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Subjective
DEMOGRAPHICS
Patient’s name, age (& DOB to double-check), Gender, Informant name & relationship (mother, father, etc.), General address

CLINICAL HISTORY
Presenting Complaint: “What would you say is the main problem?”
One sentence, preferably in patient’s/parent’s own words stating what is wrong. In multiple complaints, list in chronological
st
order (oldest symptom 1 ) & ask which specifically bought them to the hospital

History of Presenting Complaint:

 Has the child has been previously well? Or when was the child last well? Any known premorbid conditions?
 Elicit the facts & evolution of the illness, particularly time & nature of the onset
o Arrange these facts chronologically, in a narrative fashion, tracing the course of events up to present visit
o What was done for the child; any associations, aggravating/ relieving factors, what drugs were given & were
they effective? Include physical exams, lab tests & treatments which occurred before the present admission
o Record pertinent -ve and +ve info, as well as any sick contacts!
o Impact of the illness on patient’s appetite, activity, stool & urine output ( # of wet/poop diapers?), lifestyle
 Conclude with a description of the visit to clinic/emergency department which resulted in the present admission.

1. site
o where/ where worst
1
2. onset
o when & speed i.e., sudden/gradual; mins/hrs/days/wks, etc
o associated circumstances
3. character
o use patient’s adjectives to describe: sharp/ dull, stabbing /boring, tingling/ burning, crushing/tugging
4. radiation
5. associations
o any other symptoms: sweating/vomiting, etc
6. time course/ pattern & duration since onset
o • Episodic or continuous
 If episodic, duration & freq. of attacks
 If continuous, any changes in severity
o Variation by day or night, during the week or month, e.g. worse on mornings
o progression
 gotten worse/better/ same over the stated time frame
7. exacerbating /relieving factors
o activities, postures, medications, alternative medicines
8. severity on a scale of 0-10

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SPECIFIC QUESTIONS FOR COMMON PRESENTING COMPLAINTS
Cough:
 Characteristics: productive/non-productive, barking, whooping; # episodes & # of coughs per episode
 Timing: day + night/ night alone
 Triggers: cold, dust, illness, animal dander, pollen, smoke, exercise, temperature changes
 Associations: runny nose, sneezing, wheezing
 DDx: nocturnal cough  asthma, bronchiolitis, sinusitis, LRTI

Wheeze:
 Triggers: cold, dust, illness, animal dander, pollen, smoke, exercise, temperature changes, aerosols
 History of atopy (tendency to develop immediate allergic reactions to pollen, food, dander, & insect
bites & manifested by hay fever, bronchial asthma, allergic rhinitis, atopic dermatitis, or food allergy)
 Last episode, frequency of attacks, attends asthma clinic, ICU admissions, fam hx, which inhaler(s)
currently prescribed and compliance
 Clarify inhaler/spacer  facemask technique

Fever:
 Onset; measured with a thermometer, type of thermometer & where (e.g. axilla, rectal)
 Characteristics: intermittent, constant, particular pattern
 Associations: chills, rigors, excessive sweating, seizures
 Alleviating factors: 1) tepid sponging, 2) fan therapy, 3) Paracetamol

Diarrhoea & Vomiting:

 Vomiting evolution, contents, colour (green = bile, blood = haematemesis), frequency, vomiting on
empty stomach, volume, is the vomiting after a bout of coughing (post-tussive)
 Diarrhoea: evolution, frequency, consistency, blood or mucus , odour, abdo pain, urgency, outbreaks
at school, travel hx, sick contacts
 Hydration status: volumes & frequency of input & output, lethargy, irritability, sunken eyes, skin turgor

Seizures:
 Characteristics:
o Generalised/shaking all over
o Jacksonian March/start in 1 place then become generalised

1
use for non-localised symptoms e.g., cough, SOB
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o Focal/ start in 1 place & stayed in that place
 Features: duration, what was the child doing at the time of onset, describe the fit/spell: twitch in 1
muscle, violent shaking, sudden stiffness
 Associations: fever (DDx- febrile seizures), frothing, eye-rolling, tongue-biting, incontinence,
unresponsiveness, stiffness; in neonates: lip-smacking, cycling movements
 Prodrome (an early sx); aura (smell, flashing lights, etc)
 Post-ictal drowsiness & duration, weakness, Todd’s (temporary) paresis/paralysis (DDx- space
occupying lesions)
 Paternal hx of febrile seizures, Family hx of epilepsy

Meningitis:
 Photophobia, neck stiffness, headaches, visual disturbance, bulging fontanelle, irritability
(inconsolable), lethargy

Nephrotic/Nephritic Syndrome:
 Nephrotic presents with peri-orbital, pedal & scrotal oedema
 Where were the eyes swollen? One/ both eyes? Discharge? Associated erythema? Vision affected?
Itchiness? Better/ worse during the day? Anywhere else swollen (feet & scrotum)?
 Frothy urine ( proteinuria)
 Rash on legs? Sore throat? Associated viral illness (DDx: post-strep glomerulonephritis)
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Review of Systems /Past Illnesses:

 General: fever + temperature, feeding + appetite, sleeping, growing, energy/activity level (attitude)

Nervous: Cardiovascular: Respiratory:

 fontanelle bulging  cyanosis especially while feeding  Cough
 convulsions (+ details if yes;  exertion on feeding  sputum (usually coryza; if
febrile/afebrile)  murmur swallowed, ask if seen in
 abnormal movements (tics, habit  SOB on exertion/at rest vomit/poop)
spasms)  fatigability/tiredness/lethargy  runny nose + colour
 headaches (time, associations   syncope (fainting),  barking cough (croup)
eye problems)  palpitations/tachycardia (>6 yrs)  wheeze, chest tightness
 weakness  pallor  breathing problems/ mouth
 loss of consciousness breathing
 clumsiness  nasal flaring
 vision & hearing problems  nosebleed
 staring spells  sore throat

GI: Genitourinary: ENT:

 dentition  UTIs  throat infections
 mouth ulcers  dysuria  snoring + details
 vomiting  frequency, urgency,  noisy breathing (stridor)
 feeding & appetite dribbling/enuresis (incontinence)  nocturnal cough
 weight loss/gain  toilet-trained/nocturia
 abdo pain  frothy-white, blood
 jaundice  smell
 bowel habits + consistency   boys: does stream come from tip
blood/mucus seen or other of penis (hypospadias)
abnormalities (smell?)  sexually active + STDs
 diarrhoea/constipation  menarche/menses
 discharge + pruritus
Skin: Musculoskeletal: Psychological:
 general rashes  warm joints  Inquire (appropriate to age) for
 hyper/hypo-pigmented  disturbance of gait/limp o restlessness
patches/birthmarks  limb pain/swelling o tantrums
 petechiae  weakness o night terrors
 jaundice  tenderness o tics
 tingling o how does child get along with
 muscle/joint pain peers at play/in school
 other functional abnormalities/
deformities (knock-knee, pigeon
toes)
 clumsy (do full neuro exam)

Past Medical & Surgical History:

 General health: how active/ lively, any illnesses
 Chronic illness screen: asthma, sickle cell, epilepsy, thalassaemia, congenital heart disease, diabetes
o Get details in any +ves:
 when & how diagnosed, by whom; current treatment, changes over time & compliance;
#/frequency of attacks, # of hospitalisations (emergency vs admissions), who is managing it
(clinic/private dr & copies of investigations), regularity of clinic visits, complications

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 Previous hospitalisations and Admissions:
o when (child’s age), hospital & ward, why (P/C & final diagnosis), duration, treatment, complications, follow-up
o Dates, nature of & complications from any operations

Drug History:
 Drug name, why prescribed, who prescribed & when, dosage form, dose, frequency, duration, side effects, last taken,
compliance/adherence
 Allergies to drugs, eggs, peanuts, other foods, insect bites, contact

Birth & Neonatal History:

Maternal Antenatal:
 planned/unplanned  welcomed
pregnancy
 # of pregnancies & which baby is
this
 booking bloods & results (ABO,
Rhesus, HIV, VDRL, SCD, CBC)
 USS: how many, when done
 supplements (Fe, folic acid) & what
stage of pregnancy she began
taking
 TORCH & other infections
[Toxoplasmosis, Other (syphilis,
VZV, parvovirus B19), Rubella,
Cytomegalovirus, chlamydia,
gonorrhea, HIV, hepatitis, herpes,
Group B Strep, UTIs]
 maternal illness & complications
prior/ during pregnancy &
hospitalisations; gestational DM,
HTN, pre-eclampsia, epilepsy & if
illness prevented working
 alco, smoking, licit & illicit drugs
during pregnancy
Intrapartum:
 gestational age/due date
 details of labour & delivery
o which hospital
o C-section (foetal/ maternal
indication, elective/
emergency)
o vaginal (spontaneous/
induced)
o how long after water burst
did she give birth/prolonged
labour, prolonged rupture of
membranes
o position (breech/normal,
cord around neck,
meconium)
o assisted delivery
(forceps/vacuum)
Postpartum:
 birth weight
 APGAR score (condition & vigour
of infant at birth: pink,
breathing/crying, limp/active)
 Skin-to-skin initiated for ≥ 1 hr
immediately after birth
 When was breastfeeding
initiated?
 Was the baby taken away?/NICU
admissions, reasons & duration
 jaundice/put under light or
transfused
 infections & tx
 Mom & baby discharged
together?
 congenital abnormalities

Growth & Developmental History:

 DENVER (fine & gross motor, language & social/behavioural) must be covered in all pts
 For a child > 4-5 years:
o a global statement such as “the developmental history is normal” is acceptable
o Also include: vision & hearing; bladder & bowel control; school progress- had to repeat & why, grades, rank
in class, absence from school, friends in school known to parents, teacher concerns, school performance
compared to other siblings; temperament, behaviour, sleeping

Age Fine Motor- Other

Gross Motor Personal-Social Language
Adaptive Cognitive
2 Moves head side- Regards face Alerts to sound
wk to-side
1 Raises head from Visually fixes Regards face Alerts to sound
mo prone Follows to midline Calms when comforted
Hands fisted, tight
grasp
2 Briefly lifts Tracks past midline Smiles socially (if Coos (long vowel
mo shoulder while No longer clenches stroked/ talked to) sounds in musical
prone, head erect fists tightly Recognises parent, fashion), gurgles
when upright Pulls at clothes calms to familiar voice Searches for sound
with eyes
3 Supports on Holds hands open Reaches for familiar Coos
mo forearms while at rest persons or objects
prone Follows in circular Anticipates feeding
Holds head up fashion
steadily
4 Lifts up on hands Reaches for object Looks at hand Laughs & squeals
mo Rolls front to back with arms in unison Begins to work toward Orients to voice
No head lag if Raking grasp toy
pulled to sit from Brings hands to Enjoys looking around
supine midline
6 Sits unsupported Transfers object Feeds self Babbles, ah-goo,
mo Puts feet in hand to hand Holds bottle razz
mouth while Unilateral reach Stranger anxiety Lateral orientation
supine Raking grasp to bell
9 Pulls to stand Uses immature Waves bye-bye Says Dada, Mama,
mo Gets into sitting pincer grasp Plays pat-a-cake & nonspecific
position, pivots Probes with other gesture games 2-syllable sounds
when sitting forefinger Starts exploring Understands “no”
Crawls well Bangs 2 blocks environment

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Age Fine Motor- Other
Gross Motor Personal-Social Language
Adaptive Cognitive
Cruises together
Throws objects
12 Walks Uses mature pincer Drinks from a cup Says Mama, Dada,
mo Stoops & stands grasp Imitates others specific
Can make a crayon Comes when called Says 1 or 2 other
mark Cooperates with words or proper
Releases dressing nouns
voluntarily Jargoning (several
Puts block in cup unintelligible words
together w/ tone or
inflection)
15 Walks backward Scribbles Uses spoon, cup Says 3 to 6 words
mo independently Stacks 2 blocks in Follows 1-step
Creeps up stairs imitation commands without
gesture
18 Runs Stacks 4 blocks Removes garment Says ≥ 6 words
mo Throws objects Kicks a ball “Feeds” doll Mature jargoning
from standing Turns 2/3 pages at Copies parent in tasks (includes intelligible
without falling a time (sweeping, dusting) words)
Plays in the company Knows 5 body parts
of other children
2 Walks up & down Stacks 6 blocks Washes & dries hands Puts 2 words Understands
yr stairs Copies line Brushes teeth together concept of
Throws overhand Turns pages 1 at a Puts on clothes Points to pictures today
Kicks ball time Dry by day Knows body parts
Handedness
3 Steps alternating Stacks 8 blocks Uses spoon well, Names pictures Understands
yr feet going up Wiggles thumb spilling little Speech 75% concepts of
steps Undresses completely, understandable to tomorrow &
Broad jump dresses partially (puts stranger yesterday
Pedals tricycle on T-shirt), unbuttons Says 3-word
Group play, shares sentences, uses
toys, takes turns, plurals, knows all
plays well with others pronouns
Knows full name, age
& gender
4 Balances well on Copies ○, maybe + Brushes teeth without Names colours
yr each foot Draws person with help Understands
Hops on 1 foot 3 parts Dresses w/out help adjectives
Alternates feet Catches ball Tells “tall tales” Says song/ poem
going down stairs Plays cooperatively from memory
with peers Asks questions
5 Skips alternating Copies □ Plays competitive Counts
yr feet Spreads with knife games Understands
Jumps over low Abides by rules opposites
obstacles Likes to help in Prints first name
Heel-to-toe walks household tasks
6 Balances on each Copies Δ Defines words Begins to
yr foot 6 sec Draws person with understand
6 parts right & left

Immunisation:
Ask to see card, where vaccines received (LHC or private); last and next appointments. This may be summarized as:
“immunisations are up-to-date”
NOTE: for sickle cell < 3 yrs ask about pneumococcal

Schedule as of July 2016

Age Immunisation to be given against Vaccine

19-45 years MMR, Hep B
Pre-Natal for Mothers Neonatal Tetanus, Tetanus Td (Adult Tetanus, Diphtheria)
Post-Natal for Mothers Rubella MMR
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Nutritional History:
 breast/bottle-fed
o breast- how often, how long, 1/both sides;  when and why stopped
o bottle- type of formula, how much, how often, how is it mixed/quantities
o tolerance for feeds
o weaning age
o addition of solids-
 food groups, typical meals
 or 24-hr recall (breakfast + lunch + dinner + 2 snacks btwn) if over/under-feeding suspected
 child’s attitude toward eating; vitamin supplements
 Ask teen girls about attitude towards their body and eating!

Family History:
 age, state of health of each parent & sibling; parents’ jobs + highest level of education attained
 if siblings have same father/mother
 any h/o sickle cell disease, CF, miscarriages, birth defects, childhood malignancies, asthma, chronic illness screen
 any family members with similar problems

List the mother’s pregnancies in chronological order, giving details & outcomes of each. If siblings have died, note the nature
of the condition leading to the death & the results of postmortem or other examinations.
Chronic illnesses among members of the family need to be noted.
If the PC & HPC suggest the possibility of a heritable condition, explore the family for the pattern of similar conditions within
the immediate family & forbears.
Check for parental consanguinity. Mention only if clearly relevant to the current admitting problem.

Social History:
Explore living conditions for exposure to specific infections, poisons & toxic substance, psychological & emotional factors
which might be involved in the present illness
 Where does the family live & amenities
o Type & size, owned/ rented; stairs, toilets, cooking facilities, running water vs tank (how often cleaned) or
buckets (covered); electricity; garbage collection, refrigeration, poisons/toxins, guns, neighbours
 # in household; who lives in the household (smokers)
 where child sleeps
 pets
 parent occupation/unemployment, use of alcohol/drugs, parental psychiatric disorders, partnerships, get an idea of
family income
 For asthma: carpets, drapes, pet dander, stuffed animals, smokers in household
Always ask adolescents about EtOH/tobacco/illicit or IV drug use & if they’re sexually active, use of barrier protection;
school: What level are they in? Grades? Behavioural problems? Teachers’ concerns?

Psychosocial History:
 Is the child happy at home/school; child’s preferred leisure/play activities
 how illness/admission affects the family; how patient/siblings/ parents cope with illness
 extra support from extended family, financial aid, NGOs

SUMMARY
Positives & important negatives that impact on differential; approx 5 lines with pertinent information that summarizes the
important parts of the history
Include identifying info, PC, a very brief description of the HPC plus essential details from the ROS, PMSHx, and FSHx
(Be a Dr not a secretary!!!)

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Objective
OBSERVATION, PHYSICAL EXAM AND TEST RESULTS

Include vital signs, results of diagnostic tests (labs and x-rays/ imagine)

Lab Skeletons

Assessment
I. PROBLEM LIST

II. DIFFERENTIAL DIAGNOSIS

CHOPPED MINTS (mnemonic for a differential diagnoses)

C - Congenital M - Metabolic/Endocrine
H - Hematologic/Vascular I - Infectious, Inflammatory, Iatrogenic, or Idiopathic
O - Organ Disease N - Neoplasm (and Paraneoplastic syndromes)
P - Psychiatric T - Trauma
P - Pregnancy-related S – Surgical
E - Environmental
D - Drugs (Rx, OTC, Herbal, Illicit)

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Plan
ADC VANDALISM (mnemonic)
A Admit to: Ward
D Diagnosis: Primary Dx
C Condition: (Stable, Fair, Poor, Critical)
V Vitals: (q4h, as per protocol, q 30min if post-op)
A Allergies: (Penicillin, Codeine) state reaction
N Nursing: (I/O’s, daily weight, dressing changes)
D Diet: (Regular, clear liquids, low salt, diabetic, NPO if pre-op)
A Activities: (Ad lib, bedrest, encourage sitting out of bed, bathroom privileges)
L Labs: (CBC, U&Es, LFTs, cardiac enzymes)
I IV Fluids: (Type and rate)
S Studies: (CXR, MRI, CT w/Contrast, ECG) fill out and drop off request forms
M Meds: Antibiotics, pain , fever, constipation, fill out and drop off any prescriptions

(Ensure that the problem list is addressed)

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CNS ↑ ICP, hydrocephalus, brain tumour, drugs (chemo)

Infections Meningitis, UTI, pneumonia, otitis media, sepsis
Metablolic DKA, urea cycle disorders, galactosemia
Endocrine Adrenal insufficiency
Intoxication Alco, aspirin
Renal Obstructive uropathy, renal failure, renal tubular acidosis

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Differential diagnosis for a Painful Limp

Mnemonic: "The joint STARTSS HOTT"
 Septic arthritis
 Transient synovitis
 Acute rheumatic fever
 Rheumatoid arthritis
 Trauma: #, strain, sprain
 Sickle cell disease: Pain crisis (VOC); osteomyelitis
 Slipped capital femoral epiphysis
 Henoch-Schonlein purpura
 Osteomyelitis
 Tuberculosis
 Tumor: osteosarcoma, leukemia

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