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Pocket Peds H&P Card HEENT H: NCAT, A/F 1x1cm (ant.

Fontanelle)
E: PERRL(A), EOMI, conjunctiva moist, RR++
CC: “quote from historian” E: TM movement- clear and mobile
ID: Identify info, reason for admit from MD perspective N: Polyps, discharge
Historian: (reliability, vague?) T: erythema, exudate, moist, tooth develop
Referring MD:______________ Phone # st
(20 baby teeth – 1 at 6month, then 1/month)
Neck: soft, supple, LAD, thyromegaly?
HPI: This is a __yo (m/f) in USGH until X days prior to admission Chest: symmetric, CTA, retractions?
when…. 2 day PTA…. Day PTA…. pertinent (+/-)…b/c of ____ pt CV: RRR, nl S1S2 without m,r,g, femoral pulse full and equal
admitted to 4NE to…) Abd: ND, BS+, NT, -masses, -organomegaly
or birthHx: Pt was ___lb product of a __wk gestation born by NSVD GU: nl ext genitalia, descended testes?
(C-section for __) to a ___yo GXPXAbxfollowing an uncomplicated Back: CVA tenderness? Scoliosis?
pregancy w/Apgars of __/__ Ext: c/c/e
Skin: rash, birthmarks, perfusion
PMHx: 1. Hosp/illness Neuro: Grossly intact or
2. SurgHx Mental status-alert, motor-tone, bulk, mass, sensory-touch, pain,
3. Meds -- mg PO/IV BID (x mg/kg/day) vibration, proprioception, cerebellar-tremor, DTR
4. Allergies Development:gross/fine motor, language, problem solving
5. Immunization IUTD (Hep B?, varicella?)
6. Birth Hx- as above, unremarkable LABS/STUDIES:
7. Development- failure to thrive, abuse, Gross Motor,
Fine motor, language, problem solving A/P: Problem #1, 2, 3
8. Feeding Hx A.1)What do you think is causing problem
9. Menstrual Hx 2) Why? –consistent, inconsistent features w/ HPI, PMHx, PE, LABs
3) Differential
FamHx: Fam Tree P. 1) What are you going to do? W/U
SHx: Live with? Parents profession, smoker, 2) Tx further
(esp. when abuse, failure to thrive)
ROS: Difficulty seeing/hearing, pain, easy bruising? “non contributory Congenital
except for…” Infectious
Neoplastic
PE: 1)General: Interactive, active, happy, smiling, well appearing Vascular/Anatomic
-> irritable but consolable -> irritable and unconsolable Metabolic
-> toxic (mental status changes, perfusion changes) Idiopathic/Iatrogenic
2) Vitals: Temp, HR, RR, BP Toxic
3) Growth thWt (%), Ht(%), Head circ if < 3yo (%)
[present as 50 %ile of X age when hugely above/below nl] © www.medfools.com

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