Chan, Gennerich - Pediatrics - Current Clinical Strategies...

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Unformatted text preview: Current Clinical Strategies Pediatrics 2004 Edition Paul D. Chan, MD Jane L. Gennrich, PharmD Current Clinical Strategies Publishing www.ccspublishing.com/ccs Digital Book and Updates Purchasers of this book can download the digital version and updates at the Current Clinical Strategies Publishing web site: www.ccspublishing.com/ccs/ped.htm Copyright © 2004 by Current Clinical Strategies Publishing. All rights reserved. This book, or any part thereof, may not be reproduced or stored in an information retrieval network without the permission of the publisher. The reader is advised to consult the package insert and other references before using any therapeutic agent. The publisher disclaims any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this text. Current Clinical Strategies is a registered trademark of Current Clinical Strategies Publishing inc. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653 Phone: 800-331-8227 Fax: 800-965-9420 Internet: www.ccspublishing.com/ccs E-mail: info@ccspublishing.com Printed in USA ISBN 1-929622-41-4 General Pediatrics Pediatric History and Physical Examination History Identifying Data: Patient's name; age, sex. List the patient’s significant medical problems. Name and relationship to child of informant (eg, patient, parent, legal guardian). Chief Complaint: Reason given for seeking medical care and the duration of the symptom(s). History of Present Illness (HPI): Describe the course of the patient's illness, including when it began and the character of the symptom(s); aggravating or alleviating factors; pertinent positives and negatives. Past diagnostic testing. Past Medical History (PMH): Past diseases, surgeries, hospitalizations; medical problems; history of asthma. Birth History: Gestational age at birth, whether preterm, obstetrical problems. Developmental History: Motor skills, language development, self-care skills. Medications: Include prescription and over-the-counter drugs, vitamins, herbal products, homeopathic drugs, natural remedies, nutritional supplements. Feedings: Diet, volume of formula per day. Immunizations: Up-to-date? Drug Allergies: Penicillin, codeine? Food Allergies: Family History: Medical problems in family, including the patient's disorder. Asthma, cancer, tuberculosis, HIV, diabetes, allergies. Social History: Family situation, living conditions, alcohol, smoking, drugs. Level of education. Review of Systems (ROS): General : Weight loss or weight gain, fever, chills, fatigue, night sweats. Skin: Rashes, skin discolorations. Head: Headaches, dizziness, seizures....
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Chan, Gennerich - Pediatrics - Current Clinical Strategies...

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