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ClerkshipMajor Objectives Grading & Honors CLIPP and CORE Cases COMSEP Policies Related Links Fargo Students
- Pediatric Clerkship Requirements
- Intro to Inpatient/Outpatient
- Inpatient H&P Exam Outline
- Outpatient Write-Up Expectations
- Oral Case Primer
- Oral Case Presentation Template
- Nursery Infection Prevention
- Grand Rounds Preparation
- Pediatrics Mid-Clerkship Student Self-Assessment and Preceptor Feedback
- Teaching Faculty
Outline for Pediatric History & Physical Exam
This is the (1st, 2nd, 3rd) admission for this age, sex, with a reason for admission.
Chief Complaint (CC)
CC should be in parents' or child's own words if possible. If not a quote, use a succinct summary (less than 10 words).
History of Present Illness
This is the most important section of your H&P. Ninety percent of pediatric diagnoses are made with the history. All of the significant information that supports the differential diagnosis should be found in the HPI. List here all the pertinent, positive and negative direct answers to your questions. The information should be listed chronologically starting at the beginning of the story. Paint a picture from the patient and family perspective. Relevant PMH that affects the differential should be included here. The HPI should contain the important details, but these details should be written precisely, concisely and orderly. Include objective data in your narrative (e.g., x-ray reports and labs obtained in other hospitals) that pertain to the patient’s need for admission. Also include response to treatment/interventions (e.g., did wheezing improve after a neb treatment or fever drop with ibuprofen).
Bonus tips: Don't forget to tell the story from the patient and family perspective. Use time references relative to the day of admission (e.g., 3 days prior to admission). Bonus points for documenting "fears" and "frustrations."
Perinatal and Neonatal Information: This information is more important the younger the child, but could be relevant at any age depending on the situation. Examples include: birth date, hospital, city, weight and length, type of delivery, for example, spontaneous type of presentation; vertex or breech. Apgar scores, age of mother, length of gestation, exposures to infectious diseases, and medications, drugs, or alcohol including tobacco used during pregnancy should be recorded if pertinent to the case. Information regarding the newborn, might include hypoglycemia, cyanosis, pallor, seizures, jaundice, skin lesions, muscle skeletal deformities, respiratory distress or feeding problems.
Serious childhood medical problems: Illnesses, injuries and fractures, hospitalizations. Include age, severity, complications, dates and sequelae.
Surgical Procedures: List with approximate dates and complications.
Nutrition: Examples of age appropriate questions include: infants - breast fed, if formula is used which type, vitamin supplementation and past growth information. For older kids, ask about the food groups.
Allergies: Medication and others. Include a description of the reaction.
Immunization: Indicate sources of information, dates immunizations given, and which type of immunization was provided. Also include TB testing results and dates if performed.
Developmental History: Record information regarding a child's current developmental status with regard to each of the four following areas: gross motor, fine motor, social, and language skills relative to developmental milestones. Be specific.
For school age children, ask about school performance. Include academics, behavioral and social domains. For teens, this would be a good section to ask about sex/substances/psychiatric concerns.
Habits and Personality: Include sleep, temperament, behavioral concerns.
Record all known significant diseases in first degree relatives (parents, grandparents, aunts, uncles, siblings). Record all deaths in these first degree relatives. Examples that might be included in this section would be diabetes, cancer, epilepsy, allergies, hereditary blood dyscrasia, early coronary artery disease, hyperlilpidemia, mental retardation, dystrophies, congenital anomalies, degenerative diseases, cystic fibrosis and celiac disease.
Living circumstances: place and nature of dwelling, sleeping arrangements, daycare arrangements.
Parents' occupations and marital status
Potential exposures to toxins in home, for example, cigarette smoke exposure
Age of home (of children less than 3) -possible lead exposure
Review of Systems
Review each of the following systems and include all positive and pertinent negative answers to questions. The key is documenting age appropriate questions for each system.
Endocrine & Growth
II. Physical Examination
All positive physical findings should be recorded. Pertinent negative findings relevant to your differential diagnosis should also be included. This is your opportunity to practice pediatric specific exam skills for each age of patient; don't miss those chances.
Tips for different ages:
Very young infants and neonates are often easiest to examine on the examining table. From several months to preschool age it is often more effective to have the child lie or sit on the mother's/father's lap. Try to interview and examine adolescents without the parents present. If a parent is not present during the examination a student should have a nurse or the attending physician present at the time of examination or have parental permission to examine the child. Observe the child under ideal circumstances, for example, while in mother's lap and leave the more painful and uncomfortable parts of the examination until last, for example, the throat and ears.
Temp (route), resp rate, HR, BP, weight, height/length should be recorded on all patients. For kids under 2 years include head circumference. For kids over 2 years include BMI. All growth parameters (Ht, Wt, HC, BMI) need to be the percentile from a growth chart - for example 91.3 kg (55%ile). Include O2 sat and FiO2 (if applicable).
For example any obvious deformities, size appropriate for age, respiratory distress or pain, and hydration and general nutrition status.
Normal or abnormal facies and normal or abnormal head shape. Fontonelle size if open (anterior and posterior). Look for and document dysmorphic features, especially in infants.
Proptosis, sclerae, conjunctivae, strabismus, photophobia, and fundoscopic exam (or red reflexes in infants).
Hearing, pinnae and placment, external canal, discharge, tympatic membrane appearance.
Air movement, mucosa, septum, turbinate appearance, perinasal sinus tenderness.
Mouth and Throat
Color, dryness, fissure; appearance, teeth - number and caries, gum - color and hypertrophy, epiglottis - appearance, tonsils - size and appearance.
Flexibility, masses. Thyroid - size.
If abnormal in size or texture record location, consistency, tenderness, size in centimeters.
Scoliosis, mobility, tenderness.
Appearance and contour, respiratory rate and effort, regularity of breathing, symmetrical chest movement, character of respirations such as retractions.
Percussion, palpation, fremitus, auscultation.
Inspection, precordial bulge, apical heave, auscultation, rhythm, character and quality of sounds.
Palpation: PMI, thrills, heaves.
Auscultation: quality and intensity of heart sounds, murmurs, for example, timing, duration, intensity, location, radiation.
Pulses: radial and femoral pulses, rate and rhythm.
Inspection, contour, umbilicus, distention, veins, visible peristalsis, hernia.
Percussion: fluid wave, shifting dullness, tympany, liver size, spleen size, costovetebral angle tenderness, abnormal masses.
Palpation: tenderness, rebound, guarding, masses.
Record Tanner Stage
Male: circumcised, testes - appearance and size, hydrocele - presence hernia.
Female: external genitalia, appearance of vulva, clitoris, hymen.
Rectal (only if indicated)
Fissures, hemorrhoids, prolapse, sphincter tone, stool in ampulla, abnormal masses.
Texture, color, turgor, temperature, moisture, icterus, cyanosis, eruptions, lesions, scars, ecchymoses, petechiae, spider nevi, desquamation, hemangiomata, mongolian spots, nevi.
Tone, color, warmth, clubbing, cyanosis, mobility, Ortalami and Barlows maneuvers in newborns and infants, deformities, joint swelling or tenderness.
Mental status: affect, level of consciousness, speech
Motor: station and gait, muscle strength, tone, tics, ataxia
Cranial nerves: testing 2-12
Deep tendon reflexes: 2+ is average when recording
Record if Babinski present
Infant reflexes: grasping, sucking, moro, rooting, stepping, placing
Abnormal sensory findings
III. Clinical Decision Making
Summarize the key clinical data in 2 sentences. First sentence is the history, second sentence is the physical and lab findings. A good summary statement includes the essential clinical facts that define the presenting problem.
Build your differential diagnosis from your summary statement.
Defend which item on your differential diagnosis is most likely. Show your clinical reasoning here.
Management Plan (reflect the differential diagnosis)
Write the management plan in list form as if writing admission orders.
Pertinent subsequent lab results.
Write a short, one to two paragraphs in your own words, report on a specific medical topic that pertains to this patient. This might be from the differential diagnoses or problem list. Use evidence-based literature to support your information and document your references.
IV. Feedback Notes
A major part of my evaluation will be based on your inpatient write-ups. I am looking for completeness, evidence of clinical reasoning and ability to incorporate feedback into improvement.
100 point scale
You will get a score out of 100 points. The goal is to get to 90 or higher. Your feedback will be in person (or by email if schedules do not permit meeting). Points will be taken off for missing items, details, or not showing your work. Bonus points can be added for documenting "fears" and "frustrations."
H&Ps are due before 11:59 pm on Tuesdays before our scheduled time on Thursdays for Written Case Presentation Session. That will give me enough time to review them and generate meaningful feedback for your. Email write-ups to both email@example.com and firstname.lastname@example.org