2 What is the most likely differential diagnosis and why?___Balanitis___Phimosis___Paraphimosis___Balanoposthitis
3 What is the plan of treatment, referral, and follow‐up care?
4 Does this patient’s psychosocial history affect how you might treat this case?
5 What if the patient lived in a rural setting?
6 Are there any demographic characteristics that might affect this case?
Case 4.1 Rash without Fever
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
A 4‐year‐old female, Abigail, comes to the clinic for evaluation of a rash. She is accompanied to the visit by her mother. According to her mother, Abigail first developed a small, red papule between her nose and her upper lip a few days prior to the appointment today. Her mother thinks that she might have scratched or picked at that area. A few more papules appeared that became fluid‐filled vesicles for a brief amount of time. The fragile roofs of these vesicles quickly sloughed off. The newly eroded skin developed overlying honey‐colored crusts. The patient complains that the rash is sometimes pruritic, so she has been scratching the area. Abigail’s mother feels that the rash is spreading due to Abigail’s manipulation of the area. Abigail has been afebrile and has maintained a normal appetite and activity level by report.
Diet: Adequate and varied.
Elimination: Voids every 3–4 hours. Normal bowel movements daily.
Past medical history: Abigail is a healthy 4‐year‐old with no significant medical history. She does not have any chronic medical problems and has not had surgery.
Family history: One of Abigail’s cousins has a similar rash on her arm. Otherwise noncontributory.
Social history: Abigail and her mother live in a 4‐bedroom duplex with her 2 siblings, a grandmother, a grandfather, an aunt, an uncle, and 3 cousins. There are no pets in the home. Abigail’s mother works part‐time doing housekeeping for a nearby hotel. She reports that she earns minimum wage. Abigail’s father has not been in contact with the family since before she was born.
Medications: Abigail does not take any medications regularly. Her mother has not given her any oral medications to treat this problem. Her mother did apply some over‐the‐counter 1% hydrocortisone cream to the area but does not feel that it helped.
Allergies: Abigail is not allergic to any medications. There are no suspected allergies to soaps, detergents, foods, or other environmental factors.
OBJECTIVE
General: Alert, well‐nourished female in no apparent distress. She appears nontoxic and is coloring pictures calmly during the exam.
Vital signs: Heart rate: 96; respiratory rate: 16; temperature: 98.8°F; height: 40 inches; weight: 42 lbs (19 kg).
HEENT: Moist mucous membranes without ulcerations; nares patent bilaterally without drainage. Conjunctivae clear without erythema or discharge.
Lymphatic: No cervical, supraclavicular, or occipital lymphadenopathy.
Cardiovascular: Regular heart rate and rhythm; no murmur.
Respiratory: Regular respiratory rate with clear and equal air movement bilaterally.
Skin: Mildly erythematous, confluent plaque of eroded skin inferior to nares and superior to upper lip. Honey‐colored crusts overlying the affected area.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Bacterial culture___Bacterial culture of the nares___Examination of Tzanck smear___Fluorescent antibody testing of smears___Fungal culture___Gram stain___Potassium hydroxide (KOH) examination___Viral culture
2 What is the most likely differential diagnosis and why?___Atopic dermatitis___Herpes simplex virus (HSV)___Impetigo
3 What is the treatment plan?
4 What would the appropriate treatment plan for this diagnosis be if the patient were febrile and/or showing other signs of systemic illness?
5 What is the plan for follow‐up care?
6 Are any referrals needed?
7 Should the patient stay out of school and/or day care during treatment? If so, for how long?
8 What, if anything, should be recommended to unaffected household members?
Case 4.2 Rash with Fever
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Seven‐year‐old Aubrey presents to the office with a complaint of a rash for 2 days. She is accompanied by her mother, Jessica. Aubrey has also had a mildly runny nose and cough for 3 days. She has had a low‐grade fever, and her maximum temperature at home was 37.9°C (oral). Aubrey has had no vomiting or diarrhea.
Diet: Normally has a balanced diet with enough dairy, protein, fruits, and vegetables. There has been no change in appetite since her symptoms began.
Elimination: Voiding well with no complaints of dysuria.
Sleep: Sleeps approximately 9 hours at night and has no problems falling asleep or staying asleep.
Past medical history: Aubrey was born via cesarean section at 38 weeks’ gestation for a breech presentation. Since being discharged home at 4 days of age, she has had no hospitalizations. Aubrey had an emergency department visit at 5 years of age for sutures to her head after she fell and struck her head on the corner of a table. She has had no injuries or illnesses since that time
Family history: Aubrey’s mother (34 years old) has a history of migraine headaches. Her father (30 years old) is healthy and has no history of chronic medical conditions. Her 5‐year‐old sibling has Type 1 diabetes. Her maternal grandmother (68 years old) has Type 2 diabetes. Her maternal grandfather (68 years old) has a history of chronic obstructive pulmonary disease (COPD). Aubrey’s paternal grandfather (58 years old) has a history of skin cancer. Her paternal grandmother (53 years old) has hypertension.
Social history: Aubrey currently attends elementary school. She is in the second grade and is doing well, according to her mother. Aubrey lives at home with her parents and her 5‐year‐old sibling. Her father is a graduate student, and her mother is an accountant. The family has a pet rabbit.
Medications: Aubrey is not currently taking any over‐the‐counter, prescription, or herbal medications. Aubrey has no known allergies to food, medications, or the environment. At her last well‐child check, her mother refused the annual flu shot and the second varicella vaccination because Aubrey had a cold. The family did not return to the office to receive these 2 vaccines.
OBJECTIVE
General: Aubrey is alert, active, and cooperative. She appears