Age: 1.13
Sex: M
Vaccine: VARCEL
Symptoms: Pruritus, Pyrexia, Rash, Skin lesion, Urinary tract infection
Clinical narrative: Chief Complaint  poss. ck pox  Problems  07999: viral and chlamydial infection in conditions classified elsewhere and of unspecified site viral infection Onset: 03/24/2005 46611: acute bronchiolitis due to respiratory syncytial virus (rsv) Onset: 03/17/2005 46619: acute bronchiolitis due to other infectious organisms Onset: 04/15/2005 481: pneumococcal pneumonia [streptococcus pneumoniae pneumonia] Onset: 10/07/2005  Medications  None recorded.  Allergies  NO KNOWN DRUG ALLERGIES  List all non family members in the household: 4. Daycare: Y. Do you have any pets / what kind: NO. Exposure to smokers: NO. Smoke alarm in home: Y.  Family History  None recorded.  Surgical History  None recorded.  Document Review  N/A  Clinical Guidelines  Name History Status    Vitals  T: 97.7 °F (temporal artery)   Wt: 27 lbs. (12.3 kg, 29th %)   Notes: LC    Vaccines  Vaccine  Type  Date Given  Route  Site  Lot #  Manufacturer  Date on VIS  Date VIS Given  Vaccinator   Diphtheria, Tetanus, Pertussis  DTaP  03/07/2007  IM  LT  C2552AA  SANOFI-PASTEUR  07/30/2001  03/07/2007  lcampos  DTaP  05/26/2005          DTaP  03/29/2005          Haemophilus Influenzae Type B  Hib-HepB  05/26/2005          Hib-HepB  03/29/2005          Hepatitis A  HepA  03/07/2007  IM  LT  1213F  MERCK & CO.  03/21/2006  03/07/2007  lcampos  Hepatitis B  Hib-HepB  05/26/2005          Hib-HepB  03/29/2005          Measles, Mumps, Rubella  MMR  03/07/2007  SQ  RT  0986F  MERCK & CO.  01/15/2003  03/07/2007  lcampos  Pneumococcal  PCV7  05/26/2005          PCV7  03/29/2005          Polio  IPV  05/26/2005          IPV  03/29/2005           HPI  Friday noted mult lesions , 4 dAYS with fever, very itchy, mild URI. VZV vac 3/06  HPI  None recorded.  Birth History  None recorded.  Prenatal History  None recorded.  ROS  None recorded.  Physical Exam  Patient is a 2-year-old male. General Appearance: General Appearance: active and alert, smiles, playful. Level of Distress: NAD. Attentiveness: good eye contact.  Head: Head: normocephalic, atraumatic.  Eyes: Eyes: conjunctiva non-injected, no conjunctival exudate, normal lids, PERRL.  Ears, Nose, Throat: Ears: normal except where noted. Nose: normal except where noted. Pharynx: normal except where noted.  Neck: Neck: supple, no masses, normal thyroid.  CVS: Rate and Rhythm: RRR, normal S1, normal S2, arterial pulses normal.  Lungs: Respiration, Rhythm and Depth: no respiratory distress, normal breath sounds.  Abdomen: Auscultation: normal bowel sounds. Palpation: non-tender. Liver: no hepatomegaly. Spleen: no splenomegaly.  Skin: General: no cyanosis, generalized warmth. Moisture: dry. Lesions: no rash, no petechiae, mult eryth pap some with scabs in gen distribution.   Well Child ROS  Patient is a 2-year-old male.  Diagnoses / Orders  0529 - VARICELLA WITHOUT MENTION OF COMPLICATION - Aveeno bath Keep isolated at least 1 week, call OB since Mom pregn and not sure if had Dz HYDROXYZINE 10 MG/5 ML SYRUP - Submit Date: 04/17/2007    Take 11/2 teaspoon by mouth every 8 hours for itch     Qty: 1 120 ml bottle     Refills: 0      Return To Office  Appointment to see ssanchez for Sick Visit or Follow-up at  Office on 04/17/2007 - - rash. add note