Patients name

age

sex

ED/Clinic

Complaint

Abnormal Vital signs

Mrs. Gray Hello Mrs. Gray. My name is Dr. Mohammed Aty the Chief resident doctor. It is nice to meet you. Im here to take care of your child. Id like to ask you few Qs and examine your child later. Is that OK? May I have a seat? I hope if you do not mind, I will write down some notes while we are talking But I am all ears. Is that OK? OK. Mrs. Gray first of all what is your child name? So what problem caused you to bring him/her today? I am really sorry to hear that and I will do my best to make him/her feel better.

C/R PMS TOSS DEAF

C DP OF RPAP ACOB
Now I would like to ask you more Qs about his current C/O, is that OK? D: When did you first notice this problem/pain? P: Since that time till now, is he getting worse, better or it is the same? O: How did this problem start? I mean gradually or suddenly? Do you have any idea what causes this problem to start? F: Is it constant or does it come and go? How often does it occur? How long does it last? How does he feel between attacks? R: Does anything make his problem better? P: Does anything make his problem worse? A: Does he has any other complaints or symptoms beside this problem? P: Has he had similar problems in the past?

A: How much is/was it? A teaspoon? A tablespoon? A cupful? C: Tell me about its color please? O: Did you notice any unusual smell? B: Is/Was there any blood in it?

 Has he had a fever? (If yes) How long has he had a fever? Was it a low-grade or high-grade fever? Is it a continuous or intermittent fever? Does he have any chills? Has he been sweating?

Fever Chills Sweating

Sleep changes Fatigue

How is his sleep? Has she/he been feeling tired lately? Do you feel he looks tired?

Appetite changes Weight changes

How is your childs appetite? Did you notice any change in your childs weight recently? If 'YES', How much? In what period of time? Is he crying? Is his crying weak or vigorous? Did you notice any dry skin? Did you notice any dry mouth? Does he hold his head as if in pain? Did you notice any discharge from his eyes? Does he pull his ears? Do you feel that he has stiffness in his neck? Do you think that he has any breathing problems? Like fast breathing? Does he have any cough? Does he pull his legs to his belly as if in pain? Does he cry while urinating? When was his last time to void urine? How many diapers did you change for him since yesterday how many times did he urinate since yesterday? is that normal for him? Does he have any diarrhea? How many times? ACOB? Constipation?

CHANGES

CIL

Has he been in contact with any sick person? Is your child immunization up to date? How does he look? Playful, irritable, sleepy, or lethargic?

FOLLOW UP

Do you check up with pediatrician regularly? Could you please give me his name and his phone number. When was the last time? What did the doctor tell you? According to his pediatrician was he normal for weight and height.

R Now I want to ask you few Qs about his development.

How is your child developing as compared to other children? When did he first smile? 2 mo When did he first sit up? 6 mo When did he first stand up? 8 mo Does he walk? 12 mo How many words he can say?

Now I want to ask you about his health in the past. Did he have similar symptoms before? Does he have any other health problem that I should know about?

M Has he had any medications? S

Has he had any surgery? Has he been hospitalized for any other reason?

T Has he had any injury? O Does your child go to day care center/school?
Is there anyone sick at the day care? Would you describe your son as playful and social or shy and quiet? Could you please tell me more about his school? Could you please tell me what his teachers say about him? Could you please tell me about his friends?

S Now I want to ask you few Qs about your lifestyle.

(1) What type of work do you do? (2) Did you smoke during pregnancy? Now (3) Did you drink during pregnancy? Now (4) Did you use (street) drugs during pregnancy? Now (1) How is your relation with your son/daughter? (2) How is your husband relation with his son/daughter? (3) How is your relation with your husband?

S Now I want to ask you few Qs about your pregnancy.

(1) Was it a full term pregnancy ( 40 wks = 9 mo )? (2) Have you had any medical problem during pregnancy? (3) Have you had routine checkups during pregnancy? Now I want to ask you few Qs about his birth. (1) Was it normal vaginal delivery? (2) Did you have any complications after delivery? (3) Has he had any medical problem when he was born? (4) What was his birth weight? (5) How was he fed after birth? (6) Within how many hours was his first bowel movement? (7) Within how many hours was his first urination?

Now I want to ask you few Qs about his feeding. Could you please tell me about the diet of your son? (1) Was he breast fed or given formula? (2) When did he start eating solid food? 6 months.

A Is he allergic to anything? F Now I want to ask you few Qs about the health of his family.
(1) Does anyone in the family have the same symptoms? (2) Is there any medical problem in the family? Ok Mrs. Gray. Thank you for your kind co-operation. Let me summarize what I have so far. You said that your son has. for and .. What I think that he/she may has a problem in his..or What I want you to do is it bring your baby to the hospital So we can do proper physical exam for him and may be run some blood tests and some imaging studies. The health of your son/daughter is my priority. I dont want to delay the treatment but I want to give your child the proper treatment after making sure of the right diagnosis. And I want you to be sure that I am going to do all my best to make your child feels better. Does this sound good for you? Ok Mrs. Gray Do you have any Qs or concerns for me before I go? Ok Mrs. Gray I am looking forward to see you soon with Michael in the hospital. Have a nice day. BYE BYE.

Pediatric PN
- CC: .x 2 days - HPI: informant = mother on phone,1 yo, f, Elizabeth has loose stools x 2 days, getting worse, yellow, semisolid, no blood or mucus in it,2 cupful at a time. Has fever 101 F, pulls at both ear, seems to have belly pain just before passing stools. Has not urinated x since today morning. She is lethargic and has poor appetite. - ROS: (-) rash/seizures - Birth Hx: mother had regular visits in pregnancy, NVD, 36 wks, no complication - Dietary Hx: feeding for 6 months then given formula. Started solid food at 8 mo. - Development: last check up was 3 wk ago Normal growth + development. (the baby smiles at 2 mo and sit up at 6 mo and stand up at 8 mo, and walks at 1 yo and he can say 3-4 words). - PMH: no such past episodes - PSH: none - Medications: none - Allergies: Penicillin (rash) or NKA - FH: none or brother has just recovered from URI, rest non contributory - SH: lives with parents and brother - Immunization: UTD or MMR vaccine - PE: None - DD: - Work-Up: Physical exam Mental status exam. U/A Urine toxicology Otoscopy CBC Stool analysis, C & S.