History

CC:

As per mother, “he has a rash on his hands, feet and mouth ” x4 days.

HPI:

This is a 4 year old male with no significant past medical history who presents to the urgent care today with a rash on his hands, feet and mouth x4 days. Mom says that 4 days ago the pt began to complain of pain in his mouth and began eating less than he normally does due to the pain. She noticed some “blisters” on his tongue and lips at that time. She also noticed red bumps and blisters scattered on the pt’s palms and soles of feet. The blisters do not extend proximally to the arms and legs. Mom did not apply any creams or give any medications to help with relief of pain. Pt attends day care, although there is no known exposure to similar rashes in other students, and needs a provider note before returning to school. Pt is up to date with vaccines.

Denies recent illness, fever, cough, sore throat, abdominal pain, diarrhea, nausea, vomiting, drainage from the rash, drooling, hoarseness, difficulty swallowing and itchiness of rash.  

PMHx:

• None
• UTD on vaccines

Medications:

• Denies prescription medication and herbal supplement use.

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Unknown

Social History:

• Pt is a student in daycare and lives in an apartment with his mom, grandma and cousins. They have no pets. Noone in the home smokes. Denies recent travel. Pt sleeps about 12 hours each night and feels rested. He does not participate in any extracurricular activities. His diet is balanced and consists of chicken, meat, fruits, vegetables and healthy carbs. 

ROS:

• General: Admits to eating less due to pain. Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Admits to rash and blisters on hands, feet and mouth. Denies discolorations, moles, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums, epistaxis, nasal congestion and sore throat.
• Neck: Denies stiffness/decreased ROM and localized swelling/lumps.
• Pulmonary: Denies dyspnea, wheezing, cyanosis, cough and hemoptysis.
• Cardiovascular: Denies chest pain.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, dysuria and malodorous urine.
• Musculoskeletal: Denies back pain, muscle pain, joint pain and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Hematologic: Denies anemia and easy bruising or bleeding.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.

Physical

General:

• Well developed, well nourished male in no apparent discomfort. Appears stated age of 4. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP:  105/79 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 100 beats per minute, regular rate, rhythm and amplitude 
• T:  97.2 degrees F (temporal)
• Weight: 45 lbs 

Skin & Head:

• Skin: Warm and moist, good turgor. Nonicteric, no scars noted. Multiple small vesicular lesions on an erythematous base and small pink macules bilateral palms and feet/between toes.  
• Nails: Capillary refill < 2 seconds.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. PERRLA. No conjunctival injection or discharge. No sign of FB or trauma. Fundoscopic exam deferred. 
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Nose/Sinuses:

• Nose: Symmetrical. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Mouth/Pharynx:

• Oropharynx: Well hydrated. No injection, exudate, masses, or foreign bodies. Multiple small yellowish ulcers on anterior portion of tongue. One red ulcer on lower lip. Tonsils present with no swelling, injection or exudate. Uvula midline, pink with no edema or lesions.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. 
• Lymph nodes: No erythema, warmth or drainage of cervical nodes. Non-tender, non-enlarged cervical lymph nodes. 

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with flat contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. Non-tender to palpation throughout, no guarding or rebound noted. 

Differential diagnosis:

• Hand, foot and mouth disease (coxsackie)
  • This diagnosis fits due to the classic presentation of painful vesicular lesions in the mouth and on the hands and feet, which is typical in young children. The child’s age and symptom duration of 4 days also align with this condition. While mild systemic symptoms can occur, the absence of fever does not rule it out.
• Herpangina
  • Herpangina is consistent with the presence of oral ulcers and pain leading to decreased oral intake, and it primarily affects young children. However, it does not explain the vesicular lesions on the hands and feet, making it less likely in this case. The lack of these lesions is a key differentiating factor. Additionally, the lesions of herpangina typically affect the posterior pharynx (tonsils, soft palate) and are associated with high fever. 
• Aphthous ulcers
  • Aphthous ulcers match the oral lesions observed, causing similar pain and reduced eating. However, they do not account for the rash on the hands and feet, which is a critical aspect of the clinical picture. This localization to the mouth alone makes this diagnosis insufficient.
• Bedbug bites
  • Bedbug bites can cause red bumps and vesicular lesions on the skin, which might resemble the rash seen in this patient. However, they typically do not involve oral lesions or systemic symptoms, and there is no known exposure history. Additionally, the patient denies any itchiness, which is commonly associated with bedbug bites, making this diagnosis even less likely.

Assessment 

• 4 year old male with no significant past medical history who presents to the urgent care today with a rash on his hands, feet and mouth x4 days. The rash is associated with decreased intake of food due to pain, rather than loss of appetite. On exam there are multiple small vesicular lesions on erythematous bases and small pink macules bilateral palms and feet. Additionally, multiple small yellowish ulcers on the anterior portion of the tongue and one red ulcer on the lower lip is noted. There are no labs or imaging to review at this time. This pt presentation is most consistent with the diagnosis of hand, foot and mouth disease (coxsackie).

Diagnosis:

• Hand, foot and mouth disease (coxsackie)

Plan

• Hand, foot and mouth disease (coxsackie)
  • Supportive care
    • Ibuprofen or acetaminophen for pain/fever control
    • Maintain hydration
  • Pt education
    • If pt worsens (cannot maintain adequate hydration, develops neurologic or cardiovascular complications) go to the hospital.
    • Hand, foot and mouth disease is extremely contagious (especially between children) via direct contact, respiratory droplets, contaminated surfaces and infected surfaces. Therefore, strict hand hygiene and cleaning of surfaces is imperative to prevent the spread, especially in a daycare setting. 
    • Pt may return to daycare once he is afebrile, feeling up to it and once the blisters have dried up.