Infant and Childhood Development and Immunization Schedule
Admission History and Physical
Pediatric History:
- Source and reliability
- Chief complaint
- History of present illness
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Past Medical History
- Birth
- Medical
- Surgical
- Developmental
Medications/Allergies/Immunizations
- Primary Medical Doctor
- Family History
-
Social History (Infant)
- Home
- Daycare
- Feeding
- Sleep
-
Social History (Adolescent)
- Home
- Education
- Activity
- Drugs
- Sex
- Stress/Suicide
- Safety
- Strengths
Review of Systems
Pediatric Physical Exam:
- Vitals: remember that vitals vary by age! Look up normal values (and check with resident/attending)
- **Include wt/ht/head circumference and PERCENTILES in admission notes.
General appearance: very important to think about sick vs non-sick – use good descriptors - HEENT: fontanelles, head shape, dysmorphic features, red reflex, conjunctiva?, rhinorrhea? TMs? Neck supple?
- Chest: respiratory issues are common! “subtract” sound heard from nose from lung sounds, look for retractions
- Cardiac: remember to take your time listening – it’s harder when the heart is beating fast!
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Abd: similar to adults. Evaluate umbilical area in neonate – clean/dry/healing?
GU/GYN: In infants notes if testes descended/normal genitalia; in adolescents – describe Tanner staging - Ext: In infants note hip exam (“no clunks”); femoral pulses
- Back: In infants note “sacral dimple/hair tuft”; in older patients, any scoliosis
- Neuro: In infants describe general tone and reflexes
- Skin: rashes are VERY common in pediatrics! Practice writing good descriptions of lesions!
Daily SOAP
One liner: name, diagnosis, management
Subjective:
Objective:
Assessment and Plan:
By problem
By system