During your Pediatrics Clerkship you will be expected to perform a complete admitting history and physical examination on your patients, as well as dictate discharge letters. Please use the guides below to help build your skill level in those responsibilities.
Guide to Admission Orders
Admit To: (Location, Service, MDs, and pagers)
Diagnosis: (chief complaint, or known diagnosis)
Condition: (e.g. Stable, Fair, Guarded, Critical, etc.)
Vitals: (e.g. per routine, q15 mix x 4, q4h, q8h, etc.)
Allergies: (drug and food allergies - mention reaction)
Activity: (e.g. bed rest, up with assistance, OOB in chair, BR privileges, etc.)
Nursing: (e.g. daily wt, BID wt, Strict I/O's, dip urines for heme, guaiac all stools, dressing changes BID, routine trach or G-tube cares, etc.)
Diet: (e.g. NPO, Regular for age, ADA diet, Renal diet, Low Na diet, Clears, soft, etc.)
IVF: (Specify solution and rate; remember no KCI until voiding)
Meds: (List all meds with proper dosage, route, and frequency; include patient's weight)
Exams: (e.g. AP/LAT CXR, Cranial CT w/o Contrast, UGI w/ SBFT, etc. - mention reasoning when ordering)
Labs: (Note that each institution has different lab nomenclature, so if in doubt spell out each desired lab test)
Other: (e.g. HOB elevated to 30 degrees, Continuous pulse oximetry, CR monitor, seizure precautions, etc.)
Call HO: (Be specific for your concerns, e.g. T>38.0 vs T>40.5, UOP <50ml/8hrs, RR<12, O2 SAT<92%, etc.)
Elements of a History and Physical
Birth hx: mom age, G/P, OB labs (GBS, HSV, STIs), prenatal care/complications, ROM duration, GA/mode/APGARs, delivery complications, birth wt, length of hosp stay, neonatal problems
Diet: br feed vs. formula (type), amount, freq
Growth/development: physical growth, social/emotional, motor, language/cognitive
Other significant illnesses
Lives w/ (parents, siblings)
Stressors at home
Smokers, firearms, seatbelts, car seats
Travel hx, pets
Gen: fever, wt loss/gain, activity
HEENT: eye pain, vision loss, drainage, otalgia, hearing loss, otorrhea, rhinorrhea, epistaxis, dentalgia, sore throat, hoarseness
Resp: cough, wheeze, stridor, apnea, cyanosis, resp difficulty, retractions, flaring
CV: murmur, CP
GI: feeding/appetite, N/V, diarrhea/constipation, abd pain, hematochezia/melena
GU: freq/UO, dysuria, hematuria, d/c
Neuro: sz, LOC, numbness, weakness
M/S: joint swelling, tenderness, weakness
Skin: rashes, lesions
Heme/Lymph: bleeding, anemia, jaundice, swollen glands
Psych: mood, sleep problems
Vitals: Temp HR RR BO O2sat Wt Ht BMI (with percentiles
Gen: alertness, distress, body habitus, position
HEENT: NCAT, fontanelles; PERRLA, sclera, conjunctiva; nares, nasal mucosa; MM hydration, cyanosis, dentition, post pharynx
Neck: rigidity, thyroid, LNs, carotids
Chest: retractions, wheeze, crackle, stridor, focal decrease BS, I/E ratio, percussion
CV: RRR, m/r/g, distal pulses, cap refill
Abd: ND, normoactive BS, soft & NT, HSM, masses
GU: Tanner stage, circ, testicle descend, anus
Skin: rashes, lesions
Neuro: CN II-XII, sensation, DTRs, tone/bulk, strength, gait, cerebellar fxn
M/S: joints (swelling, warmth, tenderness), A&P ROM
A/P (What, Why - H&P, labs DDx W/U Tx)
The true art of a discharge (d/c) summary is to be clear, concise, give only pertinent information, and describe what follow-up is essential. The goal should be to describe the reason for hospitalization, briefly summarize the hospital course, and to permit the primary MD to assume care of the patient after discharge. NOTE: Each hospital has specific requirements regarding format, e.g. Letter vs. Basic format.
- Identify self, Attending MD on service at D/C, Service
- List what the dictation is, e.g. D/C Summary, Clinic Visit
- Identify the patient and spell full name
- List the Pt's MR Number
- List dates of admission and D/C
WHO'S IT GOING TO:
- List name and address of Primary MD
- List all carbon copies with addresses, e.g. consultants, social work, home health care agency, etc.
HISTORY of PRESENT ILLNESS (HPI):
- This should be a concise and pertinent summary of the HPI and criteria for admission. Do not repeat the entire H&P.
PHYSICAL EXAM (PE) on ADMISSION:
- Include vitals, wt, and all pertinent positives and negatives. Do not repeat your full PE from the chart.
- List significant labs, normals and abnormal values if pertinent. Do not list all labs obtained.
- You may dictate this section by problem list or by systems, e.g. fluids/electrolytes/nutrition (FEN), infectious disease (ID), hematologic (HEME), pulmonary (PULM), cardiovascular (CVS), gastrointestinal (GI), genitourinary (GU), neurological (NEURO), endocrine (ENDO), etc. However, brevity is the key, e.g. The pt was rehydrated with IVF's, not: the pt received D5W1/2NS + 20 KCL @ 50cc/hr.
- D/C date
- D/C diagnoses
- D/C meds
- Restrictions/Diet/Special Instructions etc.
- "It was a pleasure to be involved in ____'s medical care. Please do not hesitate to contact me if you have any questions or concerns."