1-10 PATIENT NOTE: CHILD WITH FEVER HISTORY: Describe the history you just obtained from this

patient. Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: THE PATIENTS GRAND MOTHER CALLED C/O MONTH OLD MALE CHILD WITH A FEVER OF 101.0 STARTED THIS MORNING. PATIENT IS PULLING EAR, COUGHING AND SHORT OF BREATH. + DIAPER RASH, + DIARRHEA FOR 3-4 DAYS , CHILLS, CRYING AND IRRITABLE. VOMITED ONE TIME CLEAR WATERY FLUID YESTERDAY. THIS CHILD IS NOT EATING AND DID NOT SLEEP LAST NIGHT. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NKDA MEDICATIONS: NONE PMH: JAUNDICE AT BIRTH SH: CHILD SPORADICALLY STAYS WITH HIS GRANDMOTHER. OTHERWISE, HE IS WITH THIS MOTHER, FATHER WHEREABOUTS ARE UNKNOWN, MOTHER IS UNAVAILABLE FOR ANY INFORMATION, THE CHILD GOES TO DAY CARE. BIRTH HISTORY: GRANDMOTHER WAS NOT AWARE OF THE DETAILS OF THE BIRTH HISTORY. MOTHER DID RECEIVE PRENATAL CARE, GRANDMOTHER DENIES ETOH OR DRUG USE DURING PREGNANCY. DIET HISTORY: BREAST MILK 3-4 TIMES A WEEK, SUPPLEMENTED WITH POWDERED FORMULA 1X A WEEK AND MULTIVITAMINS. IMMUNIZATIONS: UTD DEVELOPMENTAL HISTORY: LAST CHECK UP 2 WEEKS AGO , NORMAL, WEIGHT, HEIGHT VISION/HEARING, MILESTONES WNL. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PHYSICAL EXAM: NONE DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients 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 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: VIRAL URI HISTORY FINDING(S) - fever 101.0 with chills PHYSICAL EXAM FINDING(S)

- diarrhea, vomiting, pulling ear - goes to day care DIAGNOSIS #2: PNEUMONIA HISTORY FINDING(S) - cough - fever with chills - shortness of breath DIAGNOSIS #3: MENINGITIS HISTORY FINDING(S) - fever 101.0 with chills - ear pulling - goes to day care DIAGNOSTIC STUDIES: - PHYSICAL EXAM - PNEUMATIC OTOSCOPY - LP-CSF ANALYSIS - SERUM ANTIBODY TITRES - CBC/UA PHYSICAL EXAM FINDING(S) PHYSICAL EXAM FINDING(S)