1. ABAD.IMPERIAL.JAVATE. PALMA.UY, R. VALENCIA A Curious Case of Rashes

2. General Data Name:N. E. Age:9 Gender:F Nationality:Filipino Civil Status: Single Religion:Roman Catholic Occupation:Student Address:Antipolo, Rizal Informant: Patient and parents Reliability:Good

3. Chief Complaint Abdominal Pain Rash

4. History of Present Illness 2 weeks prior to admission,  fever that spontaneously resolved with paracetamol 4 Days Prior  Productive cough  Sought consult and was prescribed Amoxicillin  Developed rashes on her ankles that night  Mother gave antihistamines which reduced the redness but not the number 3 Days Prior  Noted increase in number of rashes

5. History of Present Illness 2 days Prior,  mother noted that the patient was complaining of pain on her left ankle One Day Prior  One episode of vomitting, followed by generalized abdominal pain described as crampy  Sought consult CBC showed normal findings Prescribed Maalox Abdominal Pain was waxing and waning A few hours prior  Abdominal pain became severe (10/10)  Sought consult at TMC Satellite and was advised admission

6. Other Pertinent Findings RoS – On and Off cough Past Medical History  No previous hospitalizations  Had “pneumonia”  Did not seek consult  Resolved upon using nebulizer 3 times Immunization History  Had: BCG, DPT/Polio, Hep B, MMR, Measles Varicella  Did not have: Pneumococcal, Influenza, Rotavirus, Hep A, Typhoid  Unknown: HiB

7. HEADSSS Home: Patient lives with the parents. Has an older sibling (Grade 7). Gets along well with family members Education: Incoming Grade 4 student in LaSalle Antipolo Activity: Doesn’t go outside to play. Stays at home and plays computer games most of the time Drugs, Sexual Activity, Substance Abuse not asked Safety: Patient feels safe at home and doesn’t perceive any threat to her well being

8. FINDINGS INITIAL ASSESSMENT PLAN Course in the ER

9. Findings Subjective – CC: Abdominal Pain – 2 weeks prior – Fever spontaneously resolved with Paracetamol – 4 Days prior– Cough. Consulted and was given Amoxicillin. Developed rash during the night – 3 Days prior – number of rashes increased. Amoxicillin started – 1 Day prior – Abdominal Pain. Sought consult. Given Maalox – A few hours – Persistence of symptoms. Sought consult in the ER – Child also complained of ankle pain/ heel pain

10. Findings Objective  T 37.1 HR 84 PR 19 BP 100/70 W 25.7 kg H 134 cm  Pale and ill-looking  Multiple erythematous non-blanching maculopapular rash on ankle  Generalized tenderness on deep palpation of abdomen  No rebound tenderness

11. Initial Assessment Primary Impression  Henoch Schonlein Purpura Differentials  Systemic Lupus Erythematosus  Wegener’s granulomatosis

12. DifferentialsRule InRule Out Henoch-Schönlein Purpura The American College of Rheumatology 1990 criteria for the classification of HSP aimed to identify diagnostic criteria to differentiate HSP from other vasculitic diseases: The four criteria identified, of which two are necessary to make the diagnosis, are:  age < 20 years at onset  palpable purpura  “bowel angina” (diffuse or colicky abdominal pain or bowel ischaemia usually with bloody diarrhoea)  biopsy evidence of granulocytes in the walls of arterioles or venules Hallmark of the disease: pinkish maculopapular rash that turns into a palpable purpura and petechiae Presence of joint pain in the ankle Systemic Lupus Erythematosus The triad of fever, joint pain, and rash in suggest the diagnosis of systemic lupus erythematosus (SLE). These three symptoms are the usual or common manifestations of patients with SLE. However, a person can be diagnosed with SLE if any 4 or more of the 11 criteria of the diagnostic criteria for SLE are present, serially or simultaneously, during any interval of observation. - American College of Rheumatology Wegener’s granulomatosis Presence of nonspecific constitutional symptoms such as fever and arthralgia Cutaneous lesions include palpable purpura and cough may be a symptom present later on The frequency of different system involvement is respiratory tract in 87% of cases, kidneys in 53%, joints in 53%, eyes in 53%, skin in 53%, sinuses 35%, and nervous system in 12%.

13. Plan Admit to ward for further assessment and management

14. HISTORY AND PHYSICAL EXAM FINDINGS IN THE WARD PROGRESS NOTES Course in the Ward

15. Progress Notes

16. Problem List

17. DIFFERENTIALS PRIMARY IMPRESSION PATHOPHYSIOLOGY Diagnosis

18. DIAGNOSTIC PLAN TREATMENT PLAN Henoch Schonlein Purpura

19. Public Health Aspect