Before entering room: Room Number, Precautions, Parents Last Name, Attending Physician, Nurse (intro)
Upon entering room: Introduce self, Team, attending. Ask relation to child (refer to parents as Mr. or Ms afterwards)
CC: “quote from historian”
ID: Identify info, reason to admit from DR perspective
Historian: (reliability, vague?)
Referring DR/PCP/Specialists: _________ Phone #
HPI: This is a__yo (m/f) in USGH until X days prior to admission (PTA) when… 2 day PTA… Day PTA… pertinent (+/-)…
b/c of ___ pt admitted to ED to…
COLDERAS – What were you doing, Pattern, Before/Now, Trauma, Recent illness
Handedness? Therapies? Qs – Head injury, infections (meningitis), febrile seizures
ED Course: (ED vitals -> meds/labs/orders/imaging)
Overnight/Today: No new seizures during stay.
ROS: Difficulty seeing/hearing, pain, easy bruising? “Noncontributory except for…”
GEN: Fever, chills, (night)sweats, changes in weight, appetite, or
sleep.
HEAD: headache or head injury
EYES: glasses/contacts, vision changes, eye pain, double vision,
photophobia, flashing lights, last eye exam
EARS: hearing change, ear pain, discharge, ringing, dizziness
NOSE/SINUSES: nose bleeds, nasal stuffiness, frequent colds
MOUTH, THROAT: bleeding gums, sore tongue, sore throat,
hoarseness, difficulty swallowing, snore
NECK: lumps, swollen glands, goiter, stiffness
BREASTS: lumps, pain, nipple discharge
CARDIAC: chest pain, swelling in hands/feet, blue fingers/toes,
high BP, skipping heart beats, heart murmur, RHD
RESPIRATORY: cough (blood?), wheeze, phlegm production
(color, amount), SOB, bronchitis/emphysema
GI: change in appetite or weight, N/V (blood?)/D/C, heartburn,
abdominal pain, excessive belching/flatus, yellowing of skin,
rectal bleed/hemorrhoids (hematochezia/melena), food
intolerance, stool incontinence, feeling each bump on the way
in (peritonitis)
URINARY: difficult urination, pain/burn on urination,
frequent urination, urine at night, urgency, urine
incontinence, dribbling, decreased stream, blood in urine,
UTI/stones/prostate infection, flank pain
GENITAL: hx STD, genital lesions, testicular mass or pain,
sexual dysfunction
VASCULAR: leg cramps (walk?), varicose veins, DVT,
orthostatic dizziness
MSK: pain, swell, stiff, ROM, broken bone, sprain, arthritis,
gout
NEURO: head injury, headache, memory loss, seizure
(tongue biting, urinary incontinence?), LOC, paralysis,
weakness, loss of muscle size, muscle spasm, facial drooping,
tremor, involuntary movement, incoordination, numbness,
feeling of “pins and needles/tingles”, confusion, dizziness
(turn head to side), head injury, speech problems,
coordination problems, vertigo, gait problems, falls
HEME: anemia, easy bruising/bleeding
ENDO: abnml growth, appetite, thirst, urine production,
heat/cold intolerance, excessive sweating, DM, thyroid
PSYCH: anxiety, depression, SI/HI, memory, sleep, mood
ALL: hives, swelling lips/tongue, hay fever, asthma, eczema,
sensitivity to drugs, food, pollens, dander SKIN: rash, itch,
change hair or nails
PMHx: Hosp/illness
BirthHx: Pt was ___ lb product of a __ wk gestation born by NSVD (C-section for__) to a ____ yo GXPXAbx following
an uncomplicated pregnancy w/ Apgars __/__. Vaginal/C-section, term?, NICU?
Developmental - FTT, abuse, Gross motor, Fine motor, language, problem solving
SHx Surgery, date, surgeon
FHx: Fam tree, age of family members
SOC: Ask who lives at home, if the child is in school or daycare, sick contacts, activities. Parent’s profession, smoker
(esp. when abuse, FTT). Full HEADSSS for children age 11 and up.
MEDS - mg PO/IV, BID/TID/Q (x mg/kg/day)
ALL (Rxn?)
Immunizations: IUTD (Hep B?, Varicella?, COVID?)
Feeding Hx: Breast (how often, how long each breast) Formula (type, how often, how much)
PE:
VITALS: Temp (Tmax, Tcurrent), HR, RR, BP, O2SAT
GROWTH: Wt (%), Ht (%), Head circ if < 3yo (%)
[present as 50th %ile of X age when hugely above/below nl]
GEN: Interactive, active, happy, smiling, well appearing ->
irritable but consolable -> irritable and inconsolable -> toxic
(mental status changes, perfusion changes)
SKIN:
HEENT: H: NCAT, A/F 1x1cm (Ant. Fontanelle)
E: PERRLA, EOMI, conjunctiva moist,
E: TM movement – Clear and mobile
N: Polyps, discharge
T: Erythema, exudate, moist, tooth develop (20 baby teeth –
1st at 6 months, then 1/month)
NECK: soft, supple, LAD, thyromegaly, carotids (stenosis?),
neck stiffness? (meningitis)
HEART: RRR, S1/S2 distinct, no MRoG
LUNGS: CTAB w/o Rales, Rhonchi, Wheezes
GI: Soft, nontender, nondistended, normoactive bowel
sounds in all 4 quadrants, no HSM, no rebound tenderness
or guarding. Negative rovsing, mcburney, heel tap
GU:
MSK:
BACK: No CVA tenderness, FROM
EXT:
VASCULAR: Capillary refill <2 seconds,
LYMPH: No edema
NEURO:
Mental status: Alert. Oriented to person, place, time and
situation. Appropriately interactive. Speech fluent.
Cranial Nerves:
II, III: visual fields full to finger counting, PERRLA
III, IV, VI: EOMI, no ptosis, normal saccades
V: Sensation intact to light touch x3 bilaterally
VII: Face symmetric without weakness
VIII: hearing intact grossly
IX, X: voice normal, elevates palate symmetrically
XI: SCM/trapezoids 5/5 bilaterally
XII: Tongue protrudes midline without atrophy or
fasciculations
Motor: Normal Bulk and tone.
Upper Extremity Motor:
Biceps: 5/5 Right, 5/5 Left
Deltoid: 5/5 Right, 5/5 Left
Triceps: 5/5 Right, 5/5 Left
Grip, interossei: 5/5 Right, 5/5 Left
Lower Extremity Motor:
Hip flexion: 5/5 Right, 5/5 Left
Knee flexion: 5/5 Right, 5/5 Left
Knee extension: 5/5 Right, 5/5 Left
Plantar flexion: 5/5 Right, 5/5 Left
Dorsi flexion: 5/5 Right, 5/5 Left
Reflexes:
Biceps: 2+ Right, 2+ Left
Brachioradialis: 2+ Right, 2+ Left
Patellar: 2+ Right, 2+ Left
Ankle jerk: No clonus
Toes are down-going bilaterally
Coordination and Gait:
Finger-nose-finger: No dysmetria
Heel-to-shin: normal
Posture, stance, station, and arm swing normal.
Tandem gait intact.
Able to walk on heels and toes.
Romberg negative.
Sensation:
Intact light touch, proprioception and temperature.
Neurodiagnostics/LABS/STUDIES/IMAGING: Include date, interpretation. Look up genes if genetic panel done.
ASSESSMENT/PLAN:
Repeat 1-liner, Stable?
Problem #1, 2, 3
Menstrual Hx
USGH: usual state of good health
PTA: prior to admission
Development: roll, sit up