HPI: Established 2yo female patient presents with generalized rash that began this morning on the abdomen and quickly spread to bilateral upper and lower extremities. Mother states patient had a cough, runny nose, and fever (highest 103.0) for 3 days prior to rash. Fever resolved yesterday, cough, and runny nose persist. Mother gave patient Tylenol for fever and denies any other OTC or prescribed medications. NKDA or any new environmental allergies. Denies new foods, detergent, soaps, or other possible irritants. Mother states patient is eating and drinking normally, with 4-5 urine saturated diapers, and 2 stools per day. Patient is not itching nor appears to be in any pain (FLACC-0).
OAP: None
MSOH: She was born full term at 38 weeks GA, born via NSVD. No complications during delivery or after birth.
RX: Tylenol as needed for fever.
ALLERGIES: NKDA
PH: Patient has been meeting all developmental milestones. Growing and developing well.
IMM:
- Birth: Hep B
- 2 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B
- 4 months: DTaP, IPV, HIB, PCV13, Rotavirus
- 6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st dose
- 7 months: Influenza 2nd dose
- 12 months: MMR, Varicella, Hep A 1st dose
- 15 months: DTaP, HIB, PCV13
- 18 months: Hep A 2nd dose
FH: Mother 32, healthy. Father, 35, healthy.
SH: Lives at home with mother and father in an apartment.