HPI: Patient is a 2 year old female who presents with a
cough and runny nose that have lasted 3 days, a fever for the
last 3 days that broke after administration of Tylenol, sudden onset rash
on the abdomen that spread to chest and extremities, and irritability.
No alleviating or aggravating factors. Patient goes to daycare.
:Questions
1. How can I help her today
2. Does she have any other symptoms or concerns we should discuss .2
3. On what part of her body did the rash start and where did it spread .3
4. Has she been having fevers .4
When did her fever start .5
Did she have any other problems two to four days before the rash started .6
What treatments has she had for her rash .7
Does she have any allergies .8
Is she taking any over the counter or herbal medications .9
Is she coughing up any sputum .10
How high is her fever .11
Is her rash painful or itchy .12
What treatments has she had for her cough .13
How many stool diapers does your child have per day 14
How many wet diapers does your child have per day 15
Have is her appetite? Any recent changes .16
Any contact with people with similar symptoms
Physical Exam
HR: 75, regular, normal
RR: 22, regular,
unlabored
BP: 90/62, normal, normal
A and O X 4
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