Patient Information

• Age/Gender: 2-year-old female
• Chief Complaint (CC): Rash that began this morning on the abdomen and spread to the arms and legs.

History of Present Illness (HPI)

• Onset of Symptoms: Rash began this morning on the abdomen and quickly spread to the bilateral upper and lower extremities.
• Associated Symptoms:
  • The patient had a cough, runny nose, and fever (highest 103.0°F) for 3 days prior to the rash.
  • Fever resolved yesterday, but the cough and runny nose persist.
• Medication:
  • Mother gave Tylenol for the fever.
  • Denies any other OTC or prescribed medications.
• Allergies: No known drug allergies (NKDA) and no new environmental allergies.
• Diet and Hydration: Mother reports the patient is eating and drinking normally.
• Urine Output: 4-5 urine-saturated diapers per day.
• Stool: 2 stools per day.
• Comfort Level: Patient is not itching and does not appear to be in any pain (FLACC-0).

Past Medical History (PMH)

• Birth History: Full-term at 38 weeks gestational age, born via normal spontaneous vaginal delivery (NSVD). No complications during delivery or post-birth.
• Medications: Tylenol as needed for fever.
• Developmental Milestones: Patient has been meeting all developmental milestones. Growing and developing well.

Immunization History (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

Family History (FH)

• Mother: 32 years old, healthy
• Father: 35 years old, healthy

Social History (SH)

• The patient lives at home with her mother and father in an apartment.