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Pediatric Visit
Sep 5, 2018
•
Mark Morgan
categories:
Pediatrics
.
history provided by patient
history provided by parent/family member
family member present during visit
chaperon/MA present during visit
interpretation provided by family member/SO
interpretation provided by MA
speech input
CC:
cold
fever
runny nose
nasal congestion
earache/pulling on ear(s)
sore throat
cough
stridor
wheezing
rash
poor appetite
abd pain
diarrhea
nausea
dysuria
speech input
HPI/SYMPTOMS:
new problem
chronic condition
acute exacerbation of chronic condition
started today
started yesterday
started several days ago
started weeks ago
started months ago
started years ago
still present
increasing in severity
persisting
occasional
decreasing
resolved
affected by medication
affected by position/movement
as in cc
speech input
MEDICATIONS:
Rx
OTC
reports no side effects
reports side effects
effective
partially effective
not effective
taking as prescribed
not taking as prescribed
did not try
none reported
speech input
PERTINENT MEDICAL HISTORY:
day care/school attendance
sick contact
contact with confirmed/suspected c19 carrier
c19 positive test
c19 negative test
c19 sx
consumption of food outside home
travel
recent ER/UC visit/hospitalization/surgery/procedure
recent diagnostic/laboratory studies
recent specialty consults
new/changed medications
ABX use
missed shots
frequent infections
frequent ABX use
asthma
allergies
eczema
non-contributory
none reported
speech input
.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:
does not report fever, tired, changed behavior, fussy
speech input
HEENT:
does not report headache, scalp swelling, facial swelling, eye redness/discharge, itching, periorbital swelling, earache, ear discharge, wax, nasal congestion, rhinorrhea, bleeding, mouth sores, infection, sore throat, hoarseness, swollen neck glands
speech input
Chest/Respiratory:
does not report shortness of breath, cough, phlegm, wheezing, or chest wall pain with breathing
speech input
GI:
does not report poor appetite, nausea, vomiting, abdominal pain, constipation, diarrhea, rectal itching/bleeding
speech input
GU:
does not report dysuria, hematuria, frequency, urine odor, discharge, or skin lesion/rash
speech input
MSK:
does not report limping, myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling
speech input
Neurologic:
does not report dizziness, seizures, balance problems, weakness, or falls
speech input
Psychiatric:
does not report anxiety, mood swings, behavioral issues, or sleep problems
speech input
Dermatologic:
does not report rashes, redness, pruritus, swelling, bruising, or wounds
speech input
Hematologic/lymphatic:
does not report abnormal bleeding/bruising
speech input
.
OFFICE DIAGNOSTICS:
none
rapid strep NEG
rapid strep POS
rapid flu NEG
rapid flu POS
rapid C19 NEG
rapid C19 POS
CXR
results discussed with family
speech input
Appearance:
well-appearing
active
interactive
non-toxic
strong suck
crying
consolable
NWOB
moist mucous membranes
age-appropriate behavior
ill-appearing
inconsolable
irritable
diaphoretic
short of breath
uncooperative with exam
speech input
Head:
normocephalic, atraumatic
normal anterior fontanel
scalp tenderness
plagiocephaly
swelling
speech input
Face:
symmetrical
no evidence of trauma
no obvious cranial nerve deficits
rash
swelling
ecchymosis
speech input
Eyes:
clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact
PERL
corneas clear
allergic shines
dennie lines
periorbital swelling
conjunctival injection
epiphora
conjunctival exudate
palpebral edema
palpebral exudates
dysconjugate gaze
speech input
Ears:
symmetrical & intact auricles bilaterally, hearing to conversation intact
no tragal tenderness
clear canals without erythema or D/C
no FB visible in canals
TMs normal in appearance
no mastoid tenderness
tragal tenderness
swelling of external auditory canal
debris in canal
cerumen in canal
dried up blood in canal
TM obscured by cerumen
TM red
pus behind TM
fluid behind TM
TM bulging
TM perforated
TM retracted
tube in TM
mastoid tenderness
speech input
Nose:
nares patent bilaterally
no facial tenderness
mucosa pink & moist
allergic salute
maxillary tenderness
frontal tenderness
deviated septum
swollen & boggy mucosa
mucosal ulceration
mucosal congestion
clear discharge
yellow discharge
crusty discharge
bloody discharge
active septal hemorrhage
clotted blood
speech input
Mouth:
tongue normal in appearance w/o lesions
moist oral mucosa without lesions
normal dentition for age
single oral ulcer
multiple oral ulcers
gum swelling
tooth caries
speech input
Throat:
normal voice, patent pharynx w/o swelling or exudates
uvula midline
clear pharynx w/o exudates
pharyngeal erythema w/o exudates
hoarseness
vesicles on soft palate
petechiae on soft palate
pharyngeal crowding
tonsilar enlargement
tonsilar erythema
tonsilar exudates
tonsilar crypts
tonsilar pustules
speech input
Neck:
symmetric with free painless ROM
no LAD
anterior LAD
posterior LAD
nuchal tenderness
speech input
Lungs:
normal work of breathing, symmetrical chest expansion
clear and equal breath sounds bilaterally
SOB
stridor
intercostal retractions
wheezing
crackles
barky cough
dry cough
wet cough
speech input
CV:
chest wall atraumatic
regular rhythm, no murmurs
pedal skin warm with good & equal pulses
tachycardia
systolic murmur
sternal tenderness
breast mass
breast tenderness
skin dimpling/retraction
speech input
Abdomen:
normal visual inspection, no distension
normal active bowel sounds throughout
soft non-tender
non-disturbed with abdomen palpation
no obvious palpable masses or hepatosplenomegaly
heel-drop negative
diffuse tenderness over entire abdomen w/o RRG
direct non-rebound tenderness
umbilical hernia
hypoactive bowel sounds
hyperactive bowel sounds
speech input
GU:
no CVAT bilaterally
no suprapubic tenderness
normal external genitalia
circumcised
uncircumcised
smooth non-tender testes
+cremasteric reflexes bil
no skin lesions
testicular tenderness
vesicles
deferred
speech input
Back:
no gross deformities, normal curvature & ROM
scoliosis
speech input
Extremities:
atraumatic w/o swelling or deformity
free and painless ROM in upper extremities
free and painless ROM in lower extremities
strength and tone symmetrical & grossly intact
DROM
tenderness
swelling
speech input
Neuro:
alert, balance & coordination grossly intact
full weight bearing
normal vocalization
CN grossly intact
no gross motor deficits
sensation symmetrical & grossly intact
reflexes normoactive
antalgic gait
speech input
Psych:
appropriate to age/situation
normal concentration and attention
good eye contact
anxious
irritable
speech input
Skin:
grossly intact, no rashes
no bruises
normal turgor
poor turgor
dry
sweaty
erythema
induration
firm
soft
deep
mobile
fluctuant
painful
abrasion
excoriation
fissure
laceration
ulceration
ecchymosis
swelling
burn
generalized rash
acral rash
symmetrical
unilateral
linear
annular
arcuate
serpiginous
red scaly
red non-scaly
macular
papular
maculopapular
follicular
urticarial
targetoid
vesicular
pustular
purpuric
non-blanching
sharply-demarcated borders
indistinct borders
speech input
Discussion:
speech input
.
PLAN OF CARE: family verbalized understanding of dx & POC,
agreed with dx & POC
did not agree with dx & POC – encouraged to seek second opinion
speech input
ORDERS - MA:
injection
XR
none
speech input
ORDERS - RX:
OTC
electronic
paper
given to MA to be transmitted to pharmacy
none
speech input
speech input
speech input
ORDERS - LABS:
CBC
CMP
TSH
A1C
C19
none
speech input
ORDERS - IMAGING:
X-ray
US
none
speech input
ORDERS - PREVENTATIVE:
UTD
flu
none
speech input
ORDERS - OUTSIDE REFERRALS:
none
speech input
ORDERS - FORMS/RELEASE/CLEARANCE:
excuse from school
cleared for sports participation
cleared for school return
without restrictions
with restrictions
none
speech input
REVIEWED/DISCUSSED:
MA notes
med list
previous visits
laboratory/diagnostic studies
advised that negative/'normal' results do not rule out pathology
specialty reports
hospital discharge
speech input
INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services,
OTC medicines and comfort measures for symptom control
adequate hydration
weight reduction/exercise
carbs restriction
age-appropriate screening and immunization
speech input
DISCHARGE CONDITION/SAFETY:
improved
stable
unchanged
appears well
non-toxic
physical exam unremarkable for any emergent condition
no safety concerns at this time
safety concerns d/t parental knowledge/mood
safety concerns d/t custody issues
speech input
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx,
here
in-person
televisit
w PCP
24 hours
2-3 days
1 week
30 days
6 weeks
3 months
6 months
12 months
f/u acute episode
f/u labs
f/u imaging
f/u med change/new
speech input
DISPOSITION:
home
referred to ER for immediate treatment via 911
referred to ER for immediate treatment via private transport
declined emergency transfer
left clinic before being discharged
asked to leave clinic
speech input
PARENTAL BEHAVIOR:
calm, pleasant, respectful
anxious
suspicious
irritable
frustrated
forceful
insisting on particular medication, test, referral, or accommodation
argumentative
hostile
raising voice
agitated
cursing, swearing
previous providers/staff criticisms
verbal threats
sexual remarks
racist remarks
flat affect
bradykinetic
indifferent
appears to be responding to internal psychotic process
speech input
BARRIERS TO CARE:
incomplete history
poor cooperation with exam
language barrier
parental affect
socio-cultural factors
vague shifting complaints
history not supported by objective findings
supporting documentation unavailable
poor compliance with POC
intolerance of/therapeutic failure on multiple meds
negative attitude to diagnostic impression & proposed tx
lack of interest in nonpharmacologic therapies
preoccupation with illness
catastrophization
overgeneralization
unrealistic beliefs
negativism
pessimism
blaming others
hostile/disruptive behavior
none noted at this time
speech input
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