Pedia: Quick Referral Template

Hello po, doc. Meron pong bagong patient Po.

Name:
Age/Sex:
AMD:
WEIGHT:
Healthcard:

CC:

HPI:

Last Vomiting:
Last BM:
Last OU:
Last Febrile Episode:

PMH
Prev surgeries/hospitalizations:
(-)Prev hosp
(-) Allergies
(-) Surgeries:
(-)Asthma
(-) Allergic Rhinitis
(-) Other:

Physical Examination:
BP
T
HR
RR
O2 at RA
Awake, Cooperative, not in respiratory distress
No pallor, no jaundice, no rashes
Pink palpebral conjunctiva, anicteric sclerae, non sunken eyeballs
Nonhyperemic PPW, moist lips and moist buccal mucosa
Adynamic precordium, normal rate, regular rhythm, no murmur
Symmetrical chest expansion, clear breath sounds, no retractions
Abdomen soft, flat, nontender on all quadrants, normoactive bowel sounds
No bipedal edema, CRT <2s, full and equal pulses

Neuro PE
CN I - Can smell mint
CN II - 2-3mm ERTL
CN III, IV, VI - Intact EOMs
CN V - Can clench teeth
CN VII - No facial asymmetry
CN VIII - Intact gross hearing
CN IX, X - Intact gag reflex
CN XI - Can shrug bilateral shoulders
CN XII - Tongue at midline

Motor and Sensory - Intact

Motor strength 5/5 RUE, LUE, RLE, LLE
Sensory 100% RUE, LUE, RLE, LLE
+2 pulses at dorsalis pedis, bilateral
Thank you po, doc.