Shelf Prep: Pediatric Patient Notes 

The Pediatrics Teaching Service provides a unique blend of complex pathophysiology 
intermixed with the developing pediatric patient. The “History and Physical” remains pivotal 
to the diagnosis and management plan with some unique elements to pediatrics. Especially 
true when navigating difficult diagnoses and social situations, remember that 
compassionate patient care is of utmost importance. 

As always, each patient encounter provides a wealth of potential learning opportunities 

that can correlate with high-yield shelf exam preparation. Still, keep in mind that real-life 
clinical decisions will not always be the correct answers on your shelf exam. As physicians, 
we strive to formulate management choices based on the latest high-quality research, but 
at times we must make decisions that are more economical or practical for the patient. 
Patient scenarios on the shelf exam assume that each patient has access to care, is 
compliant with medications, and insured without limitations on medical spending, unless 
otherwise stated. 

*The following is an example H&P for a patient presenting with shortness of 
breath. Common abbreviations you may encounter are in parenthesis following 
commonly used medical terms/phrases. 

History of Present Illness (HPI): 

Start your HPI with patient’s name, age, race, and gender (including preferred gender pronouns 
when appropriate) as well as any past medical history elements that are relevant to this patient’s 
presentation. Consistent with other clerkship histories, remember LOCATES (location, onset, 
character, alleviating factors, things that make it worse, experience of the symptoms, and severity) 
when documenting your chief complaint, including asking the patient’s parent/guardian (and 
patient if possible) the “Why today?” question. In pediatrics, many presenting complaints are 
acute, and while it is not uncommon to encounter chronic issues present for days, weeks or even 
months – it is always important to understand what precipitated today’s visit. Also include 
pertinent positives and negatives from your review of systems, which ultimately serves as key 
foundational components of your differential diagnosis and management plan. 

S.K. is a 5-year-old African American female with a past medical history of seasonal allergic 
rhinitis and mild, persistent asthma who presents to the Emergency Department (ED) on 
4/15/19 with 2-3 days of progressively worsening shortness of breath, cough, and nasal 
discharge. 

Prior to her current illness, S.K. was at her baseline health, using her rescue albuterol 
inhaler as needed with no missed dosages of her daily inhaled corticosteroid (fluticasone). 
Her symptoms began with a runny nose and mild, nonproductive cough. During this time, 
her parents stated that she remained very active and playful with no changes in her 
physical functional capacity, appetite, or sleep schedule. However, S.K.’s teacher noticed 
that she appeared very fatigued and short of breath while playing at recess just 24 hours 
prior to her current ED visit. After 3 puffs of her albuterol inhaler and ~30 minutes of rest, 
her shortness of breath improved, and S.K. stated “it was easier for her to breath.” 
However, she continued to have a dry, hacking cough. This worsened into the evening, 
when she began coughing until she vomited. Vomitus described as yellow-green and 
without blood, and her post-tussive emesis occurred three times. Parents encouraged 
some juice, but S.K. didn’t want much to drink. Because S.K. said she was “very tired,” her 
parents put her to bed early. 

The cough worsened when she laid down, but she eventually fell asleep. Upon checking on 
S.K. a couple hours later, her parents noticed she was “working really hard to breath in her 
sleep.” They also heard audible wheezes and stated her “heart rate seemed very fast.” They 
gave her 3 puffs of her albuterol inhaler. Still, her labored breathing continued, and they 
noticed a very slight, bluish color change in her lips, prompting her presentation to the ED. 

S.K. often requires her albuterol inhaler for cough/mild shortness of breath associated with 
rigorous exercise and season changes – especially during the spring and summer. 
However, she has never had shortness of breath that didn’t improve with her rescue 
inhaler nor has she been hospitalized related to her asthma diagnosis. Per S.K.’s teacher, 
there are a few children in her class with runny nose and cough, but S.K.’s parents deny any 
other known sick contacts. She is up-to-date with all in her immunizations including her 
annual influenza vaccine. Aside from visiting her maternal grandparents in West Virginia 3 
weeks ago, no recent travel. S.K. plays outside, but her parents do not recall any recent 
tick/mosquito bites or unusual exposures. She was a term birth and reportedly meeting all 
developmental milestones as expected. 

Review of Systems (ROS): 

Document all of your positive and negative findings here. 

Constitutional: ​Fatigue & reduced oral intake over past 24 hours. Negative for fever or 
weight changes. 
HEENT​: Positive for rhinorrhea, congestion, and eye redness. Negative for pharyngitis or 
vision changes. 
Respiratory: ​Positive for cough, shortness of breath, wheezing, and difficulty breathing. 
Cardiovascular: ​Positive for tachycardia and chest tightness. Negative for palpitations. 
Gastrointestinal: P ​ ositive for vomiting. Negative for epigastric pain/diarrhea. 
Endocrine: N ​ egative for polyuria and polydipsia. 
GU: P​ ositive for reduced urinary frequency. Negative for dysuria or hematuria. 
MSK: N ​ egative for myalgias and arthralgias. 
Skin: ​Positive for mild perioral cyanosis. Negative for rashes or skin wounds. 
Neurological: ​Negative for syncope, numbness, and headache. 
Psychiatric/Behavioral: ​Positive for impaired sleep.​ ​Negative for agitation, impaired 
consciousness, decreased concentration, and mood changes. 
Birth & Developmental History: 
Depending on age-related relevancy, include all obtainable birth and developmental histories, 
which may require a combination of parent/guardian history and chart review. 

Born at 39 weeks 3 days (39w3d) to a 26-year-old, G2P2002 African American married 

female via normal spontaneous vaginal delivery (NSVD). Mother with regular prenatal care. 
Prenatal screening labs as follows: group B streptococcus (GBS) negative / Rubella immune 
(RI) / hepatitis B surface antigen (anti-Hbs) non-reactive / syphilis screening non-reactive / 
chlamydia testing negative / gonorrhea testing negative / HIV antibody & antigen testing 
non-reactive. Pregnancy otherwise uncomplicated by acute or chronic maternal medical 
conditions. Rupture of membranes (ROM) after 6 hours of labor and fluid clear/without 
odor. APGARs 8 and 9, and patient transitioned to well-child newborn nursery without 
issue. Breast-fed and discharged within 48 hours without complication. Compliant with 
age-related primary care visits and developmentally meeting all milestones as expected. 

Past Medical History (PMH): 

Include all of the patient’s past medical history including age at diagnosis (if possible). 

1. Mild, persistent asthma (diagnosed at age 3) 

2. Seasonal allergic rhinitis (diagnosed at age 4) 

Past Surgical History (PSH): 

Make sure to include the timing of each surgery. Recent procedures may play an important role in 
your differential and management. 

1. Skin allergy testing (March 2016) 

2. Tonsillectomy and adenoidectomy (February 2017) 
3. Dental procedure for caries (November 2018) 

Allergies: 
In pediatrics, it can be helpful to split this history component into “medication allergies,” “food 
allergies,” “contrast allergies,” and “other allergies.” This helps reduce any parental/guardian 
confusion when addressing this topic. If you note allergies listed in the chart, especially related to 
antimicrobials such as penicillin, make sure to document the reaction. You will often find 
documentation of “allergies” that are not traditional allergies but are better classified as adverse 
drug reactions. This becomes very relevant when certain antibiotics are considered the 
gold-standard of care. 

There is controversy regarding iodine or shellfish allergies. This typically becomes important when 
a patient requires an imaging study with contrast; however, our bodies normally use iodine to 
create thyroid hormone and there is no relationship between being allergic to iodine and being 
unable to tolerate contrast. Patients unable to tolerate contrast will typically specify allergy to 
contrast. 
1. No Known Drug Allergies (NKDA) 
2. No known food allergies or contrast allergies 
3. Seasonal allergies to pollen and hay 

Home Medications: 
Include all of the patient’s home medications. This should include prescription and 
non-prescriptions drugs as well as herbal supplements as they can change the metabolism and 
absorption of other medications. Remember that for shelf examinations, only the generic named 
will be used when referring to a medication. However, in clinical practice, it helps to also know 
brand names associated with the generic name. 

1. Albuterol (ProAir HFA) 2-4 puffs inhaled every 4-6 hours PRN 
2. Fluticasone (Flovent HFA) 2 puffs inhaled twice daily 
3. Multivitamin (Flintstones®) 1 chewable tablet PO daily 

Immunization History: 
It is imperative for diagnosis and management to know the patient’s immunization history; 
however, this is not always readily available. While accepting parental/guardian history regarding 
immunizations, we recommend confirming with a thorough chart review and/or with state 
immunization records if access is available. This is especially relevant in today’s clinical practice 
where vaccine-preventable illnesses (e.g. measles) demonstrate increasing incidence. 
  
Reportedly up-to-date (UTD) per parents. 

Social History (SH): 

Keep in mind that pediatric social histories may significantly contribute to the complexity of their 
current disease process(es) as well as identify potential modifiable risks such as tobacco, drug, or 
high-risk sexual behavior in the adolescent and teenage population. After we address the patient’s 
presenting problem, it is important to engage hospital social work in the patient’s care team and 
provide longitudinal guidance at discharge if needed. Note that relevant social factors will 
significantly change depending on the age of the pediatric patient. 

Living Situation:​ A.K. lives with her biological mother, father, and brother (7-years-old) in 
Durham, North Carolina.  

Exposure History (often part of “Social History,” but can be separated): 

Include any relevant exposure history. For an admission suspicious for an unidentified infectious 
diagnoses, exposure history requires significantly more consideration and depth. 

No exposure to tobacco/cigarette/marijuana smoke, alcohol, or illicit drugs. There are two 

dogs and three cats living in their house. The family lives in a suburban neighborhood 
without exposure to livestock or other animals. They have city water, electric heat, and are 
not currently remodeling their house. Other than school peers with some cough/runny 
nose, no other notable sick contacts including a well sibling. The family traveled to West 
Virginia approximately 3 weeks ago to visit their maternal grandparents, both of whom are 
healthy and without recent acute illnesses. 

Substance/Sexual/Menstrual History (often part of “Social History,” but can be 

separated): 

This section depends upon presenting complaint as well as patient age and sex. 
  
Tobacco: N ​ ot relevant (if applicable, ask about smoke and smokeless tobacco; if needed, 
pack years is calculated as # of packs/day x number of years) 
Alcohol: N​ ot relevant (if applicable, ask about types of alcohol and number of drinks per 
week) 
Illicit Substances: ​Not relevant (if applicable, ask about non-injection and injection drug 
use; consider asking separately about marijuana, as this is not considered an illicit 
substance in some states) 
Sexual history: ​Not relevant (if applicable, inquire about sexual preference – e.g. male, 
female, or both – number of sexual partners, most recent sexual contacts, forms of sexual 
protection, and any history of sexually transmitted infections). 
Menstrual history: N ​ ot relevant (if applicable, inquire about age of first menses, last 
menstrual cycle date, length and heaviness of a typical menstrual cycle, and use of 
contraceptives such as oral birth control pill, implantable device, etc.). 

Vitals: 
Report presenting vital signs in your H&P and ranges in subsequent progress notes. Height, weight, 
and head circumference (including age-adjusted percentiles) are often reported with pediatric vital 
signs and are especially relevant for neonates and infants presenting with developmental and/or 
nutritional concerns. Also, recall pediatric medication dosing is generally weight-based, so ensure 
an accurate weight is documented upon all hospital admissions. 
  
Temp: 98.7 F (note F for Fahrenheit or C for Celsius; Celsius is often used in pediatrics) 
BP: 90/65 
HR: 196 
RR: 48 
Saturation: 91% on 4 liters nasal cannula (always note any non-invasive or invasive 
ventilatory support) 
Weight: 19 kilograms (kg), 55​th​ percentile 
Height: 110 centimeters (cm), 60​th​ percentile 
Head circumference: not measured (and likely not relevant for example scenario 
age/presenting complaint) 

   
Physical Exam: 
Document a detailed physical exam with a focus and organization influenced by the chief 
complaint. Typing a quick normal physical exam also becomes important when preparing for the 
Step 2 CS and will save you time on the exam. 

Constitutional: ​Patient is well developed, well-nourished, and appears her stated age. 
However, she appears ill and in modest respiratory distress with visible accessory muscle 
use. 
Head: ​Atraumatic, normocephalic. Fontanelles closed with no palpable sutures. 
Eyes:​ Extraocular movements intact (EOMI). Pupils equally round and reactive to light and 
accommodation (PERRLA). Mild conjunctivitis bilaterally without discharge. Sclera anicteric. 
ENT: ​Ear canals with minimal cerumen; tympanic membranes (TMs) visible, pearly gray, 
and with positive light reflex bilaterally. Clear nasal discharge with some infranasal 
crusting. Nasal turbinates & mucosa modestly erythematous & edematous bilaterally. No 
nasal polyps present. Dry oral mucosa without thrush. 
Neck: S ​ upple, trachea midline, no thyromegaly, full range of motion (ROM) without 
evidence of nuchal rigidity. 
Pulmonary: ​Tachypneic. Increased respiratory effort with abdominal and intercostal 
accessory muscle use. Expiratory wheezes appreciated bilaterally with reduced air 
movement in lower lung fields. No crackles appreciated. 
CV: T​ achycardic with regular rhythm. Normal S1/S2 without murmurs, rubs, or gallops. 
GI: A
​ bdomen is soft, non-distended (ND), non-tender (NT), and without rebound, rigidity, or 
guarding. No obvious hepatosplenomegaly (HSM). Normoactive bowel sounds. 
Extremities: ​Pulses are equally strong and symmetrical at upper and lower extremities. No 
lower extremity edema. No clubbing. Mild perioral cyanosis present initially, now improving 
with oxygen supplementation. 
Lymph:​ No cervical, supraclavicular, axillary, or inguinal lymphadenopathy present. 
Skin: ​No rashes, ecchymoses, or other visible skin lesions. 
MSK:​ Strength 5/5 in bilateral upper and lower extremities. Normal range of motion of all 
extremities/neck. 
Neuro: ​Alert with age-appropriate orientation. No focal neurological deficits. 
Psych: ​Appears anxious but consolable. Mood and affect otherwise normal. 

Labs/imaging: 
The following are the typical labs/imaging reported in every H&P. You may include certain other 
values relevant to the chief complaint, H&P, examination findings, and differential diagnoses. 

CBC: WBC 10,400 / Hgb 13.5 / Hct 40 / Plt 350,000; WBC different: segs 40%, lymphs 51%, 
monos 6%, no bands 
BMP: Na 140 / K 4.1 / Cl 100 / Bicarb 19 / BUN 17 / creatinine 0.7 / glucose 99 / calcium 9.2 
CRP: 2.03 mg/dL 
Chest x-ray: patchy perihilar opacities bilaterally without focal lung infiltrates 
Assessment and Plan: 
This section is where you will summarize the preceding information and develop differential 
diagnoses and respective management plans. 

Patient problems are listed in the following order: 

1. Pertaining to the chief complaint, 
2. Laboratory/physical exam abnormalities, and 
3. Patient’s chronic medical problems (if relevant). 

It is important to recognize the criteria which warrant an ICU versus floor admission and when 
cardiorespiratory monitoring is necessary. 

1. Acute asthma exacerbation secondary to a viral upper respiratory tract infection 

We begin with “Acute asthma exacerbation secondary to a viral upper respiratory tract infection” 
as the most likely diagnosis. The E ​ tiology​ section includes the pertinent ROS positives/negatives, 
laboratory/imaging findings, and presentation timeline that support the above diagnosis. The 
Plan​ section includes a list of orders, including the patient’s hospital admission. 

Etiology: P​ atient presenting with an initial history of nasal discharge and nonproductive 
cough that progressed to significant shortness of breath. Notable physical examination 
findings include modest respiratory distress with accessory muscle use, initial perioral 
cyanosis improved with oxygen supplementation, expiratory wheezing, and reduced air 
entry in lung bases. Lack of fever, no crackles upon lung examination, very modestly 
elevated WBC (with lymphocyte predominance) and CRP, and chest x-ray findings 
suggestive of bilateral patchy opacities without a focal infiltrate suggest an underlying viral 
etiology more readily than a bacterial source, albeit something to consider for poor clinical 
improvement with the current management plan. 

Plan: 
● Admit patient to the pediatrics floor with cardiorespiratory monitoring and 
continued oxygen supplementation, titrated to maintain oxygen saturation >92% 
and for work of breathing. 
● Check vitals every 2 hours during acute illness and space out for clinical 
improvement. 
● Make patient NPO due to respiratory distress/risk for aspiration. 
● Administer albuterol via nebulizer every 2 hours, spacing out as tolerated. T​ his likely 
requires a respiratory therapy consult depending on the institution providing care. 
● Initiate intravenous steroids as follows: methylprednisolone 1 mg/kg IV q12hr. 
● Hold home inhaled fluticasone while using IV steroids. 
● Consider allowing oral intake/changing to oral medications once acute respiratory 
distress is well-controlled. 
● No need to repeat CBC/CRP or chest x-ray unless patient becomes febrile or 
demonstrates acute clinical changes. 
2. Dehydration with mild acute kidney injury 

The “Dehydration with mild acute kidney Injury” problem that follows the chief complaint is 
recognized given the dry oral mucous membranes and moderate BUN/creatinine elevation noted 
on patient’s BMP at the time of presentation. It is important to document the etiology of 
AKI—pre-renal, renal, or post-renal and provide the appropriate support, which will then dictate 
how it should be managed. 

Etiology:​ The patient’s baseline creatinine is around 0.4 (obtained from chart review of 
previous labs). Patient presented with BUN 17 and creatinine 0.7. Suspect pre-renal injury 
(BUN:Cr is > 20:1) with poor renal perfusion in the setting post-tussive emesis, reduced oral 
intake, and excess losses from tachypnea resulting in dehydration. 

Plan: 
● Strict intake and output (I&Os) monitoring 
● Daily weights 
● Patient received 20 cc/kg bolus of 0.9% NS in the ED. Continue D5W + 0.9% NS + 20 
KCl at ~60 mL/hr maintenance fluids rate (​ask supervising resident/attending about 
insensible losses, calculating percent dehydration, and calculation of maintenance fluids 
including the “4-2-1 rule”​). 
● Monitor improvement of renal function with BMP the following day. 

We end the Assessment and Plan section by discussing the patient’s chronic medical problems, 
which add to the complexity of her hospitalization and how these problems should be managed 
while inpatient and/or upon hospital discharge. 

3. Seasonal allergic rhinitis 

Etiology:​ documented medical condition, which may be contributing to current 

presentation. 

Plan: 
● Consider initiation of oral or intranasal agent to help control seasonal symptoms 
upon discharge. 

Acutely ill patients often have their home medications withheld while inpatient unless deemed 
clinically necessary. Remember to ask yourself why you may be re-ordering patient’s home 
medications and whether they are appropriate given the circumstances of their hospitalization. 

Code Status: ​Full Code 

Finally, every patient needs a “Code Status”. While it seems implied with most all pediatric 
patients, you may encounter certain situations with chronically ill children where advanced 
directives are in place. This is a discussion that should ​ALWAYS​ occur with a senior resident and/or 
attending physician of record present with the family. 

 
Every decision you make should follow “High Value Care”. Always ask yourself why certain 
orders are placed and whether they are necessary. For example, patients typically don’t 
need daily labs, especially when significant changes are not anticipated, and the result will 
not change clinical management. 

It is important to consider a contingency plan should the patient not improve clinically as 
expected. As in this clinical scenario, fevers in the setting of productive sputum, worsening 
cough, and/or difficulty alleviating her shortness of breath with associated lab or imaging 
abnormalities may suggest an underlying bacterial source requiring antibiotic therapy. A 
management plan should be thoroughly discussed with your medical and nursing team 
before relaying information to the patient’s family/guardian in appropriate, non-medical 
terminology. This also improves patient care if the patient’s clinical status acutely changes 
after the admitting team signs out to another team or service (e.g. the overnight team).