Pediatrics
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HISTORY:
[checkbox name="historian" value="provided by child|provided by parent||MA/chaperone present during visit||complete history unobtainable d/t parental anxiety and/or lack of knowledge||interpretation provided by family member|interpretation provided by MA|"][textarea cols=70 rows=1]
CC:
[checkbox name="cc" value="cold|fever|runny nose|nasal congestion|earache/pulling on ear(s)|sore throat|cough|stridor|wheezing|rash||poor appetite|abd pain|diarrhea|nausea|dysuria|"][textarea cols=70 rows=1]
RECENT HISTORY:
[checklist name="recent" value="day care/school attendance|sick contact|consumption of food outside home|travel|ER/UC visit|hospitalization/surgery/procedure|diagnostic/laboratory studies|specialty consults|new/changed medications|ABX use"][textarea cols=70 rows=1]
Current medications:
[checkbox name="medications" value="none|Rx|OTC|no side effects|effective|partially effective||not effective|not taking as prescribed|did not try|side effects|"][textarea cols=70 rows=1]
PMH:
[checkbox name="pmh" value="reviewed|non-contributory|immunization UTD|missing shots||frequent infections|asthma|allergies|eczema|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS:
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=70 rows=1]
[checklist name="const_symptoms" value="fever|changed behavior|tired|fussy|thirsty"]
HEAD/FACE: [textarea cols=70 rows=1]
[checklist name="head_symptoms" value="headache|head injury|scalp swelling|facial pain|facial swelling"]
EYES: [textarea cols=70 rows=1]
[checklist name="eye_symptoms" value="discharge|watery|itching|lid swelling|periorbital swelling"]
EARS: [textarea cols=70 rows=1]
[checklist name="ear_symptoms" value="pain/pressure|discharge|wax"]
NOSE: [textarea cols=70 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|snoring|bleeding"]
MOUTH: [textarea cols=70 rows=1]
[checklist name="mouth_symptoms" value="sores|teething|infection|swelling"]
THROAT: [textarea cols=70 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|hoarseness"]
NECK: [textarea cols=70 rows=1]
[checklist name="neck_symptoms" value="pain|swelling|stiffness|swollen glands"]
Chest/Respiratory: [textarea cols=70 rows=1]
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing"]
GI: [textarea cols=70 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|gas|food allergies|abdominal pain|diarrhea|constipation|rectal pain/itching|rectal bleeding|laxative use"]
GU: [textarea cols=70 rows=1]
[checklist name="gu_symptoms" value="dysuria|frequency|urgency|urine odor|blood in urine|discharge|swelling|itching|skin lesions/rash"]
MSK: [textarea cols=70 rows=1]
[checklist name="msk_symptoms" value="myalgias|localized muscle/soft tissue pain/swelling|arthralgias|localized joint pain/swelling|limping"]
NEURO: [textarea cols=70 rows=1]
[checklist name="neuro_symptoms" value="dizziness|blackouts|seizures"]
PSYCH: [textarea cols=70 rows=1]
[checklist name="psych_symptoms" value="anxious|sleep problems"]
LYMPH/HEMA: [textarea cols=70 rows=1]
[checklist name="hem_symptoms" value="gland swelling|unusual bruising|blood disorder|anemia"]
ALLERGIES/IMMUNE: [textarea cols=70 rows=1]
[checklist name="allergy_symptoms" value="atopy|environmental allergies|asthma|food allergies|autoimmune dz"]
DERM: [textarea cols=70 rows=1]
[checklist name="derm_sx" value="generalized rash|facial rash|acral rash|localized rash|dryness|hives|redness|swelling|bruising|single lesion|grouped lesions|wound|bite"]



Appearance:
[checkbox name="appearance" value="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|"][textarea cols=70 rows=1]
Head:
[checkbox name="head" value="normocephalic, atraumatic|normal anterior fontanel||scalp tenderness|plagiocephaly|swelling|"][textarea cols=70 rows=1]
Face:
[checkbox name="face" value="symmetrical|no evidence of trauma|no obvious cranial nerve deficits||rash|swelling|ecchymosis|"][textarea cols=70 rows=1]
Eyes:
[checkbox name="eyes" value="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|"][textarea cols=70 rows=1]
Ears:
[checkbox name="ears" value="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|"][textarea cols=70 rows=1]
Nose:
[checkbox name="nose" value="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|"][textarea cols=70 rows=1]
Mouth:
[checkbox name="mouth" value="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|"][textarea cols=70 rows=1]
Throat:
[checkbox name="throat" value="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|"][textarea cols=70 rows=1]
Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD||anterior LAD|posterior LAD|nuchal tenderness|"][textarea cols=70 rows=1]
Lungs:
[checkbox name="lungs" value="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|"][textarea cols=70 rows=1]
CV:
[checkbox name="cv" value="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|"][textarea cols=70 rows=1]
Abdomen:
[checkbox name="abd" value="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|"][textarea cols=70 rows=1]
GU:
[checkbox name="gu" value="not examined|no CVAT bilaterally|no suprapubic tenderness||normal external genitalia|circumcised|uncircumcised|smooth non-tender testes|+cremasteric reflexes bil|no skin lesions||testicular tenderness|vesicles|"][textarea cols=70 rows=1]
Back:
[checkbox name="spine" value="no gross deformities, normal curvature & ROM||scoliosis|"][textarea cols=70 rows=1]
Extremities:
[checkbox name="extremity" value="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|"][textarea cols=70 rows=1]
Neuro:
[checkbox name="neuro" value="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|"][textarea cols=70 rows=1]
Psych:
[checkbox name="psych" value="appropriate to age/situation|normal concentration and attention|good eye contact||anxious|irritable|"][textarea cols=70 rows=1]
Skin:
[checkbox name="skin" value="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|"][textarea cols=70 rows=1]

OFFICE DIAGNOSTICS:
[checkbox name="office_diag" value="none||normal|non-specific changes|no acute findings|discussed with patient/SO|official report to follow|"][textarea cols=70 rows=1]

A/P:
[textarea cols=80 rows=8]

ORDERS:
[checkbox name="orders" value="none||laboratory studies|diagnostic studies|referrals|"][textarea cols=70 rows=1]

RELEASE/CLEARANCE:
[checkbox name="clearance" value="none||released from care for this condition with no residual disability|cleared for sports participation with no restrictions|excuse from school|fit for school with above restrictions|"][textarea cols=70 rows=1]

PATIENT/SO INSTRUCTED/COUNSELED ON:
[checkbox name="instructions" value="vital signs|exam findings|reporting medication side effects to clinic immediately|appropriate f/u w PCP||office tests; advised that negative/'normal' results do not rule out pathology||OTC medicines and comfort measures for symptom control|adequate hydration/water intake|"][textarea cols=70 rows=1]

PLAN OF CARE:
[checkbox name="poc" value="POC risks/benefits/side effects/alternatives discussed with parent, opportunity provided to ask questions|parent verbalized understanding of and agreement with POC, discharge & f/u instructions||parent did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

Parental Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||anxious|fearful|suspicious|irritable|frustrated|crying||agitated|raising voice|argumentative|hostile|forceful|demanding particular medication, test, referral, or accommodation||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC as discussed during visit, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||RTC of see PCP within 24 hours|RTC of see PCP within 2-3 days|RTC of see PCP within 5-7 days||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|"][textarea cols=70 rows=1]
HISTORY:

CC:

RECENT HISTORY:

Current medications:

PMH:


REVIEW OF SYSTEMS:
negative except as stated in HPI
CONSTITUTIONAL:

HEAD/FACE:

EYES:

EARS:

NOSE:

MOUTH:

THROAT:

NECK:

Chest/Respiratory:

GI:

GU:

MSK:

NEURO:

PSYCH:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:




Appearance:

Head:

Face:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Neck:

Lungs:

CV:

Abdomen:

GU:

Back:

Extremities:

Neuro:

Psych:

Skin:


OFFICE DIAGNOSTICS:


A/P:


ORDERS:


RELEASE/CLEARANCE:


PATIENT/SO INSTRUCTED/COUNSELED ON:


PLAN OF CARE:


Parental Behavior:


DISPOSITION:

Result - Copy and paste this output: