Patient Information: G.J. 1-month-old Hispanic female

S.

CC: Rash and 1-month-old wellness check

HPI: The patient’s caregiver reports a red rash on her face and torso for the past 2 days. Caregiver reports it does not seem to be bothersome to the patient. The rash is mild is severity. The caregiver noticed a few lesions on her face, then it spread to her chest and back. Nothing seems to make the rash worse. The rash improves after bathing the patient. She has used Baby Aveeno skin lotion. No associated symptoms of fevers, nausea, diarrhea, cough, or shortness of breath. Patients caregiver reports she stays at home and no recent sick contacts. No one else in the household has a rash.

The patient presents with her mother for 1-month-old wellness check. Patient’s caregiver has no concerns about child's development or behavior. She is in the 50th percentile for height and weight. The patient has not had any recent injury or illness. The patient’s current diet is breastmilk q2 hrs x 30 min and Similac Advance 2 oz BID. Patient has 7-8 wet diapers and 3 BMs in 24 hours. Caregiver has no concerns.

Current Medications: No current prescription or OTC medications.

Allergies: NKDA. No food allergies.

PMHx: She is up to date on her immunizations - HEP B, dose #1 given before hospital discharge. No illnesses or injuries. Normal spontaneous vaginal birth without complication. Gestational age 38 weeks 0 days. No surgeries.

Soc & Substance Hx: She lives with her mom, dad, and four other siblings in their home. No exposure to secondhand smoke. They have a pet dog in the home. She rides in a rear facing child seat in the back at all times. There are working smoke detectors in the home. No tobacco, alcohol, or drug use.

Fam Hx: Mom has thyroid disorder and diabetes - both well controlled. Dad has diabetes. Siblings are all healthy with no medical conditions. Diabetes runs on maternal side - grandparents, cousins, and brother.

Mental Hx: Caregiver has no concerns regarding patient’s mental health or behavior. Violence Hx: There is no concern for violence in the home……….. Continue