Date of Admission:
Chief Complaint:
History of Present Illness: Start with one-liner. E.g. “2 year old admitted with a presumptive diagnosis of croup.” Your one-liner should express what you think the diagnosis is.
Then continue and give a supporting HPI with pertinent positives and end with pertinent negatives.
Past Medical History: None
Birth history: Born in Montreal, FT, 2 days, weighed 6.5 lbs. No complications
Development: Smiles, coos, lifts head when prone
Diet: Nestle 150mL q 4 hours
Immunizations: UTD
Past Surgical History: None
Allergies: NKDA
Medications:
Family History: Non-contributory
Social History: [Include where and with whom child lives, exposure to smoke, peds, day care, etc).E.g.
Lives with parents and sibblings. No smoke exposure and no pets. Goes to daycare a few weeks ago.
Review of Systems: All 10 systems reviewed negative except as stated in HPI
Physical Examination:
Vital Signs:
Gen: No acute distress, awake. Smiling.
HEENT: NC/AT AFOSF, Red reflex present bilaterally, normal external ears and canal, normal mouth and throat
Neck: Supple
CVS: Normal S1 S2, no murmurs, RRR, symmetric brachial and femoral pulses
Lungs: CTAB, no retractions, no W/R/R
Abd: Soft NT ND good BS
GU: normal female external genitalia, patent anus
MSK: FROM, normal Galeazzi, Ortolani, and Barlow exam, no sacral dimple
Skin: No rashes or lesions
Laboratory Data:
Imaging Studies:
Assessment & Plan
3.5 mo female, previously healthy, now with suspected pyelonephritis
Problem List
1. Pyelonephritis
Plan
Pyelonephritis:
Continue treatment with cefotaxime 50mg/kgq 6 hours
Urine culture added to UA this AM, follow up on result
RUS
VCUG pending RUS results
Continue IVF till PO improves
Tylenol prn fever
Add Bcx if not in lab (will follow up)
CRP in AM