Admission Write Ups

Component

Details and Specific Considerations

ID/Chief Complaint

Always identify the patient by name, age and gender. For the chief complaint, use the informant's own words if possible. Identify any crucial identifiers of the patient that are pertinent to the diagnosis. Example: "This is a 6 year old boy with SS disease who presented with fever of one day duration."

Informant and Reliability

Include all sources of information for your history and their reliability (the patient, the family, outside M.D., etc.)

History of Present Illness

A good HPI can frequently identify the diagnosis. Begin with a statement that summarizes the recent past medical history and the patient's current health. Example: "Wayne was in his usual state of health, characterized by well-controlled asthma, until two days prior to presentation when he began to..."

The signs and symptoms should be described in chronological order with appropriate paragraphing and underling for emphasis so that the reader may obtain maximal information in minimum reading time. Include all recent outside medical treatments and the name of the physician who saw the child.

If the history suggests a particular disease, inquire about signs and symptoms characteristic of the disease. Include all pertinent positives and negatives, as they are of great value in differential diagnosis. Note similar illness in the family and always inquire about recent exposure to contagious diseases. Include how the disease is affecting the patient's vital life functions, i.e., level of activity and intake and output.

Past Medical History

  • Prenatal

Obtain as complete a past medical history as possible:

Pregnancy planned or unplanned; duration; any complications including bleeding, edema, hypertension, glycosuria, illness (when?); weight gain during pregnancy, unusual exposures (radiation, etc.); medications taken during pregnancy; onset of prenatal care; serology results; Rh and blood type

  • Birth

Date, place, weight; duration of labor; complications during labor; type of delivery (spontaneous, c-section, forceps); presentation (vertex, breech)

  • Neonatal

Apgars (HR, respirations, tone, irritability, cry); complications (convulsions, cyanosis, jaundice, rash, vomiting, bleeding, infection, congenital anomalies, resuscitation or oxygen required); good suck and cry; did baby go home with mother and if not, why not?

  • Feeding

Breast - entirely, partially, not at all. How long?

Artificial - when started, formula type, current formula, # feedings qd and quantity usually taken

Solids - when started, how tolerated.

Vitamins - type, amount, when started

Present diet - cereal, vegetables, fruit, egg, meat, amount of milk

Feeding problems - type, time of onset (emphasis depending on age and chief complaint)

  • Growth and Development
    (refer to Erikson and Piaget)

Weights at various periods plus linear growth. Age when smiled, held head, rolled over, sat without support, crawled, stood with support, walked, began teething, spoke words, spoke sentences. Left or right handed. Toilet training begun, completed. How does patient compare with siblings?

  • Personal - Social Behavior

Behavior problems (tantrums, breathholding, etc.); ability to get along with siblings & other children; school adjustment - grade ability; fears, speech disorders, habits (thumbsucking, nailbiting), sleep habits, recent behavioral changes.

  • Specific Illnesses

Contagious: note age, complications. Measles, German measles, mumps, chicken pox, pertussis, scarlet fever, polio. Recent exposures

Other medical: dysentery, meningitis, pneumonia, rheumatic fever, renal problems, tuberculosis, anemia, asthma (exposures), etc.

Operations, accidents: any difficulties (bleeding, transfusions etc.)

Hospitalizations: in chronological order; when, where, dx, tx.

  • Immunizations

Diphtheria, pertussis, tetanus (DPT); polio; measles, mumps, rubella (MMR); BCG. Dates, boosters, complications. Last PPD placement.

Medications

List all, including specific regimens for asthma, seizure, etc.

Allergies

List specifics of any untoward reactions to medications or foods (rash, gastrointestinal, sleepiness, irritability, etc.)

Review of Systems

  • Skin

Do not repeat information found elsewhere.

Rashes, petechiae, jaundice, infection.

  • HEENT

Frequency and nature of complaints. Otitis, nasal discharge, colds, sore throats, coughs, nosebleeds, swollen glands, snoring, coughing or choking with feedings.

  • Respiratory

Frequency and nature. Chest pain, difficult breathing, wheezing.

  • Cardiovascular

"Heart trouble," murmur, dyspnea, cyanosis, edema, easy fatiguability.

  • Gastrointestinal

Appetite, abdominal pain, vomiting (onset, type, color, frequency, relation to feeding), bowel habits (constipation, diarrhea, number, color and character of stools, bleeding), pruritis ani, parasites, pica.

  • Genitourinary

Urinary control, infection, hematuria, enuresis (diurnal, nocturnal, age of onset), vaginal discharge, menstrual history (if appropriate), circumcision.

  • Musculoskeletal

Joint or muscle pain, joint swelling, "growing pains," weakness, deformities, limp or gait abnormalities.

  • Neurologic

Convulsions (febrile or afebrile, onset, type, frequency, how controlled), syncope, paralysis, tics, staring spells, head trauma, headache, changes in personality, motor coordination

  • Special senses

Vision, hearing, speech

Family History

Familial diseases, including diabetes mellitus, rheumatic fever, allergy, blood dyscrasia, renal problems, epilepsy, mental illness, congenital anomalies, tuberculosis, syphilis. Causes of death for close relatives (grandparents, other siblings, etc.)

Social History

Parents: age, ethnicity, religion, education, state of health / date of death & cause if not living, consanguinity, marital status

Siblings: list in chronological order of pregnancy giving sex, age, and health / date of death & cause, duration of pregnancy.

Socio-economic: living conditions (size of dwelling, who lives there permanently/temporarily, sleeping arrangements, condition of dwelling [plumbing, heating, hot & cold water, refrigeration, rodents, pets, etc.], length of time at address. Any baby sitters? Relationships? Is child cared for at home? Sources of household income, insurance. Day-to-day life of child.

Physical Exam

The list below is meant as an exhaustive overview; not all findings must be checked on each patient. Thoroughness is essential, however. Be pertinent and focused in reporting your results. This means that if meningitis is in your differential diagnosis, document the state of the anterior fontanel, suppleness of neck, and +/- Kernig's and Bredzinski signs. The child must be completely undressed, but not always all at once (depending on the age); feelings and modesty of the child should be respected.

  • Vital Signs

Temperature, pulse, respiration, blood pressure (both upper extremities, lower if indicated). Pulse oximetry readings should be noted if applicable.

  • Measurements

Weight and height (state percentiles). Up to age 2 years: head circumference.

  • General Appearance

Development, nutrition, hygiene, state of health (acute or chronically ill, apparently well). State of consciousness, facial expression, cooperation, irritability, speech, cry, posture, gait. Obvious signs of distress (i.e., respiratory, obvious deformities, odor [source]).

  • Skin

Texture, color, pallor, cyanosis, jaundice, temperature, turgor, subcutaneous fat, evidence of weight loss, pigmentation, rashes (describe type and distribution), petechiae, purpura, local swelling, edema, dilated veins, insect bites, scars, signs of injury.

  • Lymph Nodes

Cervical, occipital, post-auricular, axillary, epitrochlear, inguinal, other superficial nodes. Note size (mm), tenderness, consistency, mobility.

  • Head

Size, shape, position, fontanels (size, tension), sutures, bossing, craniotabes, transillumination, bruits, condition of hair and scalp, lesions

  • Eyes

Color, sclerae, cornea, conjunctivae; lid margins; eyebrows; palpebral fissure, ptosis, edema; ocular tension; tearing; discharge; extra-ocular movements, strabismus, nystagmus; gross visual fields; pupils (size, equality, reaction to light & accommodation); ophthalmoscopic exam: fundus, disc, opacities. Dilate if necessary (check first with resident). DOES CHILD SEE?

  • Ears

Configuration, position, pre-or post-auricular swelling or excoriation, mastoid tenderness, external canals, discharge; otoscopic exam: tympanic membrane color, light reflex, landmarks, bulging, perforation. DOES CHILD HEAR?

  • Nose

Flaring of alae nasi, obstruction, discharge, septum, turbinates, mucous membranes, sinus tenderness

  • Mouth and Throat

Open or closed at rest. Lips: color, moisture, fissures, lesions (e.g., herpetic). Mucous membranes: enathem (Koplik's, etc.), ulcerations, color, moisture, excessive salivation. Teeth: number and condition, malocclusion. Gums: hemorrhage, infection. Tongue: moisture, coating, fissures, tremors, mobility, size, surface. Palate: arch, anomalies, movement. Pharynx: color, exudate, tonsils, retropharyngeal swelling. Epiglottis: appearance, if seen. Larynx: hoarseness, stridor.

  • Neck

Masses, torticollis, rigidity, retraction, webbing, bruits, range of motion. Structures: neck vessels, thyroid, trachea. Palpate clavicles in the newborns

  • Chest

Contour, symmetry, expansion, prominence of costochondral junctions, bulging or retraction of interspaces. Breasts.

  • Lungs

Respirations - type, depth, regularity. Findings on palpation, percussion and auscultation with comparison of both sides.

  • Heart

Inspection and palpation: visible apex beat, point of maximum impulse, thrills (location & time). Percussion: borders of heart. Auscultation: rate, rhythm, quality and intensity of heart sounds, splitting, 3rd or 4th sound, friction rub. Murmurs: location, time intensity, pitch, quality, transmission, effect of position & respiration.

  • Abdomen

Contour, visible peristalsis, umbilicus, bowel sounds, shifting dullness, fluid wave, hernia, muscle tone, tenderness (direct, rebound). Liver: if palpated, record size in cm, consistency, character of surface and edge, tenderness. Spleen: if palpated, record size in cm, describe as above. Kidneys: bladder distention, other masses.

  • Genitalia and Anal Area

Male: circumcision, phimosis, meatus, testicles descended, hydrocele, urinary stream, hernia.

Female: irritation, discharge, urethral and vaginal orifices, synechiae, clitoral enlargement, signs of puberty, anomalies, evidence of infection, hernia.

Anal region: excoriations, fissures, rectal prolapse; patency of anus in newborn; rectal examination as indicated.

  • Back and Extremities

Back: lordosis, scoliosis, kyphosis; motion of spine; vertebral or costovertebral tenderness; tufts of hair, dimples, discolorations, cysts or masses.

Extremities: peripheral pulses (radial & femoral, equality & volume), cyanosis, clubbing, edema; anomalies, length, shape, symmetry, deformities.

Joints: range of motion, swelling, redness, tenderness. In infants, test specifically for hip dislocation.

Musculature: tone, atrophy, hypertrophy, tenderness, spasm, paralysis.

  • Neurologic

Motor and sensory function, coordination, deep tendon reflexes, superficial reflexes (abdominal, cremasteric), clonus, tremor, twitching, choreiform movements, athetosis, spasticity, rigidity, paresis, paralysis; Kernig, Brudzinski, Chvostek, Babinski. Examination should be more detailed when indicated and depending on age. In infant, Moro, tonic neck, reflex grasp, such, cry. Evaluation of motor and mental development

Labs

Present all lab results obtained on admission, including imaging studies. Circle abnormal results

Summary:

This is the same thing as presenting a bullet

Give a 1/4 to 1/2 page summary (much as a lawyer gives a short summation of a long case). Mention all pertinent positives and negatives of the history, physical and labs to sell your working diagnosis to the reader/listener.

Assessment/Plan

Develop a problem list and discuss each problem using both the textbook and medical literature if you can. The first problem should always be the differential diagnosis. You should discuss the differential in a way that shows you are trying to decide which diagnoses are the most likely and least likely. This is how you develop "clinical judgment." When discussing each problem, use pathophysiology to back up your assessment of what is going on and to justify your plan to solve the problem.