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 well hydrated and well nourished.
Vital signs: Weight in the office today is 33 kg. Her temperature is slightly elevated at 37.9° Celsius (oral).
Skin: A predominantly maculopapular rash is noted on her back and chest. Two vesicles are noted on the upper right side of her chest. There is no rash noted elsewhere in her body. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted. Skin has elastic recoil.
HEENT: Normocephalic; red reflexes are present bilaterally; and her pupils were equal, round, and reactive to light. There is no ocular discharge noted. Aubrey’s external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, both tympanic membranes are gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Aubrey’s mucous membranes are noted to be moist when examining her oropharynx. There is no inflammation of her tonsils, and there are no oral lesions noted.
Neck: Supple and able to move in all directions without resistance. There is no cervical lymphadenopathy noted.
Respiratory: Rate is 20 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiac: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. No evidence of hepatosplenomegaly.
Genitourinary: Normal prepubertal female genitalia.
Neuromusculoskeletal: Good tone and full range of motion of all extremities; extremities are warm and well perfused. Capillary refill is less than 2 seconds. Spine is straight.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Tzanck smear___Viral culture___Direct fluorescent antigen testing___Varicella polymerase chain reaction___Potassium hydroxide (KOH) smear___Throat culture for group A beta‐hemolytic streptococci (GABHS)___Nasal swab for influenza
2 What is the most likely differential diagnosis and why?___Varicella zoster virus (breakthrough)___Herpes zoster___Scarlet fever___Viral exanthem___Lyme disease___Tinea corporis
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 4.3 Red Eye
By Andrew Konesky, MSN, APRN
SUBJECTIVE
Will, a 12‐year‐old male, was referred to the school‐based health center (SBHC) at the request of his mother for a red right eye, noticed this morning upon awakening. Will reports waking up this morning with his right eyelid “stuck together like glue.” He reports washing his face and eyes with warm water, allowing him to open his eye. He noticed his eye was “a little red,” but did not report any pain or itch. He has had to wipe his eye a few times since washing his face, as “yellow stuff keeps coming out.” Will reports wearing glasses daily and has never worn contact lenses. He is experiencing no visual disturbances and denies blurriness and double vision. Will’s mother was contacted by the SBHC to provide confirmation of history and further details. His mother denies sick contacts at home, but Will’s cousin, whose house he slept at over the weekend, was given “eye drops” last week by his primary care provider.
Birth history: Will was born full term. His birth weight was 8 lbs 5 oz and birth length was 20 in.
Past medical history: Will has seasonal allergies, which are exacerbated every fall, that are well controlled on daily allergy medication. He has myopia and has been wearing glasses since age 6. He had an appendectomy 2 years ago when he was 10 years old. He has multiple visits to the SBHC for acute, unrelated presentations. He has no further significant history, hospitalizations, or surgeries.
Social history: Will lives with his mother, father, and older sister in a single‐family house. Will is in the seventh grade and plays on the school lacrosse team. He wants to one day be a professional lacrosse player. He is also the team manager for the town’s local hockey team, and enjoys art and music in his spare time. Will has multiple friends at school and a few close friendships.
Diet: Will eats 3 meals a day and reports a normal appetite. He consumes a varied diet of fruits, vegetables, dairy products, and protein sources.
Elimination: Denies difficulty going to the bathroom. Reports regular bowel patterns.
Sleep: Sleeps an average of 8 hours per night. Denies nighttime awakenings, snoring, and restlessness.
Family medical history: Will’s family history is positive for heart disease on his father’s side; his father had a myocardial infarction several years ago. His father may have high blood pressure, but he is not sure. Will denies family history of cancer and or diabetes. His paternal and maternal grandparents are alive and well. He is unsure of his grandparent’s medical history.
Medications: 10 mg Zyrtec daily, Naphcon allergy eye drops as needed, daily multivitamin.
Allergies:
