C A S E F I L E A Rash of Symptoms I was a newly graduated nurse working in the emergency room of a large urban children’s

A Rash of Symptoms
I was a newly graduated nurse working in the emergency room of a large urban children’s hospital when Dale was brought in by his mother. Dale was a 6-year-old who, until a few days prior, had been very healthy. Dale’s mother told the triage nurse that Dale was very sick and had a rash “all over.” As was policy, Dale was given a mask to wear because he was coughing and was sent back out to the waiting room after having a brief history taken and a set of vital signs.
Dale had been triaged as urgent due to his cough, high fever, and elevated heart rate, so it wasn’t long before I called Dale to an exam room to perform a more in-depth history and head-to-toe assessment. According to Dale’s mother, Dale had initially complained of a sore throat. Within a day, he also complained of a headache and developed a high fever, which his mother treated appropriately with acetaminophen. He then developed a cough, which his mother assumed was part of a “bad cold.” She was not overly concerned until Dale developed a rash, which started on his face and head and rapidly spread to his chest and back, and then to his arms and legs.
I had Dale’s mother undress him and put him in an examination gown, and it was only then that I realized the extent of Dale’s rash. It was winter and Dale had been covered in clothing from head to toe, having only his jacket removed when seen by the triage nurse. Dressed in a gown, I saw that Dale’s mother was not exaggerating-Dale’s rash covered almost all of his body. It was a maculopapular rash and did not look like any childhood rash that I had ever seen, before or since.
The physician on duty came in to see Dale and immediately asked Dale to open his mouth. She asked the mother about Dale’s immunizations, and his mother admitted that she did not believe in immunizations and Dale had never been immunized. The physician then turned immediately to me and asked me to put Dale in an isolation room. Upon my return, she spoke to Dale’s mother, and I will never forget what she said: “Well, it was a very bad decision to not have Dale immunized, because now he has the measles. Not only does your son have the measles, but by bringing him here you exposed everyone in the waiting room to what can be a life-threatening illness.” She then ordered a chest X ray and blood work to confirm the diagnosis and said that she would immediately notify the state health department.
• Why was a chest X ray performed?
• Why was the state health department contacted?

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