Identifying Data:
Patient Initials: JL
Age: 9Y 11M
Date & Time of Encounter: 4/30/24 at 2:14pm
Location of Encounter: Jamaica, Queens
Source of Information: Mother/Self
Reliability: Reliable
Chief Complaint: “Rash on nose” x 2 weeks
History of Present Illness:
9YOM bib mom concerned for rash on Pt’s nose x 1 week. She notes an erythematous, bumpy area on Pt’s external R nostril that began soon after he sustained a small laceration to the area from a branch at the park. Pt says the area is warm and tender to touch, but denies unprovoked pain or itchiness. Mom reports that the Pt has continued to pick at the newer lesions on his face, and they have become more prominent since onset. They have not spread beyond his nose, they deny known rash or skin lesions elsewhere on the body. Denies fever, congestion, cough, eye pain/swelling/discharge, visual changes. Denies h/o similar symptoms. Denies known sick contacts. Mom says she has tried topical aloe vera to the area without relief or improvement.
Past Medical History:
Present illnesses – Denies
Past medical illnesses – Denies
Immunizations – Per CIR, Pt is UTD on all eligible vaccinations.
Screening tests and results – Last annual physical with CMP and CBC on 6/6/23 without abnormal findings. Vision 20/20 OU uncorrected. Last dental appointment 1/2024.
Past Surgical History:
None
Medications:
None
Allergies:
NKDA, denies known food or environmental allergies
Family History:
Father: alive 37 yrs, healthy
Mother: alive 31 yrs, healthy
Family medical history unknown.
Pt has no siblings.
Social History:
JL is a 9YOM who lives at home w/ his mother and father. There are no other members of the home.
Habits – N/A
Travel – None
Diet – Mom says PT eats an omnivorous diet rich in most fruits and vegetables.
Exercise – Mom says PT plays sports seasonally, but is otherwise sedentary.
Sleep – 9-10 hours a night uninterrupted
Safety measures – Pt travels primarily by bus
Review of Systems:
General: Denies fever, chills, fatigue, loss of appetite.
Skin, hair, nails: Reports an area of rough, erythematous skin with multiple raised lesions on external R nostril. Denies pruritus, swelling, erythema, or rash elsewhere on body.
Head: Denies headache, head trauma, dizziness.
Eyes: Denies swelling, pruritus, warmth, and erythema.
Ears: Denies pruritus, pain, discharge, or hearing loss.
Nose/Sinuses: Describes rash on R nostril as described above. Denies discharge, congestion, epistaxis, anosmia.
Mouth and throat: Denies sore throat, voice changes, dental pain.
Neck: Denies localized swelling, pain, or decreased range of motion.
Respiratory: Denies cough, shortness of breath, difficulty breathing, wheezing.
Cardiovascular system: Denies chest pain, palpitations.
Gastrointestinal system: Denies loss of appetite, nausea and vomiting, dysphagia, abdominal pain, diarrhea.
Genitourinary: Denies urinary frequency, urgency, dysuria.
Musculoskeletal System: Denies deformity, swelling, pain.
Peripheral Vascular System: Denies peripheral edema, color change.
Nervous System: Denies sensory disturbances, weakness,
Psychiatric: Mom reports Pt is generally in good spirits. Denies h/o psychiatric care.
Physical
General: 9YOM who appears his stated age, appears well-groomed and dressed appropriately for the weather. Pt maintains eye contact and answers questions appropriately without signs of acute distress.
Vital Signs:
Temperature: 97.9F
O2 Sat: 100% RA
Height: 51”
Weight: 76 lbs.
BMI: 20.54
Respiratory Rate: 18
Heart Rate: 84bpm
Hair, Head, and Face:
Head is normocephalic, atraumatic. Facial features are symmetrical with no signs of drooping or swelling.
Skin, and Nails:
The skin is warm and moist. Non-icteric with no swelling or signs of ecchymosis. No rash or lesions on torso, back, or extremities.
Eyes:
Symmetrical OU. PERRLA, EOMs intact with no nystagmus or lid lag. Visual fields full OU.
No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. No discharge.
Ear:
Ears are symmetrical and appropriate in size. No lesions, masses, trauma, or FBs on external ears. TMs pearly white with intact light reflex AU. No foreign bodies, discharge, effusions, perforations, or erythema AU.
Nose and Sinus:
Singular erythematous 1.5×1.5 cm area containing multiple honey-colored vesicles and pustules on lateral aspect of external R nostril. The nose is otherwise symmetrical without masses, deformities, trauma. Nasal mucosa is pink and moist.
Mouth and Pharynx:
The lips are pink with no blisters, fissures, or cyanosis. Tongue and buccal mucosa are pink and moist without swelling. Oropharynx without swelling, erythema, cobblestoning. Tonsils present without swelling, erythema, or exudates.
Neck, Thyroid, and Lymph Nodes:
The trachea is midline without masses or scars. No anterior cervical lymphadenopathy on palpation.
Cardiac:
Regular rate and rhythm, S1 and S2 present on auscultation. No murmurs, gallops, rubs, S3, or S4.
Thorax and Lung:
Lung sounds CTA in all lobes B/L. No adventitious sounds.
Assessment:
9YOM presents with yellow-crusted erythematous plaques localized to the external right nostril.
DDx:
- Impetigo
- Erysipelas
- Molluscum
- Tinea
- Verrucae Vulgaris
Plan:
- Skin Pustules of R nare
- Mupirocin Ointment to R nostril 2x a day for 5 days
- Wash hands before and after application and otherwise avoid contact with the affected area
