HISTORY:
Fever and rash for
Up to: °,
Rash location:
Type: , , ,
Treatments tried: ,
,
,
,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- Throat swab
- Covid test
- Urinalysis and culture
- Blood work: , ,
-
-
- Encourage hydration
- Antibiotics
- Follow-up in
- Return if fever persists for more than 3 days, if new symptoms develop, or if condition worsens
- Go to ER if seizures, severe headache, stiff neck, or other signs of serious illness occur