Identifying Data:
Full Name: LR
Address: Jamaica, NY
Date of Birth: xx/xx/2012
Date & Time: 5/11/2022
Source of Information: Self and mother
Reliability: Reliable
Chief Complaint: “tiny brown spots on arms” x 3 months.
History of Present Illness:
10-year-old male with no PMH was referred by primary care physician due to concern for petechiae. Patient c/o non-itchy, painless brown spots over both hands, arms, and over the bridge of the nose since February 2022. Patient’s mother states that she first noticed the spots on his nose, then when she searched his body, she found more spots on his hands and arms. She states that there has been no change in size or number since they first noticed them. Patient is otherwise eating, drinking, and behaving normally. No additional drainage, bleeding, or bruising around the area. Denies trauma, injury, recent illness, sick contacts, traveling, history of gum bleeding, epistaxis, or abnormal bleeding with injury. Denies family history of bleeding disorder.
At initial evaluation in 4/2022, platelets (376 K/uL) were WNL with mildly prolonged PT (13.8 sec).
Past Medical History:
Denied past medical history
Immunization uptodate
Received flu shot and 2 COVID vaccine (Pfizer) last year
Past Surgical History:
Denied past surgical history or dental procedures
Medication:
Denied medication use
Allergies:
NKDA
Family History:
Mother – alive and well
Father – alive and well
Denied family history of bleeding disorder
Social History:
Habits: Denied alcohol, tobacco and illicit drug use.
Travel: Denied recent travel.
Occupation: Patient goes to 3rd grade.
Home: Living with parents. Independent in all ADLs and IADLs.
Diet: Reported that he consumes a balanced diet.
Review of System:
General –Denied decreased appetite, recent weight change, fever, and night sweats
Skin – Small brown spots on hands, arms, and bridge of the nose
Head – Denied headache, light-headedness, recent head trauma.
Eyes – Denied visual changes.
Ears – Denied tinnitus, deafness, pain.
Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.
Mouth/throat – Denied sore throat, mouth ulcers, voice change.
Pulmonary system – Denied SOB, sputum, wheezing.
Cardiovascular system – Denied chest pain, palpitation, syncope.
Gastrointestinal system – Denied abdominal pain, nausea, vomiting, diarrhea
Genitourinary system – Denied urinary frequency, urgency, and oliguria.
Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.
Musculoskeletal system – Denied joint pain, back pain, muscle pain.
Endocrine system – Denied polydipsia, polyphagia, heat intolerance, or excessive sweating.
Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
Temp: 98.3 F, temporal
BP: 102/64, LA, sitting
Pulse: 75, regular
RR: 18/min, unlabored
O2 saturation: 100% room air
Ht: 4’5’’ in
Wt: 87 lb
BMI: 21.87 kg/m2
General – AAO X3. Not in acute distress. Appears his stated age. Well developed and well groomed.
Skin – A few petechial lesions scattered over the bridge of the nose, and back of the hands and forearms. No associated tenderness. Skin iswarm and dry, good turgor. No jaundice.
Hair – Average quantity and distribution
Nails – No clubbing, capillary refill <2 seconds on fingers and toes.
Head – Normocephalic, atraumatic.
Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex.
Eyes – Symmetrical OU. EOMs intact with no nystagmus. No pallor, or scleral icterus.
Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.
Neck – Supple. No lymphadenopathy. No cervical adenopathy noted.
Lungs–Clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Heart – RRR, S1 and S2 are distinct, no murmurs, click or rubs.
Abdomen –Abdomensoft, non-distended, BS present. No signs of splenomegaly or hepatomegaly. No CVA tenderness.
Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation.
Neurologic – Sensation intact to touch in bilateral upper and lower extremities.
Peripheral Vascular – Extremities are symmetric in color, size, and temperature. No lymphadenopathy.
Labs from 4/2022
- WBC: 6.64
- RBC: 4.35
- HGB: 12.0
- HCT: 36.3
- MCV: 83.4
- MCH: 27.6
- MCHC: 33.1
- RDW: 12.7
- PLT: 376
- Neutrophil %: 45.0
- Lymphocyte %: 42.3
- Monocyte %: 5.4
- Eosinophil %: 6.0
- Neutrophil Abs: 2.99
- Lymphocyte Abs: 2.81
- Monocyte Abs: 0.36
- Eosinophil Abs: 0.40
- Basophil Abs: 0.05
- Immature Gran %: 0.5
- PT: 13.8
- INR: 1.2
DDx:
- Vitamin K deficiency
- Viral infection induced petechiae
- Local physical pressure/accidental injury
Assessment:
A 10-year-old male with no PMH was referred to the hematology clinic due to concern for petechiae for 3 months. Petechiae are noted on both hands and arms, and over the bridge of the nose. Per patient’s mother, the size and number of petechiae have been consistent over the past 3 months. Denies any personal or familial bleeding history. The patient is not on any medication and is otherwise healthy, making medication effects and active infection unlikely. Initial evaluation from 4/2022 showed normal CBC, which r/o thrombocytopenia. PT was mildly elevated at 13.8 sec. Symptoms are most likely from past viral infection vs. vitamin K deficiency.
Plan:
- CBC w/diff
- PT/PTT – if continue to be abnormal, will check the level of clotting factors
- EBV, CMV titers to r/o history of infection
