Talia Bardash 

Name – LC

Age – 12-month-old

Gender- Male  

Race – Caucasian

Date – 2/24/21

Time – 4:45 p.m.

Location – Premier Pediatrics

Source of information- Mother and Father (Reliable)

Mode of transport – Personal vehicle

CC: “He has a high fever and rash all over his face and body.” x2 days 

HPI: LC is a 12-month old white male who presents to the office due to a high fever and a maculopapular rash that covers his face and body. The patient has had the fever and rash for the last two days. LC came to the office on 2/22 because of a fever of 101 F and a slight rash on the back of his arms. On that visit the patient admitted to vomiting and a stuffy nose. The patient received an MMR vaccine on 2/13 in the office. Parents state that he has had a fever of 103.5 F since Sunday. They say that they went to wake the child up to find that the rash had spread to his face and now covers the trunk and is present on both arms. They gave him Motrin and they see that today the fever is slowly breaking. Parents note that the rash, however, seems to be getting more prominent as the day progresses.  Parents admit that the child is slightly more irritable than normal and is scratching the rash. Parents deny diarrhea, cough, vomiting, or changes in diet. Parents deny any other person at home that is sick or any recent travel. 

PMH

Current Illness- None

Past Medical Illness – Eczema 

Surgeries- None

Allergies- None  

Medications – None

Immunizations – Up to date

Hospital – LC has never been hospitalized

Injuries – LC has had no injuries

Diet – Diet has not changed. Still receiving 8 ounces of formula. 

Past Family/ Social History

Father – Has Multiple Sclerosis

Mother – Alive and well  

Illness – No one at home is sick

Smoking – No one smokes at home.  

Pets – Dog

Siblings – None

School- Does not attend.  

Home- Lives at home with parents.

Travel – Has not traveled recently.

ROS

General – Admits to fever that has now resolved due to medication. Denies weakness, wheezing, and weight loss or gain, chills, or fatigue.   

Skin- Rash that has significantly increased from just the back of his left arm and now covers his entire trunk, arms, face, legs and toes. The rash is slightly itchy.

Head- No trauma, head is symmetrical and no jaundice noted. Denies sinus tenderness.

Ears – Denies any hearing changes or ringing in the ears.  

Throat- Denies swollen glands or throat pain.

Respiratory – Denies any difficulty breathing or abnormal breath sounds.

Cardiac- Denies any history of murmurs or palpitations.

GI- Denies any changes to GI.   

GU- Denies any changes to GU.    

MSK – Denies swollen areas or painful joints.

Neuro -Denies any dizziness, changes in hearing, and walking.

Psych- Denies emotional problems.

Physical Exam

General – Patient is alert and oriented, seems to be in no apparent distress, but slightly irritable.

Weight- 22 lbs.

Temp – 97 F tympanic

Skin-  Maculopapular red rash that covers bilateral arms, trunk, and cheeks, legs and toes.

Ears – Tympanic membranes are clear- no redness or bulging noted.   

Mouth/Throat- No redness noted.  

Thorax – Chest is clear bilaterally

Cardiac- No murmurs or palpitations noted.

Abdomen- Abdomen is soft, no tenderness noted.

Summary statement: LC is a 12-month old white male who presents to the office due to a high fever and a maculopapular rash that covers his face and body.

Problem: 

1.      Pyrexia

2.      Rash   

Assessment:

1.      Reaction to MMR Vaccine 

2. Viral Exanthem – (Roseola)  

Plan:

1. Ensure that the patient stays hydrated and provide supportive care. 
2. If fever becomes elevated again Tylenol and Motrin can be switched off every 3 hours. With the child’s weight the dosage of Tylenol would be 1 teaspoon and the dosage of children’s Motrin would also be 1 teaspoon.