL by mouth two times a day for five days 
• Ibuprofen 100 mg/5mL – take 8.2 mL by mouth every 6 hours as needed
• Follow up with pediatrician in two days 
• COVID Testing 
• Patient may return, if in childcare for this week, 24 hours after initiation of antibiotics.
• If child gets worse or in case of emergency come back to emergency room or call 911