Age: 1.62
Sex: M
Vaccine: DTAPIPVHIB, PNC
Symptoms: Cytomegalovirus test, Diarrhoea, Epstein-Barr virus antibody, Face oedema, Haematocrit normal
Clinical narrative: CHIEF COMPLAINT: Rash and swollen hands and feet.  HISTORY OF PRESENT ILLNESS: This is a 19-month-old male who was well until about a week ago. States that he awoke in the middle of the night about 7 days ago and had emesis. She feels that he likely threw up more than a couple of times during his sleep because there was a large volume of vomitus in his bed. He seemed to be fine then for the next couple of days, then proceeded to have 3-4 loose stools every day since. Mom has noticed no blood in the emesis or the stools. There has been no mucous in the stools. It is just been watery and brown. There has been no fever. She became more concerned when she noticed a rash. It started with a few spots in his inner left thigh 2 days. In the last 24 hours it has progressed to cover his extremities, trunk and face. She noticed some slight edema of the hands and feet and thought his face was a little swollen too so she took him into the Emergency Center last evening on 11/25.  At that point, some blood work was obtained and a white blood cell count was noted to be 10.1 with a hemoglobin of 12.1, hematocrit of 36 and platelet count of 390,000. They performed a rapid strep test which was negative. A sed rate was noted to be 3. Electrolytes revealed a sodium of 142, potassium 5.3, chloride 106 and a bicarb of 27. Glucose was 80, BUN was 19, calcium 9.1. Creatinine was 0.3. Alkaline phosphatase was 205, AST was 33, ALT was 38. Total bilirubin was 0.1, total protein was 6.3 and albumin was 3.5. Dr. called me last evening to discuss the case and it sounded to me that the patient was stable, comfortable, and labs looked reasonable. I advised him to have the parents contact their primary care physician or return to the emergency department if there were further problems. Mom denies any recent use of antibiotics or over-the-counter medications for this patient. The following morning mom felt that the baby had not slept well and seemed to be more fussy. She thought that there was more edema of the hands and feet, although the patient was ambulating. They brought him back into the Emergency Center at which point Dr. was still on staff and elected to transfer the patient down here for us to assess his status in more detail.  REVIEW OF SYSTEMS:  GENERAL: Mom states that he has had reasonable energy level.  HEENT: There has been no discharge from the eyes. No ear pain. Some slight runny nose.  CHEST: Mom says that he has had a slight cough in the past couple of days. There has been no wheezing noted.  CV/HEART: There has been no color changes and no chest pain per say.  ABDOMEN: She feels that his belly has been a little distended in the past 24-48 hours but he continues to have a normal appetite.  GU: She denies any dysuria, urgency or frequency with urination.  MUSCULOSKELETAL/NEUROLOGIC: See HPI above. It appears that he is not in any pain as he is able to ambulate.  SKIN: See above for rash.  PAST MEDICAL HISTORY: He was admitted last January 2009 for what mom describes as flu symptoms; vomiting, diarrhea and dehydration for which he was in the hospital 2-3 days. This was at another facility.  BIRTH HISTORY: He was born near term. Uncomplicated pregnancy. Birth weight was just over 7 pounds.  PAST SURGICAL HISTORY: None.  IMMUNIZATIONS: Are up to date including recent vaccination on 11/18. At that time he did receive his MMR and varicella vaccination.  DEVELOPMENT: Language Development: He has a few words, 6-7 words, per mom. He is walking normally and is starting to run and climb onto furniture. He is interactive with other persons, making good eye contact.  MEDICATIONS: None.  FAMILY HISTORY: Negative for any rheumatologic disease, kidney disease, or vasculitides. SOCIAL HISTORY: Is significant for patient living with his mother as well as mom's female roommate and her young son who is presently ill with vomiting and diarrhea.  PHYSICAL EXAMINATION:  GENERAL: When I arrived to the room the patient was in mom's arms, sitting comfortably, in no distress, playing with his car.  VITAL SIGNS: Temperature was 98.6 by temporal measurement, pulse 125, respiratory rate 24, blood pressure of 117/65 and pulse ox of 97% on room air. Weight is 11.52 kg which places him between the 80th and 90th percentile for weight.  HEENT: Head is atraumatic. Pupils are equal, round, reactive to light. Extraocular muscles are intact. There is no scleral icterus and there is no conjunctival injection or discharge. Nasal mucosa is slightly congested. Tympanic membranes are normal bilaterally. Throat was moist. There are some palatal petechia noted at the junction of the hard and soft palate, but no exudate on the tonsils. Lips are not chemotic. Facies in general appear slightly edematous over on the periorbital regions, see below for skin examination.  NECK:  Supple. Trachea is midline. There is no significant cervical adenopathy. CHEST: Lungs reveal some inspiratory rales throughout all lung fields. It is scattered.  CV/HEART: Regular rate and rhythm. Normal S1 and S2. No murmurs.  ABDOMEN: Soft, nontender, nondistended. Liver span is normal. There is no palpable spleen tip.  GENITOURINARY: Reveals a normal male with descended testicles bilaterally. No edema noted of the testes.  MUSCULOSKELETAL/NEUROLOGIC: Infant is moving all extremities equally. He does not seem to be in pain when I touch his feet or his hands or any other joints. He does have some edema of the feet, ankles and maybe the lower extremities up to the knees. His hands seem to be a little edematous as well.  SKIN: He has blanching erythematous macules and patches over all extremities including some pinpoint macules on the palms and soles. Also noted rash over the facies.  LABORATORY/X-RAY: Please see the history above for labs obtained at the outside institution.  ASSESSMENT AND PLAN: This is a 19-month-old male admitted for rash and diarrhea and edema. The differential is quite long, including infectious etiologies, vasculitis and rheumatologic disease, as well as possible kidney pathology. We will obtain a number of labs including a repeat CBC, comprehensive panel, a sed rate, CRP, ASO titer, blood culture, and throat culture. We will do a urinalysis, likely by catheter specimen given the frequency of the diarrhea. We will do some stool cultures as well as titers for mycoplasma IgM and IgG, cytomegalovirus, Epstein-Barr virus, and Lyme disease (mom states that there are deer around their home but she is not concerned there is known exposure to ticks at this point). We may consider further workup for Rocky Mountain spotted fever, but the patient looks well and there has been no documented fever per say. I think it is very less likely that it is Kawasaki disease given our normal inflammatory mediators and the length of the illness that the patient has shown over the past week. Mom was apprised of the situation and seems to understand that a number of things need to be evaluated, then later when I have some results back I will sit down and discuss them further in detail with her about additional studies. We will do a chest x-ray as well just to assess his lung status because of the cough and rales that I am hearing.