433 DxR Team

Pediatrics 3

Ricky Anderson (Rash)

Ricky, a 14-year-old male, is being seen for evaluation of a rash.

Please note the following:

✓ Gray: patient’s own words
✓ Black: What you HAVE TO ask, write or do.
✓ Blue: Program Questions to guide you.
✓ Green & Red: Our notes to clarify As possible xD

Ricky Anderson – Rash (Pediatrics case)

 2 Ricky Anderson (Rash)

Ricky, a 14-year-old male, is being seen for evaluation of a rash.

Interview
Present illness I 1. Why are you here today? What problems are you having?
"I have a rash on my arms and legs."
2. When did you first notice the problem? When did it start?
"It started about three or four weeks ago as little 'spots' on my feet."
3. Can you describe the symptoms?
"Well, it started with these little red 'spots' on my feet. They got bigger and
spread to my legs. Now my arms have them, too. They itch a lot, but
otherwise I feel OK."
4. 4. 4. Does anything else happen when you feel these symptoms?
"Not really. I feel OK otherwise."
Present illness II 5. Have you been ill recently? When? What kind of illness?
I had strep throat about two months ago, but other than that I've been OK.

Please enter and/or review your Hypothesis List before continuing.

Concise statement of the patient's major problem:
Itchy rash on arms and legs
Your list of Diagnostic Hypotheses...
1. Guttate psoriasis
2. Tinea corporis
3. Drug eruption
4. Pityriasis rosea
5. Psoriasis
6. Smallpox
7. Contact dermatitis
8. Eczma
9. lichen simplex chronicus

Medical 1. Drugs, present medication, past medication, non-medical uses

History "I'm not taking nuthin' now. I just have that pen thing for when I get a
bee sting, but I haven't had to use it. Oh, and they gave me an
antibiotic when I had the sore throat . I can't remember the name,
though."
2. Allergies [Medical History]
"Just to bee stings. I have to take those shots or else I swell up and can't
breathe."
3. Past medical history including psychiatric, surgical, previous lab
"I've always been pretty healthy."
Lifestyles 1. Over-the-counter drugs: Laxatives, aspirin, cold preparations, etc.
"I don't take anything, just that cream my mom gave me for the rash."
 Ricky Anderson (Rash) 3

Exam
Ricky is a pleasant, comfortable, normal-appearing teenager.

Height: 5'7" (170 cm)

Weight: 133 pounds (60 kg)

Head 1. View| Scalp

Hair distribution is full; hair is thick, with good luster.
The patient's scalp is smooth and supple; no lumps, interruptions, or other
lesions are noted; the size and contour are normal, without apparent
deformities, and there are no areas of tenderness.
2. View| Face-Left
The patient is able to raise the eyebrows equally well bilaterally. The
forehead is furrowed symmetrically and there is good strength when
eyebrows are forcibly pushed downward. The patient is able to close both
eyes equally well, and the eyelashes are obliterated to the same degree on
both sides. The patient's smile, both on volition and reflexively when
laughing, is seen to be symmetrical. Skin shows a few erythematous
papules and pustules on the cheek, nose, and chin.
3. View| Face-Right
The patient is able to raise the eyebrows equally well bilaterally. The
forehead is furrowed symmetrically and there is good strength when
eyebrows are forcibly pushed downward. The patient is able to close both
eyes equally well, and the eyelashes are obliterated to the same degree on
both sides. The patient's smile, both on volition and reflexively when
laughing, is seen to be symmetrical. Skin shows a few erythematous
papules and pustules on the cheek, nose, and chin.
Body 1. View| Arm-Left
The patient's arms are symmetric, well developed and well formed. There
are no scars or growths. The muscles are of normal bulk and contour. There
are a few small lesions seen, as shown in the picture; a close-up of a typical
lesion is shown on the right.
Interpretation: numerous erythematous, well-circumscribed, scaling lesions
2. View| Arm-Right
The patient's arms are symmetric, well developed and well formed. There
are no scars or growths. The muscles are of normal bulk and contour.
There are a few small lesions seen, as shown in the picture; a close-up of
a typical lesion is shown on the right.
Interpretation: numerous erythematous, well-circumscribed, scaling
lesions
3. View| Leg-Left
 4 Ricky Anderson (Rash)

The patient's legs are symmetric, well developed and well-formed. There
are no scars or growths. There is no edema; no varices are present on the
legs. The muscles are of normal bulk and contour. Several skin lesions
are seen; a close-up of a typical lesions is shown on the right.
Interpretation: numerous erythematous, well-circumscribed, scaling
lesions
4. View| Leg-Right
The patient's legs are symmetric, well developed and well-formed. There
are no scars or growths. There is no edema; no varices are present on the
legs. The muscles are of normal bulk and contour. Several skin lesions
are seen; a close-up of a typical lesions is shown on the right.
Interpretation: numerous erythematous, well-circumscribed, scaling
lesions
5. View| Foot-Left
The skin over the foot has normal hair distribution and is without lesions
or edema, including calluses and corns.
The arches are concave. There are no areas of redness. The toenails are
pink and without deformity, onycholysis or onychomycosis.
6. View| Foot-Right
The skin over the foot has normal hair distribution and is without lesions
or edema, including calluses and corns.
The arches are concave. There are no areas of redness. The toenails are
pink and without deformity, onycholysis or onychomycosis.
7. View| Chest
The chest is symmetric; the ratio of AP to lateral diameter is about 1:2.
Respiratory movements are full, symmetric, and without retractions;
there is no paradoxic movement on expiration; breathing is regular at 16
per minute, without apparent effort or use of accessory muscles. Two
small, well circumscribed, scaly erythematous patches are seen on the left
chest.
8. View | Back-upper left
When lying down, the patient breathes easily and symmetrically. No use
of accessory muscles is noted. The expansion of the chest and abdomen is
synchronized. No skin lesions are seen.
9. View | Back-upper Right
When lying down, the patient breathes easily and symmetrically. No use
of accessory muscles is noted. The expansion of the chest and abdomen is
synchronized. No skin lesions are seen.
Abdomen 1. View | Abdomen-upper Left
On inspection, the abdomen is symmetric; skin is smooth and soft without
striae; venous pattern is minimal and there are no rashes. The abdomen is
scaphoid and symmetric without local bulges; no peristalsis or pulsations are
 Ricky Anderson (Rash) 5

visible. The umbilicus is small, inverted, midline, and without signs of

inflammation or herniation.
2. View | Abdomen-upper Right
On inspection, the abdomen is symmetric; skin is smooth and soft without
striae; venous pattern is minimal and there are no rashes. The abdomen is
scaphoid and symmetric without local bulges; no peristalsis or pulsations
are visible. The umbilicus is small, inverted, midline, and without signs of
inflammation or herniation.

Lab

Common Tests 1. CBC w/diff

WBC 5,200/mm3
RBC 5.10 m/cmm3
Hemoglobin 14.6 g/dL
Hematocrit 43.8%
MCV 85.3 fL
MCH 28.9 pg
MCHC 33.9%
Platelets 152,000/mm3
Bands 1% WBC count
Neutrophils 61% WBC count
Lymphocytes 27% WBC count
Eosinophils 2% WBC count
Monocytes 10% WBC count
Basophils 1% WBC count
2. Throat Culture
Normal throat flora
3. Sedimentation Rate
3 mm/hr
4. Urinalysis, Routine (UA)
Specific Gravity 1.015
pH 7.0
Protein negative
Bilirubin negative
Glucose negative
Ketones negative
Occult Blood negative
RBCs/HPF 0-3
WBCs/HPF 0-3
Bacteria negative
Epithelial Cells few
Casts none
Nitrates negative
Urobilinogen negative
 6 Ricky Anderson (Rash)

Microbiology 1. KOH Prep

No spores of hyphae found
Immunology 1. Anti-streptolysin O
1:340 Todd units
2. Serum Antibody Titers
Negative
3. Immunoelectrophoresis
IgG 1080 mg/dL
IgA 360 mg/dL
IgM 189 mg/dL
4. Rheumatoid Factor
Negative
Blood A-G 1. C-Reactive Protein (CRP)
.8 mg/dL
Other Biopsy- Skin
This skin biopsy shows epidermal hyperplasia with hyperkeratosis,
parakeratosis with scale formation, a decreased granular layer with
an acanthotic epidermis, tortuous vessels in the papillary dermis,
and an inflammatory infiltrate in the dermis. All of these findings are
consistent with a diagnosis of psoriasis.

Diagnosis

A. SOAP Subjective data:

Ricky is a 14 year old male who came in with a itchy rash that started three
weeks after a thought infection on his leg and went to his arms. He is
allergic to bee stings and is currently on no medications except a cream a
mom gave him. His mom gets the same rash sometimes.
Objective data:
Several erythematous, well-circumscribed, scaling lesions are seen on arms
and legs. The skin biopsy shows epidermal hyperplasia with
hyperkeratosis, parakeratosis with scale formation, a decreased granular
layer with an acanthotic epidermis, tortuous vessels in the papillary
dermis, and an inflammatory infiltrate in the dermis. All of these findings
are consistent with a diagnosis of psoriasis.
Assessment data
Ddx:
Guttate psoriasis
Tinea corporis
Drug eruption
Pityriasis rosea
Psoriasis
Smallpox
 Ricky is a 14 year old male who came in
with a itchy rash that started three
Rickyweeks
Anderson (Rash) 7
after a thought infection on his leg and
went to his arms. He is allergic to bee
Contact dermatitis
stings and is currently on no medications
Eczma except a cream a mom gave him. His
lichen simplex
momchronicus
gets the same rash sometimes.
Plan Data
Treatment resolves around symptomatic relief. Start patient on an anti-
inflammatory and recommend Tar shampoo and medium potency topical
steroid ointment. Also refer to a dermatologist for follow up and educate
parents on disease process.
B. 1- Select
guttate psoriasis
2- Use this space to expand your selected diagnostic hypotheses into a
complete but concise pathophysiologic diagnosis.
guttate psoriasis following an episode of streptococcal pharyngitis
3- Justify your diagnosis with supportive findings from history, physical
exam, and lab.
Hx and the skin biopsy showed epidermal hyperplasia with
hyperkeratosis, parakeratosis with scale formation, a decreased granular
layer with an acanthotic epidermis, tortuous vessels in the papillary
dermis, and an inflammatory infiltrate in the dermis. All of these findings
are consistent with a diagnosis of psoriasis.
4- Very Confident
C. Problems list:
1. Skin Rash

Management
Treat patient as an Outpatient
Collaboration 1. Dermatologist
To help in follow up and progress of patient
Follow-up 1. Return Visit
To monitor her compliance to the medication
Education 1. Disease Process
To explain to patient reason for rash
2. Preventative Health
To explain to patient what he can do to prevent and lessen effects of
psoriasis
Medications 1. Miscellaneous | Anti-inflammatory | Hydrocortisone
Dose: 1 mg Route: Topical Interval: BID Twice Daily
To treat the psoriasis
8 Ricky Anderson (Rash)

Results
Ricky Anderson (Rash) 9
10 Ricky Anderson (Rash)

Thank yo

Thank You and good luck