PEDIATRIC HISTORY & PHYSICAL
MRN#
Patient Room:
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
Identifiers: NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of ***
HPI explained by patient:
Pertinent ROS:
Pertinent physical exam findings:
ED/ICU course:
PAST MEDICAL HISTORY
Prenatal History:
Neonatal History:
Other History:
Immunizations:
PAST SURGICAL HISTORY
ALLERGIES
MEDICATIONS PRIOR TO ADMISSION
NUTRITION
SUBSTANCE USE
SEXUAL HISTORY
SOCIAL HISTORY
FAMILY HISTORY
REVIEW OF SYSTEMS
VITAL SIGNS
GROWTH/DEVELOPMENT
Head circumference:
Weight:
Height:
INTAKE/OUTAKE
I/O(24hours):
Net I/O:
PHYSICAL EXAM
General:
Cardiovascular:
Respiratory:
Abdominal:
Genitalia:
Extremities:
Musculoskeletal:
Neurological:
Dermatological:
HEENT:
- Head:
- Eyes:
- Ears:
- Nose:
- Oropharynx:
- Neck:
LABS
IMAGING
ASSESSMENT AND PLAN
NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of *** found to have ***, concerning for ***. Patient has the following medical issues which require the associated interventions:
- Problem #1
- Intervention #1
- Intervention #2
- Intervention #3
- Problem #2
- Intervention #1
- Intervention #2
- Intervention #3
- Problem #3
- Intervention #1
- Intervention #2
- Intervention #3
Mr. Stepwards, MSIII
DATE
Pager: XXXX