By Hannah Kotler MD, Children’s National Medical Center

HPI:

18mo healthy male presenting with 3 days of fever (Tmax 101.5), associated with fatigue, decreased urine output (3-4 wet diapers daily), and non-bloody loose stools. He had a negative COVID test performed by his PMD. Referred by PMD for MISC workup. 

ROS:

Constitutional symptoms: Fever, Diapers:: Decreased amount, Oral intake:: Decreased appetite, taking liquids well, denies chills, denies fatigue. 

Skin symptoms: denies jaundice, denies rash, denies diaper rash. 

Eye symptoms: denies pain, denies discharge, denies redness. 

ENMT symptoms: Ear pain: Has been tugging his ears.. 

Respiratory symptoms: denies shortness of breath, denies cough, denies wheezing. 

Gastrointestinal symptoms: no abdominal pain, no vomiting, no diarrhea, no constipation. 

Neurologic symptoms: no seizure, no altered level of consciousness. 

Hematologic/Lymphatic symptoms: bleeding tendency negative, no petechiae, no gum bleeding, no swollen nodes. 

PE:

General:  Alert.  appropriate for age.   

Skin:  Warm.  pink.  intact.   

Neck:  Supple.  no lymphadenopathy.   

Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.  no discharge.  no jaundice.   

Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.  Right TM: Redness and no light reflex. Left TM: WNL..  Yellow mucus over the nostrils..  

Cardiovascular:  Regular rate and rhythm.  No murmur.  No gallop.  Normal peripheral perfusion.  Extremity pulses equal.   

Respiratory:  Lungs are clear to auscultation 

Musculoskeletal:  Normal ROM.  moves all extremities.   

Gastrointestinal:  Soft.  Nontender.  Non distended.  Normal bowel sounds.  No organomegaly.   

Genitourinary:  Normal genitalia for age.  no tenderness.  no discharge.   

Neurological:  Developmentally normal 

Lymphatics:  No lymphadenopathy 

Patient was discharged home without additional testing, with a diagnosis of likely viral acute otitis media. 

He returns 4 weeks later, complaining of intermittent fever for 1 month, typically worse at night. His mother has been checking temp multiple times throughout the day and it ranges from 99-101.8. He is in daycare, and they keep sending him home due to fever. Mother has also noted “bugbites” on shin since yesterday though they don’t appear itchy. Has been tested for COVID multiple times and has been negative. He has no URI symptoms and his loose stools have resolved.  Stools have never been bloody. No easy bleeding or bruising that mother has noted, no lumps/bumps or swollen nodes. 

Vitals: P 160, T 37.8, SPO2 100%, BP 92/60

Physical exam within normal limits except for the below rash, which is nonblanching and located only on the anterior shins. The lesions are raised and tender to the touch. There are no other petechiae, bruising, or other lesions anywhere else on the body. 

Results:

CBC: 16.15>10.8/31.3<381

Diff: 49%N, 37%L, 10% Monos, 3% Reactive lymphs, 1% Myelocytes, no bands, ANC 7910. 

ESR 49, CRP 1.02

D-Dimer 0.75

Na 137, K 3.6, Cl 105, CO2 23, BUN 9, Cr 0.21, Glucose 110, Ca 9.2,

Albumin 3.2, AST 28, ALT 26, ALK 209, Bili 0.2

BNP 192,Troponin <0.02

UA- 3 RBCs, 7WBCs, <1 epi, neg for protein/glucose/nitrites/bacteria, SG 1.028

His heart rate improves with time in the department and he passes a PO challenge. He is able to ambulate.