Pediatrics H&P

Chief Complaint: ___ year (month) old male (female) present with _______________ x _____ days (months).

History of Present Illness: Health and behavior prior to onset of symptoms; epidemiology; any therapies tried by parents or PMD.

Previous Medical History:

Birth History: Gestational age, cesarean versus vaginal, GxPx of mother, prenatal course (meds, infections, fetal activity), delivery, neonatal course (home with mom? feeding, fevers).

Feeding History (if infant): how often and what content.

Growth and Development: growth curves and motor milestones (too short, too tall, too heavy, too thin, bottle/cup, toilet training, school performance, interactive skills and independence, sleep habits, elimination habits).

Medical History:

Hospitalizations and Surgeries:

History of urinary tract infections or otitis media:

Allergies:

Immunizations:

Medications:

Parental Concerns: (if any)

Review of Systems:

Skin: rashes, hair, birthmarks
Neuro: changes in mental status, headaches, loss of consciousness, ataxia, dizziness, tingling, numbness
ENT: glasses, snoring, teeth, malocclusion, orthodontia
Cardiovascular/Respiratory: murmur, edema, sputum, cough
GI: nausea, vomiting, diarrhea, constipation, jaundice, belly pain
GU: frequency, dysuria, hematuria, genitalia
Musculoskeletal:  joints, gait, posture
Endocrine: puberty, lethargy, polyuria, polydipsia
Miscellaneous: temperment, activity, special senses

Weight: ___ kg = (___) % ile        Height ___ cm = (___) % ile        Head Circumference = ___ cm = (___) % ile

Vitals signs as per _________: (with cry?)  HR:___   BP:___  RR___  T____

General: A statement of patient's condition: color, nutrition, hydration, respiration, speech, gait, alertness, cooperation, activity.
H: head shape, symmetry, hair, facial symmetry, chin, fontanelle, craniotabes
E: EOMs, pupils and iris, fundi, prominence, conjuntivae, sclera, discharge, ptosis, strabismus, nystagmus, cataracts?
E: Malformations, discharge, cerumen, tenderness, TMs, injected? mobile? landmarks, fluid level?
N: Nares (patency, turbinates), septum, secretion, color of mucous membranes, sinus tenderness
T: Mouth breather? Lips: color, eruptions, fissures; Teeth: number, caries, gums, malocclusion; Tongue: moisture, color, size; Oral lesions, mucous membranes moist? Palate: type of arch, deformity, cryptic, exudation, inflammation; Epiglottitis: color, swelling; Voice: cough, stridor.
Neck: supple, ROM, masses, cysts, nodes, trachea midline, lymph nodes, thyroid
Clavicles: crepitus, nodes, axillae
Chest:

• Contour and shape: costochondral junctions. Respiration rate, depth, symmetry, distress, retractions; Pectus? breast tissue.
• Lungs: auscultation: quality of breath sounds, wheezing or crackles, transmitted sounds

percussion: fremitus where applicable.
• Heart: Inspection for pulsations; palpation for point of apex beat, thrills. Auscultation: Cover all areas of the heart. RRR?  Character of the first and second heart sounds over valvular areas and apex. Third sound? Split sounds? Murmurs: time: location of greatest intensity, transmission, character, change with position. Listen for bruits over large vessels.
• Pulse: rate, volume, rhythm, fullness, femorals.
• BP
Abdomen:
shape, scars? distended? soft, hard, cord, hernias, palpable loops
palpate and percuss: liver, spleen, kidneys, aortic pulse. Tympani? Fluid?
bladder percussion and tenderness
Genitals:
hernias, testicles descended bilaterally, circumcised?, cremasteric reflex? urethral discharge? phimosis? hypospadias? labia, hymen, perineal area. Tanner Staging, edema in newborn (esp. breech)
Rectal:  masses, tenderness, stools, heme test, prolapse? dimples? hemorrhoids?
Extremities
pulses, edema, clubbing, cyanosis, capillary refill, muscle atrophy, stance, body deformities
joints: range of motion, pain, swelling, warmth
hips: Ortolani to relocate, Barlow to dislocate
Back: spine, flank pain, L/S abnormalities
Neuro: Alert and oriented, MSE for age, speech, gait, attention, CNs, sensory, strength, DTRs, coordination
Skin: Quality: dry, moist, scaly, turgor, hydration. Color (pale, jaundice), rashes, bruises, subcutaneous fat, birth marks, eruptions, hemorrages, petechiae, desquamation, cyanosis, icterus, edema, local swelling, bites. Describe lesions, distribution, measure size, photograph if possible).
 
Assessment and Plan
 
This section should begin with a brief summary of the patient's present status, this is usually only one paragraph.  The remainder of the combined assessment and plan section is divided by systems (for example: respiratory, cardiac, FEN, renal, neuro, etc.).  The patient is assessed in terms of each system and a plan is devised to address each aspect of the assessment.
 
 
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