Skip to main content

Pediatric History and Physical Write-Up

Please do this on an infant with conjunctivitis
Pediatric History and Physical Write-Up
Students are required to do a full history and physical write up for patients encountered during practicum. A write-up must be conducted for (1) pediatric patient chosen from each of the following age groups: Infant, Toddler, Preschooler, School Age or Adolescent. These write-ups should include a complete history and physical, along with differential diagnosis, plan of care, billing codes, medications prescribed, etc. Each H&P should be submitted to a separate drop box with a file name indicating the age group examined for the submitted H&P. Example: Wallace HandP Toddler.docx. There is a sample H&P that students are welcome to use for formatting available in the resources section of Canvas. In addition, see the rubric on pages 9-11 of syllabus.

Pediatric History and Physical Rubric
Required Element Points Available Comments Points Earned
Content. H&P should include ALL of the following content areas (see sample H&P posted to Canvas). 90 (see points breakdown of each section below)
-          Provider information and date of service
-          Patient information (initials, age, race/ethnicity, insurance)
-          Allergies
-          Medications
-          Chief Complaint
-          Historian (patient, parent,etc.)
-          History of Present Illness (4 points)
Past Medical History
-          Birth History (Prenatal, Natal, Postnatal)
-          Medical/Surgical History
-          Injuries
-          Hospitalizations
-          Family Medical History (2 generations- parents and grandparents)
-          Social History
-          Immunizations
-          Restate any allergies and current medications in this section as well
-          Herbal/Vitamins/Alternative Supplements/Treatments
-          Lead exposure?
-          TB exposure? (5 points)
ADL’s and Habits
-          Diet
-          Elimination
-          Sleep
-          Activity
-          Oral Health
-          Safety/Risk Assessment (age appropriate) (4 points)
Growth and Development
-          Physical Growth (include a growth chart as appendix)
-          Motor
-          Cognitive
-          Verbal
-          Social
-          Personality
-          School (10 points)
Review of Systems
-          Constitutional
-          Skin
-          Neurological (include sensory)
-          HEENT
-          Oral/Teeth
-          Cardiovascular
-          Respiratory
-          GI
-          GU
-          Reproductive
-          Musculoskeletal
-          Endocrine
-          Infectious Disease
-          Psychological/Mental
-          Developmental (15 points)
Physical Exam
-          Weight
-          Height
-          BMI
-          Vital Signs
-          General
-          Mental status
-          Neuro (include cranial nerves checked, reflexes, sensory and motor)
-          Emotional/Psychological
-          Skin
-          Hair/Nails
-          Neck
-          Lymph nodes
-          Head
-          Eyes
-          Ears
-          Nose
-          Throat
-          Mouth/Teeth
-          Cardiovascular
-          Pulmonary/Thorax
-          Chest
-          Abdomen
-          Genitourinary
-          Rectum/Anus
-          Musculoskeletal
-          Extremities
-          Joints
-          Back (15 points)
Stages of Development
-          Erickson
-          Piaget
• Include explanation of WHY this patient is in the identified stage of development AND if it is developmentally appropriate for their age group.
-          Motor sensory development
-          Overall developmental assessment (Is this patient’s development appropriate for their chronological age?) (5 points)
Overall Impression of Assessment
- (5 points)
Presumptive Diagnoses (include codes) (5 points)
Differential Diagnoses (at least 5) (5 points)
Plan with Evidence-based rationale (include references) (10 points)
Billing Codes (include both ICD and CPT codes) (7 points)
APA format, correct spelling and grammar. Paper should include title page, appropriate headers and headings, in-text citations as appropriate, and reference page. 10 points





Comments

Post a Comment

Popular posts from this blog

Identify and discuss a key milestone in the history of computers that interests you and why.

  Part 1Title: Lab ResponseDiscuss one feature of MS Word and one feature of MS Excel that you found challenging within the lab and why. Examples are WordArt, inserting shapes, adding borders, cell styles, etc. This response should be at least one paragraph in length. Part 2Title: History of Computers Identify and discuss a key milestone in the history of computers that interests you and why. This section should be at least one paragraph. Part 3Title: System Software vs. Application Software In your words, explain the difference between application software and system software as if to another coworker who has limited technical knowledge. Use examples to support your rationalization. This section should be at least two paragraphs. Part 4Title: Blockchain and Cryptocurrency In a minimum of one paragraph each: 1. Conduct some research on the internet and discuss one underlying technology of cryptocurrencies like blockchain, cryptography, distributed ledger technol...
Post a Comment
Read more

Cybersecurity and Infrastructure Security (CISA)

 Develop a research paper that identifies a specific Department of Homeland Security (DHS) operating agency. Fully describe 1 DHS operating agency from the following list: Cybersecurity and Infrastructure Security (CISA) U.S. Customs and Border Protection (CBP) U.S. Citizenship and Immigration Services (USCIS) Federal Emergency Management Agency (FEMA) U.S. Coast Guard (USCG) U.S. Immigration and Customs Enforcement (ICE) U.S. Secret Service (USSS) Transportation Security Administration (TSA) The information must include a discussion of the selected DHS agency. Identify the agency’s mission, goals, objectives, and metrics. Conduct an analysis of how these mission areas address the threats or challenges. Recommend agency program priorities among the current set of goals, objectives, metrics, or budget items. Justification of all choices is an essential element of this assignment. Reference all source material and citations using APA format. WE OFF...
Post a Comment
Read more

You have been given the t

PPMP20009 Leading Lean Projects Term 2, 2018 Page 1 of 3 Assessment 1 (Individual Work – 40%) Case study: Managing Lean Project Introduction You have been given the task to organise the FIFA 2018 World Cup football tournament ( https://ift.tt/2If0UDE ). (For those not familiar with football, you may change the event to the recently concluded 2018 Gold Coast Commonwealth Games: https://gc2018.com/ ). Your tasks This assessment item requires you to work INDIVIDUALLY. 1. As the project manager in charge of delivering such as an important world sporting event: i. Identify and elaborate the following terms with regards to the event. a. Voice of the Customer (VOC) b. Critical to Customer Requirements (CCR) c. Critical to Quality parameters (CTQ) ii. In what ways would you have implemented lean project management for this event? Identify and elaborate processes from PMBOK, PRINCE2, Organisational Project iii. Management Agile Practices and Lean Six Sigma (DMAIC Me...
Post a Comment
Read more