IHUMAN CASE STUDY:WEEK 6‘‘A 2
Y/O FEMALE PATIENT WITH RASH THAT
BEGAN THIS MORNING ’’ 2022-2023
VERSION/A+ GRADE
Week 6 iHuman notes
CC:
... [Show More] Rash that began this morning on the abdomen and spread to the arms and legs
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 forfever.
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.
GC: Recent fever 103.0 thatsubsided yesterday, current fever-no. Denies weight gain/loss, malaise,
change in eating/drinking habits, night sweats, and insomnia.
SB: Recent rash began on abdomen this morning and spread to A4E, denies itching.
HEENT: Current nasal congestion, and cough. Denies eye redness/discharge,sore throat, and earache.
CARDIO: Denies SOB or irregular heartbeat.
RESP: Nonproductive cough for 3 days. Denies SOB, or difficulty breathing.
GI: Denies vomiting, diarrhea, constipation. 2 normalstools daily.
GU: Wears diapers. No history of UTI [Show Less]