Date: ________ Time: _________ Room No.

: _______ Chief Complaint: ____________ Informant: Mother Father other _______________ Care giver Phone number ____________________ team Referral Source: Emergency Room Clinic Urgent Care Transport

Reason for hospitalization: Failure of non hospital therapy Acute or unresolved changes in physiologic status unable to ensure patient safety other specify HPI :(elements include location, quality, severity, duration, onset/timing, modifying factors, signs/symptoms, context)

Clinical Course and treatment received by Emergency Room/ Outside Facility/ Transport team/ Operative room (please get history from the caregiver and check notes and document below)

Sick contacts/ Daycare

Review of Systems: (Please circle the pertinent positives and duration, if negative check the box negative) Constitutional: fever, fatigue, weight change, _________ Negative Eyes : pain, redness, drainage, edema, visual disturbances, negative Ears : pain, discharge, hearing disturbances, negative Nose : Nasal discharge, Congestion, Bleeding negative Oral Cavity/Throat : Tooth pain, sore throat, oral cavity lesions, hoarsensess negative Respiratory : Cough, Increased work of breathing, Shortness of Breath, Wheezingm Apnea negative Cardiac : Chest pain, Syncope, palpitations, murmurs negative GI: Nausea, vomiting, diarrhea, constipation, abdominal pain, appetite, feeding problems negative

GU: Dysuria, Frequency, Hematuria, Male : discharge, scrotal/testicular pain Female : Age at menarche : Abnormal discharge, LMP____ Abnormal bleeding, Dysmenorrhea, Cycles Neurology: Headaches, Seizures, loss of consciousness, weakness, negative Musculoskeletal : Joint pain, Swelling, stiffness, erythema, strength, negative Skin: Rashes, Lumps, infections, edema negative Hematological: pale, bleeding, bruising, swollen glands negative Allergy : frequent and unusual infections negative Psych : Sleep or mood disturbances, depression, abnormal behavior negative Other pertinent or abnormal ROS:

Past Medical History no major medical illness trauma Bronchiolitis Asthma Diabetes UTI Seizures Allergies Other pertinent history

no prior hospitalizations no surgical history

Medications (include name, dosage in mg and frequency): Allergies: NKDA No Food allergies other pertinent allergies _____________ Birth History: Gestation: Preterm/Term ______ weeks NSVD C-section Indication ___________ Birth weight _______________kg Postnatal Complications:________________ Nutrition: Regular for age Restrictions if tube feeds type of formula/amount/duration Formula (name and amount for infants)_____________ Immunizations Uptodate Missing vaccinations ____________ Developmental history: Communication: Gross motor: Fine motor: Problem solving: Personal-Social: Other:

Family history (draw a pedigree) Environmental and Safety Social History: Patient lives with ______________ _____________ Mother employment ________ Care giver ___________ Father employment __________

WIC _______ Medicaid __________ Food Stamps ________ Other insurance ____________ Exposure to smoke yes no ____________ Car seat/Seat belt yes no ____________ Bicylce helmet yes no ____________ Guns at home yes no ____________ HEADSS assessment for adolescents Home environment: __________ Education/Employment: ____________ Activities:________ Depression:_________ Substance abuse:________ Smoking:__________ Alcohol:_________ Sexual activity & Sexually transmitted infections:______________ Physical Examination Vitals Signs : Temp : ______ Pulse _____ RR _____ BP ______ SpO2 ______ O2 _______ Weight : _________ Height/Length : _____ Head Circumference ________ BMI ________ General Alert Active Playful Smiling Co-operative Fussy Irritable HEEENT Head : normocephalic Ant Fontanel ______ Eyes: conjunctiva Pupils _____ Fundus Ears: Pinna _______ Tympanic Membrane R ___ L ____ Nose: mucosa Turbinates nasal congestion nasal septum _____

Oropharynx: Oral cavity __________ Tongue __________ Buccal Mucosa________ lips _____ teeth _______ Tonsils________ pharynx _______ Neck : trachea ______ thyroid _________supple lymphadenopathy __________ Respiratory System Pectus Carinatum Pectum exacavatum Bilateral CTA normal airentry normal excursions no adventitious sounds Respiratory distress mild moderate severe Retractions intercostal subcostal suprasternal substernal crepitations ___________________________ wheezing _________________ prolonged expiratory phase Cardiovascular Normal Regular Rate and Rhythm Normal Heart Sounds _______ Murmur ___________ Thrill Pulses Carotid _______ Brachial ______ Radial _______Femoral ________ Abdomen soft non tender non distended no masses no hepatosplenomegaly normal bowel sounds Other positive signs __________ CVA tenderness _________ Genitalia Male : Testes : Normal Testes Tanner stage _______ Pubic Hair Tanner stage ________ Penis Tanner stage_________ Circumcised Non Circumcised Female: Breast _______ Tanner stage ______ Pubic Hair tanner stage______ Vulva _____ Pelvic examination_______ Neurology Mental Status: _______________ GCS ____________ Cranial Nerves: _______ Motor: Tone: ___________ Strength __________ Deep tendon reflexes ___________ Babsinki ________ Gait ___________ Cerebellar Signs ___________ Sensation _____________ Lymphatics Cervical Lymphnodes __________ Axillary Lymphnodes ____________ Inguinal Lymphnodes _____________ Skin Rash _________________________________________________

Musculoskeletal Extremities Upper Limb ______________________________________________________________ Lower Limb ______________________________________________________________ Spine ___________________________________ Psychiatry Effect Orientation Memory Judgment Problem List 1.__________________ 2.__________________ 3.__________________ 4.__________________ Assessment:

Laboratory Data

Neutrophils ____ % Bands ___% Lymphocytes ___% Monocytes____% Eosinophils ___% Absolute Neutrophils ___________

Ca ___ Mg ____ Phosphorous ______ Alb/Prot______ Total Bilirubin_______Direct Bilirubin____ AST ____ ALT _____ALP_____GGT______ Prealbumin_________ CRP________ ESR_______ UA: Type of specimen Cath Clean Catch Suprapubic SG _______Glu____ Prot______ Blood _______ Bact _______ WBC _____ RBC _____ LE _______ Nitrite _________ Urine Culture __________________________ Blood Culture ___________________ Stool Studies Rotavirus ___________ WBC __________ Stool Occult Blood ______________ Respiratory Viral Panel ________________ Chest X Ray _________________ Ultrasound Abdomen______________ CT Scan ___________________ MRI __________________________

Treatment Plan

Resident Sign _________________ Resident Name _________________________ Above was discussed with _____________________( name of attending physician) Attending Physician Note: I personally performed a History and Physical examination of this patient and discussed their management with the resident and patient. I agree with the above findings and plan of care as noted

I have spent a total ______ minutes of floor time on this patient care today