Taking notes on Ihuman case studies is important as it helps in identifying the essential details for a patient. These notes help in establishing a layout plan on how to handle the patient's diagnosis and compile the fine print of the patient's issues and health background.
Below is an Ihuman case study of Olive Chanley
CC: Rash that began this morning on the abdomen and spread to the arms and legs
Problem Statement:
She is a 2yo female named Olive Chanley who has ben brought in by the parents since she is an infant. The patient presents with generalized maculopapular pink rash that began this morning on the abdomen and quickly spread to bilateral upper and lower extremities. Mother states patient has a cough, runny nose, and fever for 3 days prior to rash, with highest fever 103.0 on day 2. Fever resolved yesterday, cough, and runny nose persist. Mother gave patient Tylenol for fever and denies any other recent OTC or prescribed medications. NKDA or any new environmental allergies. Immunizations are up to date. Denies new foods, detergent, soaps, or other possible irritants. Mother states patient is eating and drinking normally, with 4-5 urine saturated diapers, and 2 stools per day. Patient is not itching nor appears to be in any pain (FLACC-0). HEENT physical exam unremarkable.
Diagnosis:
The patient is diagnosed with Roseola Infantum (Exanthem Subitum) a common viral disease of childhood. Roseola infantum, also known as exanthema subitum or sixth disease, typically presents in children younger than two years of age. Patients with the virus classically present with acute onset high-grade fever up to 104.0Fand upper respiratory symptoms lasting between three to five days. After that, a rapid defer vescence of the fever is accompanied by a nonpruritic, pink maculopapular rash that begins on the trunk and spread to extremities. The rash generally last between 1-3 days. Human herpes virus-6 (HHV-6) is responsible for most cases, with HHV-7 a rare occurrence. HHV-6 has 2 variants A and B. A is acquired in adulthood and B in childhood. Approximately 90% of the population are infected with HHV-6B within the first 3 years of life with minimal to no lasting health problems.
HPI: Established 2yo female patient presents with generalized rash that began this morning on the abdomen and quickly spread to bilateral upper and lower extremities. Mother states patient had a cough, runny nose, and fever (highest 103.0) for 3 days prior to rash. Fever resolved yesterday, cough, and runny nose persist. Mother gave patient Tylenol for fever and denies any other OTC or prescribed medications. NKDA or any new environmental allergies. Denies new foods, detergent, soaps, or other possible irritants. Mother states patient is eating and drinking normally, with 4-5 urine saturated diapers, and 2 stools per day. Patient is not itching nor appears to be in any pain (FLACC-0).
OAP: None
MSOH: She was born full term at 38 weeks GA, born via NSVD. No complications during delivery or after birth.
RX: Tylenol as needed for fever. ALLERGIES: NKDA
PH: Patient has been meeting all developmental milestones. Growing and developing well. IMM: Birth: Hep B
2 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B 4 months: DTaP, IPV, HIB, PCV13, Rotavirus,
6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza1st dose 7 months: Influenza 2nd dose
12 months: MMR, Varicella, Hep A 1st dose 15 months: DTaP, HIB, PCV13
18 months: Hep A 2nd dose FH: Mother 32, healthy
Father, 35, healthy
SH: Lives at home with mother and father in an apartment.
GC: Recent fever 103.0 that subsided yesterday, current fever-no. Denies weight gain/loss, malaise, change in eating/drinking habits, night sweats, and insomnia.
SB: Recent rash began on abdomen this morning and spread to A4E, denies itching.
HEENT: Current nasal congestion, and cough. Denies eye redness/discharge, sore throat, and earache. CARDIO: Denies SOB or irregular heartbeat.
RESP: Nonproductive cough for 3 days. Denies SOB, or difficulty breathing. GI: Denies vomiting, diarrhea, constipation. 2 normal stools daily.
GU: Wears diapers. No history of UTIs in the past. Has 4-5 wet diapers per day. MS: No recent trauma, no weakness.
NEURO: No history of seizures.
AI: NKDA. Up to date for immunizations until 18 months. LE: Denies swollen lymph nodes.
HEMO: No history of anemia.
PSYCH: Appears to be happy and content. PE:
General: Patient is lying quietly in NAD on exam table. Alert and happy skin w/d, with generalized pink maculopapular rash. Respirations even/ul, afebrile 98.6 F.
Skin: Skin is W/D with maculopapular pink rash on abdomen and A4E. Normal skin turgor. Hair distribution and thickness normal for age. Capillary refill <3 seconds.
HEENT: head normocephalic, atraumatic, no deformities, facial features symmetrical, temporal arteries nontender to palpitation, frontal, and maxillary sinuses non tender. Eyes no ptosis erythema or swelling, conjunctivae oink without DC, orbital free of tenderness and lesions. Visual acuity 20/20 bilaterally.
External auditory canals unremarkable, TM pearly grey bilaterally, no scarring or DC noted with normal landmarks. Bilateral nares without polyps, erythema, and no sinus tenderness. No hoarseness, oropharynx not injected, clear mucosa, tonsils without exudate. Tongue normal color and symmetrical, no swelling or ulcerations, gag reflex intact. Neck supple, with FROM, trachea midline, and no accessary muscles used during respirations. No palpable lymph nodes.
CV: Chest is symmetrical with normal AP diameter. PMI is 5th ICP & MCL. AudibleS1 and S2 heart sounds with no murmurs.
Resp: Respirations symmetrical, with no use of accessary muscles. Clear lungs in all lobes with no advantageous sounds.
GI: BS in A4Q, nontender to palpitations, no masses, hepatomegaly, spleen nonpalpable, and liver span normal.
GU: Normal genitalia without diaper rash. MS: FROM in all extremities.
OS: Not assessed at this time.
Neuro: 5/5 strength in all extremities, bilateral pupils normal reactive to light. Psych: Alert and happy.
AI: Not assessed at this time.
Lymph: No pathologically enlarged lymph nodes. Hema: Not assessed at this time.
Conclusion
There is no specific treatment for Roseola Infantum. The rash is nonpruritic, therefore medication is not warranted. Symptom relief of fever with Tylenol 10-15/mg/kg every 4-6 hours, and keeping child hydrated, with plenty of rest is recommended. There is a chance of febrile seizures, therefore fever management is critical. If fever persists above 100.4 after administration of Tylenol, seizure activity, lethargy, nausea, vomiting, diarrhea, shortness of breath, or neck rigidity occurs go to the ER. Follow up in 3 days or sooner if symptoms increase.
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