PEDIATRICS TEMPLATES:
Newborn: PedNew
VITALS: Weight. Height ?? . HC??.
GENERAL: Vigorous, healthy infant.
HEAD: Normocephalic. Ant. fontanelle soft and flat.
EYES: Conj. not injected. Bilateral red reflex present. EOMs appropriate for age.
PERL.
ENT: Helices well formed, ears in nl position. TMs normal. Oropharynx and nares w/o
deformity.
NECK: Supple, w/o masses. Thyroid nl.
CHEST: Symmetrical. NL breast tissue. Clavicle intact.
RESP: No grunting, flaring or retractions. Chest clear to auscultation.
CV: Regular sinus rate and rhythm. Normal S1 and S2. No murmurs. Femoral pulses
full and symmetric.
ABD: Soft, nontender. No HSM or abd masses. Umbilicus healing normally.
GU: ??(female) NL external genitalia. *OR* ?? (male) NL phallus with both testicles
descended.
LYMPH: Cervical and inguinal nodes nl for age.
MSK: Five digits per extremity. NL palmar creases. NL and symmetric strength and
tone. No hip click or subluxation.
SKIN: No rashes, jaundice or induration.
NEURO: NL suck, grasp and motor reflexes.
ATTACHMENT: Parent/infant bond appropriate.
Birth to one year: PEDO
VITALS: Weight ??. Height ??. HC??.
GENERAL: Alert, interactive and appropriate.
HEAD: Normocephalic with nl anterior fontanelle.
EYES: Conj. not injected. Bilateral red reflex present. EOMs intact, w/o strabismus.
PERL.
ENT: TMs clear, oropharynx and nares nl.
NECK: Supple w/o masses. Thyroid nl.
CHEST: Symmetrical. NL prepubertal breast tissue.
RESP: Breathing not labored. Chest clear to auscultation.
CV: Regular sinus rate and rhythm. Normal S1 and S2. No murmurs. Femoral pulses
full and symmetric.
ABD: Soft, nontender. No HSM or abd masses.
GU: ??(female) NL external genitalia. *OR* ?? (male) NL phallus with both testicles
descended.
LYMPH: Cervical and inguinal nodes nl for age.
MSK: Spine straight w/o scoliosis. NL and symmetric strength and tone. Hips nl.
SKIN: No rashes or induration.
NEURO: Appropriate for age.
One year to Prepubertal: PED1
VITALS: Weight ??. Height ??. HC??. BP ?? (4 yo and older)
GENERAL: Alert, interactive and appropriate.
HEAD: Normocephalic.
EYES: Conj. not injected. Bilateral red reflex present. EOMs intact, w/o strabismus.
PERL.
ENT: TMs clear, oropharynx and nares nl.
NECK: Supple w/o masses. Thyroid nl.
CHEST: Symmetrical. NL prepubertal breast tissue.
RESP: Breathing not labored. Chest clear to auscultation.
CV: Regular sinus rate and rhythm. Normal S1 and S2. No murmurs. No edema.
ABD: Soft, nontender. No HSM or abd masses.
GU: ??(female) NL external genitalia. *OR* ?? (male) NL phallus with both testicles
descended.
LYMPH: Cervical and inguinal nodes nl for age.
MSK: Spine straight w/o scoliosis. NL posture. Gait appropriate for age. NL muscle
tone.
SKIN: No rashes or induration, or cyanosis.
NEURO: Appropriate for age.
PSYCH: Affect nl.
Pubertal Male: PM
VITALS: ?? Weight ??. Height ??. BP ??
GENERAL: Well developed and nourished.
HEAD: Normocephalic.
EYES: Conj. not injected. Bilateral red reflex present. EOMs intact, w/o strabismus.
PERL.
ENT: TMs clear, oropharynx and nares nl.
NECK: Supple w/o masses. Thyroid nl.
CHEST: Chest wall symmetric w/o breast enlargement
RESP: Breathing not labored. Chest clear to auscultation.
CV: Regular sinus rate and rhythm. Normal S1 and S2. No murmurs. No edema.
ABD: Soft, nontender. No HSM or abd masses.
GU: Tanner stage ??. NL phallus with both testicles descended.
LYMPH: Cervical and inguinal nodes nl for age.
MSK: Spine w/o scoliosis. NL posture. Gait appropriate for age. NL muscle tone.
SKIN: No rashes or induration, or cyanosis.
NEURO: Appropriate for age.
PSYCH: Affect nl.
Pubertal Female: PF
VITALS: ?? Weight ??. Height ??. BP ??
GENERAL: Well developed and nourished.
HEAD: Normocephalic.
EYES: Conj. not injected. Bilateral red reflex present. EOMs intact, w/o strabismus.
PERL:
ENT: TMs clear, oropharynx and nares nl.
NECK: Supple w/o masses. Thyroid nl.
CHEST: Chest wall symmetric. Breasts Tanner Stage ??
RESP: Breathing not labored. Chest clear to auscultation.
CV: Regular sinus rate and rhythm. Normal S1 and S2. No murmurs. No edema.
ABD: Soft, nontender. No HSM or abd masses.
GU: Tanner stage ??.
LYMPH: Cervical and inguinal nodes nl for age.
MSK: Spine w/o scoliosis. NL posture. Gait appropriate for age. NL muscle tone.
SKIN: No rashes or induration, or cyanosis.
NEURO: Appropriate for age.
PSYCH: Affect nl.