PICU Admission Notes

[text name="variable_1" default="PICU Admission Notes"]


Admitted From

Chief Complaints (Include duration of complaints)
_

History of Present Illness
_

PEC TREATMENT SUMMARY (if applicable):
_

Review of Systems
General: active and playful child
Skin: no rash, jaundice or skin lesions
Head: no trauma
Eyes: no discharge, pain, excessive tearing, or itchiness
Ears: no ear pain or discharge
Nose: no discharge
Cardiovascular: no history of murmur, syncope, cyanosis, or palpitations
Respiratory: no cough, wheezing, difficulty breathing
Gastro-enterology: no vomiting, diarrhea
Genitourinary: no history of UTI. no dysuria or hematuria
Musculoskeletal: moves all extremities equally
Neurology: no difficulty with gait or balance, no history of seizures or headaches
Hematology: no easy bruising, bleeding
Psychological/ Behavioral: Normal Behaviour

Past Medical History
Perinatal and Natal History: _
Infancy / Childhood History (if significant): _
Previous Hospitalizations (if any): _
Infectious Disease History (if any): _
Past Surgical History (if any): _

Nutritional History


Immunization History
Up to date (if not specify): _

Allergy History (if any): _

Medication History (if any):­­

Home Medications 
_

Developmental History
Gross Motor: _
Fine Motor: _
Speech: _
Social: _
Psycho-Social History

Father Occupation: _
Mother Occupation: _
Housing Condition / Place of Residence: _
School Performance (if applicable): _
Relation with Parents, Siblings and Peers: _
Toilet Training (if applicable): _
Others "Household Pets, Cigarette Smoke Exposure, etc" (if applicable): _

Family History
Consanguinity (if any): _
Siblings (if any): _

No qualifying data available.
Physical Examination
Vitals:

Temperature        
Systolic Blood Pressure       
Diastolic Blood Pressure       
Pulse        
SpO2       
Respiratory Rate      

Measurements:



General : not in respiratory distress, well hydrated, hemodynamically stable
Head: normocephalic
ENT/Dental: both ears are clear, throat, nose and oral cavity are clear
Neck: no pain no lymphadenopathy
Skin: no visible lesions or rashes. No jaundice
CVS: Hemodynamically stable, good volume peripheral pulse, Capillary Refill Time less than 2 seconds,
S1 & S2 normal, No murmur
Respiratory: not in respiratory distress, Air entry equal bilaterally, no crepitations, no rhonchi
Abdomen: soft and lax, not tender, not distended, no masses felt, no organomegaly
Genitourinary: Normal genitalia
CNS: conscious and oriented, no focal neurological deficits, power and tone normal. Deep Tendon Reflexes normal, Pupils bilaterally equal and reactive to light
Musculoskeletal/Spine: normal

Laboratory and Radiological Work-up (if any):
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_

Assessment (Including Differential Diagnosis)
_

Management Plan
_

Expected Length of Stay: _ days

Family Education
The current condition of the patient and the management plan of care discussed with _