Patient Information:
Name: A.P. Age: 13-year-old Race: Hispanic
Gender: Female Insurance: Private
Chief Complaint (CC): "My daughter has been having intense scalp itching”.
Subjective:
History of Present Illness (HPI): A.P is a 13-year-old Hispanic child who is reported for
intense scalp itching (pruritus) and presence of nits and live lice for the last six days. The child
stated that itching is all over the scalp and occurs randomly and worsens at night. Her mother
explained that she had not administered any anti-itching, or anti-lice drugs.
Past Medical History (PMH): According to the mother, A.P. has no serious health issues.
Current Medications: She hasn't been administered any drug concerning itching and lice.
Medication Intolerance: No history of medical intolerance.
Allergies: No previous history of allergies was reported.
Immunization Status: Immunizations were updated with the shots of COVID-19 vaccine last
month.
Hospitalizations/Surgeries: The mother rejected any previous surgical treatment or
hospitalization.
Family History:
Father (dead): Attempted suicide at the age of 41 due to financial issues.
Mother (alive): 37 years old and healthy.
Maternal Grandparents (alive): Grandmother is 73 years old and diagnosed with diabetes
Mellitus and grandfather is 70 years old and healthy.
Paternal Grandparents: Grandmother is 70 years old and healthy, and grandfather is 71 years old
diagnosed with hypertension.
Social History: A.P. is the only child who lives in Beverly Beach in her own home near the
beach, with her maternal grandparents and her mother. She is very disciplined and goes to the
school that is close to her home.
ROS (As the child is too young to involve in health assessment, mother provided all details)
Constitutional: Mother denies the patient's weight changes, malaise, night flashes, and pyrexia
during the last few months.
Skin: The patient denies skin lesions, acne, dry skin, nodules, and eczema. The patient reports
intense itching in her scalp that is severe at night and that she has white nits and lice in her hair.
The patient reports pain by scratching the scalp.
Eyes: Denies eye irritation, conjunctivitis, and abnormal lacrimation bilaterally.
ENMT: Denies sinus pressure/congestion, sinus pain, mucus discharging from the nose,
epistaxis, sore throat, general mouth problems, changes in taste, dry mouth, pain, sores, issues
with gums, tongue, or jaw, difficulty swallowing, voice changes, or swollen nodes.
Cardiovascular: The patient denies tachycardia, bradycardia, palpitations, orthopnea, or chest
pain.
Respiratory: The patient denies rhinitis, dyspnea, hemoptysis, cough, or secretions.
Gastrointestinal: The patient denies appetite changes or abdominal pain. Reports regular bowel
movements.
Genitourinary: The patient denies pain or burning during urination, genital lesions, hematuria,
or discharges.
Musculoskeletal: The patient denies bone fractures, muscle injury, malaise, cramps, spasms.
Integumentary: No nail clubbing or other deformity.
Neurological: The patient denies dizziness, migraines, tremors, and disorientation.
Psychiatric: No insomnia, depression, anxiety, hallucinations, and delusions are reported.
Endocrine: No hirsutism, sweating, cold intolerance, anorexia, mood changes, excessive
appetite.
Hematologic/Lymphatic: The patient denies easy bruising, epistaxis, rectal or urethral bleeding,
anemia, and lymphadenopathy.
Allergic/Immunology: Patient denies (mother confirms) no allergies to food or medications.
Objective:
Physical examination
Temp: 97.8°F (36.6°C) oral, Radial Pulse: 89, Resp: 29, BP-Sitting- 109/76, Weight: 100lbs
(44kg), Height: 61 ft 4 inch (157 cm), SpO2: 98.7% on RA, BMI 18.6 kg/m2, Growth
curve: appropriate. Pain rate: 8/10.
General: Well-developed and well-nourished, oriented X 4, and cooperative.
Eyes: Conjunctiva, iris, and pupils are intact. The sclera is white and clear.
HNMT: Normocephalic, atraumatic, facial muscles normal tone, no lesions, no rashes, no
deformities, or dandruff to the scalp. Itchy and red watery eyes, presence of thick purulent
discharge and blurred vision. PERRLA. Symmetrical and bilateral ears. Pinnae normal with no
rashes, no masses, no scars bilateral. TMS gray, non-bilging, freely mobile bilateral nares. Good
dentation, no foul breath, pink, and oral mucosa pink and moist. No erythema on the posterior
oropharynx, no lesions, no exudates, no cobble stoning. Midline tongue.
Chest/Lungs: Denies dyspnea, no accessory muscles, pectoriloquy, present normal breath
sounds, lungs clear bilaterally on auscultation.
Heart/Peripheral Vascular: Auscultation: normal heart sounds, S1 S2, regular rhythm, no
murmurs, no rubs or clicks.
Abdomen: Abdomen round, symmetric, no visible masses, scars, or lesions. No palpitation or
guarding.
Genital: Deferred.
Musculoskeletal: No muscle mass, pain, or deformity is present. Strength 5/5 in all extremities
with the full range of motion.
Skin: Presence of sores on the head as a result of scratching.
Neurological: All nerves are intact, and deep tendon reflexes are present.
Psychiatric: Mood and verbal responses are appropriate to the clinical situation.
Assessment:
• Atopic dermatitis (ICD-10 L20.9): The term atopic dermatitis or eczema collectively
describes various skin disorders characterized by pruritus and inflammation of the skin.
The skin becomes dry, red, itchy, and bumpy. Early in its presentation, it is erythematous
with papulovesicular lesions that ooze and crust (Nankervis et al., 2017). Some of the
signs of atopic dermatitis are similar to Pediculosis, like itching and acute maculopapular
lesion; therefore, A.P. can be differentially diagnosed with Atopic Dermatitis, but A.P.
has red erythematous macules in the scalp, white nits, and lice in her hair which is not the
diagnostic hallmark of Atopic Dermatitis.
• Impetigo (ICD-10 L01.00): A superficial vesiculopustular and contiguous skin infection
commonly persists among children. The most common symptom of Impetigo is pruritus
from the lesions (red, itchy sores that break open and leak a clear fluid or pus for a few
days). During the initial stages, the disease resembles various other skin disorders
because plaques form as vesicles. The roofs of plaques break down and leave shallow
erosions with yellowish crusts (VanRavenstein et al., 2017). The secondarily infected
skin lesions in Pediculosis resemble Impetigo, most specifically crust, and erythema.
Therefore, A.P. can be differentially diagnosed with Impetigo, but A.P. has white nits and
lice in the hair shaft. Additionally, leaking a clear fluid or pus from erythema is also
absent, which is prominent in the case of Impetigo.
• Seborrheic Dermatitis (ICD-10 L21.9): This is another prevalent skin disease clinically
manifested with the symptoms of intense scalp itching, red patches, and greasy scales on
the skin. It also presents crusty yellow or white flakes on the scalp (Hoi, 2020). Because
intense scalp itching (pruritus) is a common symptom, A.P. can be differentially
diagnosed as a patient of Seborrheic Dermatitis. Still, she neither has red patches and
greasy scales nor crusty yellow flakes on the scalp. Additionally, she presents the white
nits and lice in the hair shaft.
Primary Diagnosis:
• Pediculosis Capitis (ICD-10 B85.0): 6-12 million of the American population is
diagnosed with Pediculosis annually and the disease is most prevalent among school-age
children (van der Wouden et al., 2018). The lice are blood-obligate parasites that feed and
reproduce on the human scalp. The infestation is due to direct head-to-head contact: lice
from the hair of one person transfer to another person's hair (van der Wouden et al.,
2018). The disease presents with the intense itching scalp (worsens at night), red
erythematous macules and nits, and lice in the hair. The diagnosis of Pediculosis is based
on both the history of pruritus and the finding of white nits or lice on the hair shaft. The
physician must look for nits or lice in the area of pruritus (van der Wouden et al., 2018).
During A.P.'s assessment, nits and lice are found in the hair shaft (Wood’s light
examination), red erythematous macules, and intense itching (pruritus) were also present.
Therefore, the patient is diagnosed with Pediculosis.
Plan:
Pharmacological Management:
• Permethrin (Nix) 1% cream applied on hair daily up to 5-7 days. Permethrin not only
kills the nits and lice but is also effective in treating pruritus and erythema. It is reported that 20-
30% of nits are killed first (van der Wouden et al., 2018). When using Permethrin cream, care
should be taken to avoid contact with the eye, nose, or mouth. Shower after 8 to 14 hours to
remove the cream. In case of contact, they should be rinsed with plenty of water. If irritation
persists, consult a doctor.
Non-Pharmacological Management:
• Manual delousing and eliminating nits with a fine-toothed comb proved highly effective
(Cummings et al., 2018).
Additional Diagnostic Test:
• Additional testing is not recommended.
Education:
• Keep the scalp and hair clean with frequent washing and avoid sharing hats, combs,
scarves, headsets, towels, and bedding with others.
• Bedding must be washed and dried at high temperatures.
• Vacuuming of furniture and carpets is recommended.
• Brushes, combs, barrettes, and other hair accessories should be soaked in hot water for at
least 5 to 10 minutes.
Referral:
• No referral is required.
Follow-up:
• Mother is instructed to report after seven days if the symptoms persist or worsen.