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patients name - t is is potentia!!" a HIPAA #io!ation$ Informant: (Generic patient, mother, father, etc.) Primary Care Physician: Referring Physician (if not Primary Care Physician): CLINICAL HISTORY Chief Complaint: Include the patients age, ethnic origin, se , and reason for admission. Present Illness: !licit the facts of the illness, particularly the time and nature of the onset. "rrange these facts in a chronological order and relate them in a narrati#e fashion, tracing the course of e#ents up to the time of the #isit. $hat %as done for the child& %hat drugs %ere gi#en and %hat %ere the results of such treatment' Pay special attention to recording (pertinent negati#e) data as %ell as positi#e information. *his includes physical e ams, la+oratory e#aluations and treatments %hich occurred +efore the present admission. ,o% has the illness affected the patients lifestyle' *he ,PI should conclude %ith a description of the #isit to clinic or emergency department %hich resulted in the present admission. Past ,istory: Prenatal-Perinatal: .uration of pregnancy, maternal illness prior or during pregnancy, maternal conditions during pregnancy. .etails of la+or and deli#ery. Condition of infant at +irth. "PG"R scores (if a#aila+le). Gestational age. .rugs ta/en during pregnancy. 0irth and 1eonatal Period: Condition and #igor of infant at +irth. 0irth %eight, postnatal pro+lems such as neonatal cyanosis, 2aundice, con#ulsions, s/in eruptions, initial feedings, etc. 3eeding ,istory: Initial feeding, +reast or +ottle, %hat /ind of feedings. *olerance for feeds. $eaning. "ddition of solid foods. Current dietary inta/e, +alance, and childs attitude to%ard eating. 4itamin supplements. 5sually discussed in detail %hen patient less then 678 years old. Gro%th and .e#elopment: 0irth %eight, length and head circumference. ,istory of dentition. $hen did anterior fontanelle close. $eight at different ages (if /no%n to informant.) .e#elopmental landmar/s: 3irst smile, held head erect, rolled o#er, recogni9ed people, sat alone, stood %ith support, stood alone, cra%led, %al/ed, used %ords and sentences. If the child is greater than :7; years, a glo+al statement such as (the de#elopmental history is normal) is accepta+le. Past Illnesses-Re#ie% of <ystems: Infectious disease (measles, ru+ella, mumps, chic/en po , pertussis diphtheria, poliomyelitis, scarlet fe#er), details of onset, se#erity and complications or residuals. Respiratory system: 3unctional status. .etails of otitis media, tonsillitis, repeated 5RIs, allergy, +ronchitis, pneumonia, cer#ical adenitis, chronic cough, croup, mouth +reathing, persistent fe#ers, sleeping patterns. Gastrointestinal system: ,istory of early feeding difficulties, diarrhea, constipation, stool a+normalities, #omiting in relation to infections and emotional difficulties. Cardio#ascular system: In=uire a+out cyanosis, dyspnea, e cessi#e s%eating in infancy, fatiga+ility, syncope, 2oint paints and epista is. Genitourinary system: <ignificant items are infections of urinary tract, hematuria, dysuria, fre=uency, urgency, dri++ling, enuresis, edema oliguria. Repeated +outs of une plained fe#er. 1er#ous system: In=uire a+out con#ulsions (get details if they ha#e occurred), tics, ha+it spasms, emotional lia+ility, tremors and incoordination. Psychological: In=uire (appropriate to age) for restlessness, tantrums, night terrors, tics. ,o% does child get along %ith his associate at play, in nursery school, in school. <ome indication of the parents attitude to%ard the child can +e o+tained from these and other =uestions. <urgical ,istory: .ates, nature of and complications from any operations. "ccidents-In2uries: .ate, nature of and complications of any in2uries. >ention only if rele#ant to the present illness or

serious in nature. Immuni9ations: ta+ulate dates of all immuni9ations and tests for immunity. *his may +e summari9ed as: (immuni9ations are up7to7date.) Current >edications: 1ame, dosage form, dose, fre=uency, and ho% long patient has ta/en it if germane to presenting pro+lem. 3amily ,istory: "ge, physical condition and state of health of each parent and si+ling. ?ist mothers pregnancies in chronological order, gi#ing details and outcome of each. If si+lings ha#e died, gi#e the nature of the condition leading to the death and the results of postmortem or other e aminations. Recent acute illnesses in the family need to +e descri+ed. Chronic illnesses among mem+ers of the family need to +e noted. If the CC and PI suggest the possi+ility of a herita+le condition, e plore the family for the pattern of similar conditions %ithin the immediate family and for+ears. Chec/ for parental consanguinity. >ention only if clearly rele#ant to the current admitting pro+lem. <ocial ,istory: ! plore the li#ing conditions for the family to o+tain a /no%ledge of the en#ironment in %hich the patient li#es in order to appreciate the chance for e posure to specific infections, poisons and to ic su+stance, as %ell as to appreciate pertinent psychological and emotional factors %hich might +e in#ol#ed in the present illness. PHYSICAL EXAMINATION General information: for e ample: (in general the patient %as a health appearing, chu++y infant no acute distress.) 4ital signs: $eight and ,eight: Record for this patient and gi#e percentiles from comparison against normal range for age. ,ead Circumference: Record for this patient and gi#e percentiles from comparison against normal range for age. >ention in any child less then 678 years old. *emperature (%hen ta/en) Pulse rate Respiratory Rate 0lood Pressure (%hat e tremity and in %hat position: sitting, supine, etc.) <p@6 (%hen applica+le) General Inspection: ,a+itus, Choice of posture. *ype and amount of spontaneous mo#ement. Restless, irrita+le, calm, apprehensi#e, dro%sy, apathetic, stuporous, comatose. <igns of pain. 1ature and =uality of +reathing. Color of s/in and lips (Cyanotic, pale, flushed) 1ature of cry (short catchy cry of pneumonia, hoarse cry of laryngitis, sharp painful cry of acute inflammatory process of fracture %hen +ody or +ed is touched.) ,ead: <utures and fontanels& open or closed. Craniota+es. <calp (lesions, edema, hair distri+ution, parasites). <hape normal or a+normal. !yes: Condition of con2uncti#ae and lids. Ptosis, stra+ismus, other paralysis. Pupillary reactions and asymmetry. Corneal ulcers or opacities. <cleral appearance (2aundice, +lue, inflamed). Gross #isual acuity in older children. !ars: ! amine e ternal canals for lesions and infection, tympanic mem+rane for inflammation, +ulging, retraction, perforation, serous fluid +ehind drum, mo+ility. 1ose: "ppearance of mucous mem+ranes and presence of foreign +odies, purulent or serous drainage, +lood7tinged drainage. 1asal flaring. >outh: "ppearance of mucous mem+ranes of lips, gums and +uccal areas. 1um+er of teeth, presence of caries. ?oo/ for enanthemata. Condition of tonsils, soft and hard palate, posterior oropharyn . Presence of e udates, mem+ranes, petechlae or #esicular of ulcerous lesions. 1ec/: >o+ility, head tilt, limitation of motion, nuchal spasm or rigidity. Position of trachea. Presence of masses or s%ellings.

Chest: <hape and symmetry in relation to patients age. <ymmetry of mo#ements %ith respiration. <upersternal, infrasternal or intercostals retractions. ?ungs: Auality of +reathing, +reath sounds, #oice sounds should +e descri+ed. 4ariations of symmetry of transmission or =uality of these sounds should +e descri+ed. Presence of ad#ential sounds such as crac/les, %hee9es or ru+s. ,eart: .escription of rate, rhythm, =uality of heart sounds, location of P>I, presence and location of murmurs, description of murmurs (intensity, =uality, transmission) sometimes the heart is e amined first in apprehensi#e infants. "+domen: <ymmetry. <tatus of um+ilicus. Presence or a+sence of palpa+le organs or masses. *enderness. .istention. Presence of signs of ascites. Percussion note. Auality of +o%el sounds. Genitalia: >ales: phimosis, paraphimosis, meatal stenosis, hypospadias descent of testes, inguinal hernia, hydrocele. 3emales: Perforate hymen, normal location of urethra, #aginal discharge (nature and =uantity). Presence of any dermatitis. Position, tone and appearance of anus. *run/ and <pine: <ymmetry, presence of spinal cur#ature (descri+e) ! tremities: ?oo/ for clu++ing, cyanosis, #enous engorgement, nail a+normalities, lesions of s/in, palms and soles, edema, hemorrhage, and contusion. Chec/ for asymmetry or deformities. Chec/ for presence and strength of central and peripheral pulses. Chec/ for capillary refill. </in: Rashes, turgor, edema, erythema, cyanosis, pallor <uperficial ?ymph 1odes: Cer#ical, a illary, inguinal, and epitrochlear. <i9e, consistency, tenderness (measure %ith tape). 1eurological: <tatus of cranial ner#es. Chec/ .*Rs, clonus, 0a+ins/i response, a+dominal and cremasteric refle es. Chec/ for touch and pain sensation. >ental status (orientation). Cranial ner#es II thru BII. >otor. <ensory (pain, light touch). Refle es. Coordination and gait. Infants: the primiti#e refle es, including moro. *onic nec/, Parachute, etc. ASSESSMENT ?ist pertinent diagnoses or pro+lems in order of importance +eginning %ith pro+lem that most directly resulted in the patients admission. Include the appropriate IC.7C code for each. 3or each pro+lem, list your differential diagnoses +eginning %ith most li/ely one. ! ample: D) $hee9ing (EFG.HE) .ifferential diagnosis: asthma, +ronchiolitis, cystic fi+rosis, or gastroesophageal reflu disease 6) "llergic rhinitis (:EE.;) @R D) <tatus asthmaticus (:C8.C) 6) "cute respiratory failure (;DF.FD) 8) Influen9a #irus infections ('') PLAN ?ist your treatment plan as you %ould if you %ere %riting orders to admit this patient. DISCUSSION Gi#e a +rief t%o7paragraph rationale for your differential diagnosis and selection of most li/ely diagnosis and for your treatment plan. ?ist pertinent clinical =uestions that remain regarding diagnosis and plan for treatment. .iagnostic <tudies are traditionally mentioned after the physical e am, ho%e#er, some attendings may prefer a discussion of the assessment and plan prior to mentioning la+ results. Remem+er that if la+ results are o+tained prior to patients arri#al at the current hospital, they are appropriately mentioned in the ,PI.