St. Georges Medical University Pediatric Clerkship Mim coe - DOCUMENTING THE PEDIATRIC HISTORY & PHYSICAL EXAM 1. Remember — Chief complaint should include duration of symptomatology prior to admission and should be just a phrase. : EXAMPLE: Wheezing and SOB x 6 hours PTA 2. Always begin HPI with standard opening. EXAMPLE: This is the first UH admission for this 2-year-old black male, who was well until 3 days PTA when he developed... 3. For children with chronic disease, state underlying condition in first sentence of HPI. EXAMPLE: This one of multiple admissions for this 2-year-old black male, known to ‘have mild intermittent asthma since 6 months of age, who was well until... 4, HPI should contain: First Paragraph ~ onset of symptoms, in chronologic order duration of each (if some end sooner than others) a description of symptoms (a headache is not just a headache, a cough is not just a.cough) - course of illness/treatment at home t ill contacts (when infectious illness is a consideration) - prior similar symptoms in patient or family ~ = reason(s) for seeking medical care - findings at initial visit PMD, ER) - reason for admission - pertinent negatives Second Paragraph . relevant past history do not need to repeat this information in PMH section 5. Refer to PTA days, weeks rather than day of week or dates.