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Admission Write Ups
Component
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Details and Specific Considerations
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ID/Chief Complaint
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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."
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Informant and Reliability
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Include all sources of information for your history and their
reliability (the patient, the family, outside M.D., etc.)
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History of Present Illness
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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.
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Past Medical History
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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
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Date, place, weight; duration of labor; complications during labor;
type of delivery (spontaneous, c-section, forceps); presentation
(vertex, breech)
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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?
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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)
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- Growth and Development
(refer to Erikson and Piaget)
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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?
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- Personal - Social Behavior
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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.
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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.
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Diphtheria, pertussis, tetanus (DPT); polio; measles, mumps, rubella
(MMR); BCG. Dates, boosters, complications. Last PPD placement.
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Medications
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List all, including specific regimens for asthma, seizure, etc.
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Allergies
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List specifics of any untoward reactions to medications or foods
(rash, gastrointestinal, sleepiness, irritability, etc.)
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Review of Systems
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Do not repeat information found elsewhere.
Rashes, petechiae, jaundice, infection.
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Frequency and nature of complaints. Otitis, nasal discharge, colds,
sore throats, coughs, nosebleeds, swollen glands, snoring, coughing
or choking with feedings.
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Frequency and nature. Chest pain, difficult breathing, wheezing.
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"Heart trouble," murmur, dyspnea, cyanosis, edema, easy fatiguability.
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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.
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Urinary control, infection, hematuria, enuresis (diurnal, nocturnal,
age of onset), vaginal discharge, menstrual history (if appropriate),
circumcision.
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Joint or muscle pain, joint swelling, "growing pains," weakness,
deformities, limp or gait abnormalities.
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Convulsions (febrile or afebrile, onset, type, frequency, how
controlled), syncope, paralysis, tics, staring spells, head trauma,
headache, changes in personality, motor coordination
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Vision, hearing, speech
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Family History
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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.)
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Social History
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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.
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Physical Exam
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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.
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Temperature, pulse, respiration, blood pressure (both upper extremities,
lower if indicated). Pulse oximetry readings should be noted if
applicable.
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Weight and height (state percentiles). Up to age 2 years: head
circumference.
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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]).
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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.
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Cervical, occipital, post-auricular, axillary, epitrochlear, inguinal,
other superficial nodes. Note size (mm), tenderness, consistency,
mobility.
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Size, shape, position, fontanels (size, tension), sutures, bossing,
craniotabes, transillumination, bruits, condition of hair and scalp,
lesions
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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?
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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?
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Flaring of alae nasi, obstruction, discharge, septum, turbinates,
mucous membranes, sinus tenderness
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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.
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Masses, torticollis, rigidity, retraction, webbing, bruits, range
of motion. Structures: neck vessels, thyroid, trachea. Palpate clavicles
in the newborns
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Contour, symmetry, expansion, prominence of costochondral junctions,
bulging or retraction of interspaces. Breasts.
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Respirations - type, depth, regularity. Findings on palpation,
percussion and auscultation with comparison of both sides.
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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.
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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.
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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.
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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.
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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
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Labs
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Present all lab results obtained on admission, including imaging
studies. Circle abnormal results
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Summary:
This is the same thing as presenting a bullet
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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.
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Assessment/Plan
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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.
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