HISTORY

Introductory Statement

This is the (1st, 2nd, 3rd) admission for this age, sex, with a reason for admission.

Chief Complaint (CC) (if applicable) in parents or child's own words.

History of Present Illness

Information in this section is of greatest importance. Remember that 90% of pediatric diagnoses are made with the history. All of the significant information that supports the differential diagnosis should be found in the HPI. List here all the pertinent, positive and negative direct answers to your questions. The information should be listed chronologically and should include the initial symptom and then the subsequent symptoms. The portions of past history that would be pertinent to the present illness should be included in the information of the HPI. The HPI should contain a number important details, but these details should be written precisely, concisely, and orderly. Include objective data in your narrative (e.g., x-ray reports and labs obtained in other hospitals) that pertain to the patient's need for admission.

Past History

Perinatal and Neonatal Information: More emphasis will be placed on this information especially when it pertains to an infant patient. The information in this section might include birth date, hospital, city, weight, and length. The type of delivery, for example, spontaneous and the type of presentation; vertex or breech. Apgar scores, age of mother, length of gestation, exposures to infectious diseases, and medications, drugs, or alcohol including tobacco used during pregnancy should be recorded if pertinent to the case. Information regarding the newborn, might include hypoglycemia, cyanosis, pallor, seizures, jaundice, skin lesions, muscle skeletal deformities, respiratory distress or feeding problems.

Nutrition: Questions regarding nutrition should be appropriate for the child's age. For example, infants - breast or bottle fed, if formula is used which type, vitamin supplementation, and past growth information.

Developmental History: Record information regarding a child's current developmental status with regard to each of the four following areas: gross motor, fine motor, social, and language skills. When children are of school age include information regarding academics and physical activities such as sports.

Immunization: Indicate sources of information, dates immunizations given, and which type of immunization was provided. Also include TB testing results and dates if performed.

Habits and Personality:
- Sleep
- Issues with regard to behavior

Previous Illnesses : Age, severity, complications, and sequeli. Report as a list and include dates.
- Serious childhood illnesses, injuries and fractures, hospitalizations

Surgical Procedures: List with approximate dates, and complications

Allergies (Medication and Others)

Current Medications: Create numbered list, i ncluding name of medication, dose, route, frequency and indication for the medication.

Family/Genetic History

Record all known significant diseases in first degree relatives (parents, grandparents, aunts, uncles, and siblings). Record all deaths in these first degree relatives. Examples that might be included in this section would be diabetes, cancer, epilepsy, allergies, hereditary blood dyscrasia, early coronary artery disease, hyperlipodemia, mental retardation, dystrophies, congenital anomalies, degenerative diseases, cystic fibrosis, and celiac disease.

Social History

-Living circumstances: place and nature of dwelling, sleeping      arrangements, daycare arrangements.
- Economic circumstances
- Parents occupations and marital status
- Household pets
- Potential exposures to toxins in home, for example, cigarette      smoke exposure
- Age of home of children less than 3 (possible lead exposure)
- Water source

Review of Systems

Review each of the following systems and include all positive answers to questions.
- General
- HEENT
- Respiratory
- Cardiovascular
- Gastrointestinal
- Genitourinary
- Skin
- Muscle/Skeletal
- Hematologic/Lymphoid
- Endocrine & Growth
- Neurologic
- Psychiatric

PHYSICAL EXAMINATION

All positive physical findings should be recorded and pertinent negative findings to that specific differential diagnosis should also be included in the physical examination. The following list of physical findings are examples of those things that might be included.

A successful pediatric examination varies with the age of the patient. Very young infants and neonates are often easiest to examine on the examining table. From several months to preschool age it is often more effective to have the patient lie or sit on the mother's lap. It may be best to interview and examine adolescents without the parents present. If a parent is not present during the examination a student should have a nurse or the attending physician present at the time of examination or have parental permission to examine the child.

Observe the child under ideal circumstances, for example, while in mother's lap and leave the more painful and uncomfortable parts of the examination until last, for example, throat and ears.

Vital Signs: Record vital signs which include temperature, pulse, respiratory rate, and blood pressure (arm and legs). Weight, height, and head circumference should be measured, preferably using the metric system, and should include percentiles. Plot these parameters on a growth chart if not previously done. Record O2 saturations and the amount of oxygen delivered if appropriate.

General Appearance: For example any obvious deformities, size appropriate for age, respiratory distress or pain, and hydration and general nutrition status.

Head: Normal or abnormal facies and normal or abnormal head shape. Fontonelle size if open (anterior and posterior).

Eyes: Include all positive findings on eye examination and include proptosis, sclerae, conjunctivae, strabismus, photophobia, and fundoscopic exam.

Ears : Hearing, external canal, discharge, tympatic membrane appearance.

Nose: Air movement, mucosa, septum, turbinate appearance, perinasal sinus tenderness.

Mouth and Throat: Color, dryness, fissure; appearance, teeth - number and (?)caries, gum - color and hypertrophy, epiglottis - appearance, tonsils - size and appearance.

Neck: Flexibility, masses. Thyroid - size.

Lymph node: If abnormal in size or texture record location, consistency, tenderness, size in centimeters.

Spine: Scoliosis, mobility, tenderness.

Thorax: Appearance and contour, respiratory rate and effort, regularity of breathing, symmetrical chest movement, character of respirations such as retractions.

Lungs: Percussion, palpation, fremitus, auscultation.

Cardiovascular:
- Inspection, precordial bulge, apical heave, auscultation, rhythm,      character and quality of sounds.
- Palpation: PMI, thrills, heaves.
- Auscultation: quality and intensity of heart sounds, murmurs, for      example, timing, duration, intensity, location, radiation.
- Pulses: radial and femoral pulses, rate and rhythm.

Abdomen:
- Inspection, contour, umbilicus, distention, veins, visible      peristalsis, hernia.
- Percussion: fluid wave, shifting dullness, tympany, liver size,      spleen size,
- Costovetebral angle tenderness, abnormal masses.
- Palpation: tenderness, rebound, guarding, masses.

Genitalia:
Record Tanner Stage
     - Male: circumcised
          -testes - appearance and size
          -hydrocele - presence hernia.

Breasts:
Record Tanner Stage

Rectal (only if indicated):

Fissures, hemorrhoids, prolapse, sphincter tone, stool in ampulla, abnormal masses.

Skin:

Texture, color, turgor, temperature, moisture, icterus, cyanosis, eruptions, lesions, scars, ecchymoses, petechiae, spider nevi, desquamation, hemangiomata, mongolian spots, nevi.

Extremities:

Tone, color, warmth, clubbing, cyanosis, mobility, Ortalami and Barlows maneuvers in newborns and infants, deformities, joint swelling or tenderness.

Neurologic:
- Mental status: affect, level of consciousness, speech.
- Motor: station and gait, muscle strength, tone, tics, ataxia.
- Cranial nerves: testing 2-12
- deep tendon reflexes: 2+ is average when recording.
     - Record if Babinski present.
     - Infants, for example grasp, suck, moro, rooting, stepping,           placing.
- Abnormal sensory findings.
- Meningeal signs

PROBLEM LIST

CLINICAL IMPRESSION
Which of the differential do you think is most likely and which are less likely.

MANAGEMENT PLAN (Reflects the differential diagnosis)
Write the management plan in list form as if writing admission orders.

ADDENDUM
Pertinent subsequent lab results.

LEARNING ISSUE
Write a short, one to two paragraphs in your own words, report on a specific medical topic that pertains to this patient. This might be from the differential diagnoses or problem list. Use evidence-based literature to support your information and document your references.