Professional Documents
Culture Documents
Pedia WW Doc Template Tuvs
Pedia WW Doc Template Tuvs
Pedia WW Doc Template Tuvs
History
I. General Data
a. Name
b. Age
c. Date
d. Place of birth
e. Sex
f. Race
g. Religion
h. Present address
i. Number and date of hospital admission
j. Informant
k. reliability
II. Chief complaint
d. Feeding
i. Infancy
1. Breastfeeding
2. Formula
3. Complimentary
a. Calorie computed
ii. Childhood and adolescent (2-20
)
1. Appetite or picky eater
2. Food intake – amount per day
3. Compute for ACI compare with
RENI
4. Sample food
e. Developmental/behavioral
i. Young 1-5
1. Dental eruption
2. Urinary continence day and
night
3. Completion of toilet training
4. Temper tantrums
5. Head banging
6. Phobias
7. Pics
8. Night terror
9. Sleep disturbances
10. Other behavioral problems
ii. Middle childhood 6-11
1. School performance
2. Sexual development (tanners)
iii. Adolescence 10-20
1. Home
2. Education
3. Eating
4. Behavior
5. Activities
6. Drugs
7. Sexual
8. Suicide Source of funds
9. Sexual development – tanners’
maturity IX. Environmental history
a. Circumstances
f. Past medical history b. Exposure to cigarette smoke
i. Measles
c. Environmental pollutants
d. Garbage disposal
ii. Varicella
e. Sewage disposal
iii. Mumps
f. Water source
iv. Pertussis
v. Other illness (hospitalized) Physical examination
vi. Allergy, eczema, asthma, food
I. General
or drug sensitivity a. Mental state or sensorium
vii. Injuries i. Level of activity
• Clinical course of disease ii. Shrieking cry
VI. Immunization history iii. Grunting
a. Type iv. Affect
b. Date b. Cardiopulmonary distress
c. Place i. Color
d. Unwanted reaction ii. Chest retraction
VII. Family history c. Gait
a. Parents i. ambulatory
i. Age ii. bedridden (position)
ii. Occupation d. Nutritional state
iii. State of Physical/mental i. Well, under over
health e. Looks
iv. Living or cause of death i. Well, mildly ill, severely ill
b. Siblings II. Vital signs
i. Number a. Temperature
ii. Ages b. Cardiac rate
iii. State of health c. Pulse rate
iv. Age and cause of death d. Respiratory rate
c. Familial illness or anomalies e. Blood pressure 3 years old up
i. TB f. Anthropometric
ii. Diabetes i. Weight
iii. Syphilis ii. Length < 3yr
iv. Cancer iii. Height > 3 year
v. Epilepsy iv. Head circumference < 3
vi. Rheumatic fever years
vii. Allergy 1. Other measurement
viii. Hematology for special
ix. Mental retardation a. Chest
x. Congenital defects b. Abdomen
v. BMI = Wt kg/ M3
VIII. Socioeconomic history vi. Z score
a. Living circumstances III. Skin
i. Place a. Color
ii. Nature of dwelling b. Turgor (wrinkle or loss or elasticity)
iii. Number of persons c. Loss of subcutaneous tissue
iv. Living in house d. Rash or eruptions
b. Economic e. Hemorrhage
i. Working members f. Scars
ii. g. Edema
h. jaundice Mucus membrane
IV. HEENT v. Dentition
a. Shape or contour vi. Palate
b. Scalp vii. Posterior pharyngeal wall
i. Hematoma viii. Tonsils (color)
ii. Abscess 1. Tonsil grade
iii. Edema
c. Fontanels in infant V. Neck
i. Sutures a. Masses
1. Open b. Venus engorgement
2. Overlapping c. Flexibility
3. Gaping d. Rigidity
ii. Posterior 2-4 months e. Lymph node
iii. Anterior 9-18 months f. Torticollis
d. Hair g. Thyroid
i. Color VI. Chest/ lungs
ii. Quantity a. Retractions
e. Face b. Lung expansion
i. Symmetry c. Asymmetry
ii. Unusual facies d. Tactile fremitus
iii. Deformities e. Breath sounds
f. Eyes f. Adventitious sounds
i. Lid i. Crackle
ii. Conjunctivae ii. Wheezed
iii. Sclerae iii. Ronchi
iv. Opacities iv. Friction rub
v. Discharge v. Stridor
vi. Red orange reflex (infants) vi. Grunting
vii. Corneal light reflex VII. Heart
viii. Vision (snelles, E chart) a. Precordium
g. Ears b. Visible pulsation
i. Size c. Apex beat (4th until 7)
ii. Shape d. Thrills
iii. Location e. Heart sound
iv. Position f. Rhythm
v. Tympanic membrane g. pulses
h. Nose
i. Patency VIII. Abdomen
ii. Alar flaring a. Distension
iii. Discharge (character b. Prominent vessls
iv. Septum c. Striate
v. Sinus tenderness d. Pulsation
i. Mouth and throat e. Peristaltic movement
i. Lips f. Bowel sound (high pitch)
ii. Gums g. Percussion
iii. Tongue h. Ascites
iv. i. Liver span
j. Tenderness direct rebound
k. Spleen (normally not palpable
unless 2-3x enlarge
l. CVA tenderness
IX. Inguinal region
a. Hydrocele
b. Undescended testes
c. Lymph nodes
X. Genitalia
a. Prepuce – easily retractable
b. Cryptorchidism
c. Female genitalia
XI. Anus and rectum
a. Patency
b. Anal tags
c. Hemorrhoids
d. Presence of pinworms
e. Prolapse
XII. Extremities
a. Clubbing
b. Cynosis
c. Mobility of joints
d. Deformities
XIII. Spine
a. Sacrococegeal dimple
b. Pilnodial sinus
c. Local tenderness
XIV. Lymph nodes
a. Occipital
b. Posterior hairline
c. Post auricular before going
downward
Neurologic Examination
I. Cerebrum
II. Cerebellar
III. Cranial nerves
IV. Motor
V. Sensory
VI. Reflex
Admitting impression