Pediatric History And Physical Exam

Front 1

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Back 1

Initial information

Front 2

Includes age, gender, marital status and occupation. Source of history or referral can be the patient, a family member or friend or the medical record. Helps you asses the type of information providedand any possible biases.

Back 2

Identifying Data

Front 3

Should be documented if relevant. This judgement reflects the quality of information provided by the patient.

Back 3

-Reliability

Front 4

Is always important. Routinely document the time you evaluate the patient

Back 4

Date and Time of History

Front 5

Complete, clear, and chronologic account of the problems. Prompting the patient to seek care:

Onset of the problem

Setting in which it has developed

Manifestations

Any treatments

Back 5

Present illness

Front 6

Quote patients own words. If noovert complainsreport their goals instead.

Back 6

Chief of complaint

Front 7

When did the chief complaint occur

Back 7

-Onset

Front 8

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Back 8

-Prior occurrence of this problem

Front 9

Is this problem getting worst or better. Isthere anything that the patient does that makes it better or worse.

Back 9

-Progression

Front 10

Is there pain and if so what type-how would the patient describe it in words

Back 10

-Quality

Front 11

On a scale of 1 to 1, how bad are the symptoms

Back 11

-Scale

Front 12

When do the symptoms occur? At night, all the time, in the morning etc

Back 12

-Timing

Front 13

Do the symptoms radiate to anywhere in thebodyandi if so, where?

Back 13

-Radiation

Front 14

Info about the chief complaint that has not already been covered.

Back 14

-Associated symptoms

Front 15

name, dose, route, and frequency of use. Also list home remedies, nonprescription drugs, medicines borrowed from family members or 'friends. Ask patients to bring in all of their medications so you can see exactly what they take.

Back 15

Medications

Front 16

Specific reactions to each medication.

Rash

Nausea

Allergies to foods

Insects

Environmental factors

Back 16

Allergies

Front 17

Type used and are often reported in pack-years. If someone has quit, note for how long.

Back 17

Tobacco use

Front 18

use should always be investigated.

Back 18

Alcohol and drug

Front 19

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Back 19

_______History

Front 20

such as measles, rubella, mumps, whoop- ing cough, chickenpox, rheumatic fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses.

Back 20

Childhood illnesses

Front 21

Adult Diseases

Illnesses such as diabetes, hypertension, hepatitis, asthma, and HIV; hospitalizations; number and gender of sexual partners; and risky sexual practices

Back 21

Medical

Front 22

Dates, indications, and types of operation

Back 22

Surgical

Front 23

menstrual history, methods of contraception, and sexual function

Back 23

Obstetric/Gynecologic

Front 24

Illness and time frame, diagnoses, hospitalizations, and treatments

Back 24

Psychiatric

Front 25

Especially immunization and screening test

Back 25

Health Maintenance

Front 26

Health Maintenance

whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenza type B, and pneumococci.

Back 26

Immunizations

Front 27

review tuberculin tests, Pap dile smears, mam- mograms, stool tests for occult blood, and cholesterol tests, together with results and when they were last performed

Back 27

Screening Test

Front 28

Outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren. Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease etc.

Back 28

Family History

Front 29

Patient's personality and interests, sources of support, coping style, stengths and fears.

Includes:

Occupation

Schooling

Source of stress

Important life experiences

Leisure activities

Religious and spiritual beliefs

Activities of daily living

Back 29

Personal and Social History

Front 30

asking series of questions going from head to toe and questions pertain to symptoms.

Back 30

Review of Systems

Front 31

Review of Systems

Usual weight, recent weight change, any clothes that fit more tightly or loosely than before. Weakness, fatigue, or fever.

Back 31

General

Front 32

Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails; changes in size or color of moles.

Back 32

Skin

Front 33

1. Headache, head in- jury, dizziness, light headedness.

2. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts.

3. tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or non use of hearing aids.

4. Frequent colds; nasal stuffiness, discharge, or itching: hay fever, nosebleeds; sinus trouble.

5. (or mouth and pharynx): Condition of teeth and gums; bleeding gums; dentures, if any, and how they fit; last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness.

Back 33

HEENT

1.Head

2.Eyes

3.Ears Hearing

4.Nose and sinuses

5.Throat

Front 34

"Swollen glands"; goiter; lumps, pain,or stiffness in the neck.

Back 34

Neck

Front 35

Lumps, pain, or discomfort; nipple discharge; self-examination practices.

Back 35

Breast

Front 36

Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.

Back 36

Respiratory