Reporte zur Charge U6560BA

Symptomtext

Patient presents today via virtual visit for rash. Virtual appointment has been arranged since we are in the middle of COVID-19 pandemic. Mother and patient were the historians. Patient had Gardasil, influenza, meningococcal MCV for PE, and Tdap vaccination on 1/5/2021. Patient went to the emergency room in on 1/10/2021 for a rash that developed on 1/8/2021. The rash developed on bilateral lower extremities. It started on the feet and has been ascending up the legs and is now located on the lower abdomen according to the ED notes. In the ED note the rash was painful and pruritic. According to the ED note the rash itself was very characteristic for Henoch Schoenlein purpura. Patient does not have any abdominal pain but she does have bilateral knee arthralgia. Patient had labs completed which showed mild leukocytosis. Her electrolytes and LFTs were within normal limits. Inflammatory markers including sed rate and CRP were both minimal. UA were worse without any evidence of UTI. There was no proteinuria. She has microscopic hematuria. In the ED she was mildly tachycardic. She received 1 L of IV fluids and her heart rate trend went back to normal. Patient then had follow-up appointment with her doctor on 1/11/2021. Patient had urine analysis completed in the doctor's office which showed trace ketones and trace leuks. Patient's CMP was within normal limits. Patient's CRP was minimal. Patient's sed rate was within normal limits at 15. Patient clinically looks well nontoxic. Mother reports that patient also had leg edema along with a rash which started to go down since the ED visit, however 3 days ago that the leg swelling came back. The rash has not worsened, but it has persisted. It continues to be painful and pruritic. They have not been doing any treatments. Patient denies fever, shortness of breath, dry cough, chills, shaking repeatedly with chills, muscle pain, headache, nausea, vomiting, diarrhea, sore throat, or new loss of taste or smell.