CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Maria Sterling is the mother of the patient who is also the informant. Child is an 18 month old infant
complaining of fever or the past 2 days. Fever was recorded at 101F with partial relief with Tylenol. 3
months ago, he had an ear disorder that was treated with Amoxicillin. A week ago, he started having
productive cough that lasted for a few days with associated poor appetite and looking tired. 2 days
ago, he was noticed to be doing some ear pulling and rash formation that started from the head going
down to the trunk and belly. Lesions were tiny red spots and slightly elevated primarily on the chest
and face. Vomiting episode, non-billous and non-projectile was noted 1 day ago. Denies ill contacts.
Immunizations are up to date.
ROS: none except above
PMH: Ear infection 3 months ago x amoxicillin
Meds: Tylenol
All: nka
PSHx: none
FH: none
Birth history and Devt history: 40 wks born via NSVD, uncomplicated, development is at par

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.

DATA INTERPRETATION: Based on what you have learned from the history and the physical
examination , list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses
from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the
positive or negative findings from the history and the physical examination (if present) that support
each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis
(e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1: Measles

History Finding(s) Physical Exam Finding(s)

cephalocaudal distribution of rash none
dew drop spots
fever
ear pulling
poor appetite, looks tired

Diagnosis #2: Scarlet fever

History Finding(s) Physical Exam Finding(s)

cephalocaudal distribution of rash none
poor appetite, looks tired

Diagnosis #3: Acute otitis media

History Finding(s) Physical Exam Finding(s)

hx of otitis media 3 months ago
ear pulling
fever
poor appetite, looks tired

Diagnostic Study/Studies
pneumatic otoscopy
cbc with differential
UA and UCx
LP with csf analysis