Sample Pediatric History and Physical Exam

History of Present Illness:

Cortez is a 21-day-old African American male baby who developed LBCH with a 1-day rash on his
abdomen. Cortez's mother said her baby seemed healthy from discharge from daycare until 1 day before
the performance, September 5, when he noticed an elevated erythematous rash on Cortez's abdomen. She
too noticed that her baby vomited her breast milk after three meals. Consequently, she changed formula,
which he handled without vomiting. There were no rashes anywhere else on his body. On the morning of
the presentation, she noted that the rash had filled with fluid and spread throughout the entire area of the
anterior diaper, including the groin region and the upper left and right thigh. However, grandma said that
Cortez was a little more irritable today.

ROS:
CONSTITUTIONAL: No fever, weight loss. Grandmother reported increased irritability.
EYES: Seems to have difficulty focusing at distances.

Immunizations:
Hepatitis B vaccine was given in the nursery.

Diet:
Cortez was breast-fed exclusively until one day prior to admission. Since then he has received Similac,
3-4 oz. every 3-4 hours. He receives occasional water.

PHYSICAL EXAM
Vitals: Temp 37.8 rectal Pulse 156 Respiratory Rate 45 BP 86/47 SpO2 98% on room air.

Labs: (Date and Time all labs)

 CBC w/ differential: WBC 12.7 (N 29%, L 59%, M 9%, E 3%, B 1%), Hgb 15.9, Hct 47.5, Plts
458, RBC 4.39, RDW 14.7
 CMP: Na 137, K 5.2, Cl 103, bicarb 23, BUN 6, Cr 0.5, Glu 102, Ca 10.6, Total Protein 6,
Albumin 3.3, Total bilirubin 0.7, ALT 7, AST 30
 Urinalysis: (Date and Time) Collected by catheterization. Negative for bacteria, leukocyte
esterase, nitrite, WBC and RBC
 CSF (Date and Time) Glucose 49, Protein 161 (H), WBC 3, RBC 28,565 (H), No organisms
seen on gram stain
 Blood and urine cultures are pending.

Diagnostic Imaging:
CXR (Date and Time) Preliminary findings are negative. Official reading pending.

Differential:
Causes of Generalized Rashes include: Herpes Simplex, Erythema toxicum, Transient neonatal pustular
melanosis, Epidermolysis bullosa, Incontinentia pigmenti, Congenital erosive and vesicular dermatitis,
Congenital varicella, Staphylococcal scalded skin syndrome, Neonatal scabies.
Causes of Localized Rashes include: Miliaria, Bullous impetigo, Herpes simplex.

Plan:
1. Vesicular rash possibly due to HSV, SSSS, or bullous impetigo; worsening
2. Irritability
3. Elevated protein and RBC count in CSF
4. Vomiting; Fluids, Electrolytes, Nutrition (FEN)
5. Health Maintenance
6. Social

Disposition:
Cortez requires inpatient care due to need for further diagnostic workup, IV antibitoics, and IV hydration.