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Sample Pediatric History and Physical Exam
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Sample Pediatric History and Physical Exam
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Sample Pediatric History and Physical ExamDate and Time of H&P: 9/6/16, 15:00
Historian: The history was obtained from both the patient’s mother and grandmother, who are
both considered to be reliable historians.
Chief complaint: "The rash in his diaper area is getting worse."
History of Present Illness: Cortez is a 21-day-old African American male infant who presented
to LBCH with 1 day of worsening rash on his abdomen. Cortez’s mother stated that her baby
seemed to be healthy since his discharge from the nursery until 1 day prior to presentation,
September 5th, when she noticed a raised erythematous rash on Cortez's abdomen. She also
noticed that her baby vomited her breast milk after three feeds. Consequently, she switched to
formula, which he handled without vomiting. There were no rashes anywhere else on his body.
On the morning of presentation, she noticed the rash had become fluid filled and had spread
throughout the anterior diaper area including the inguinal region and upper right and left thigh.
No intervention was attempted to treat the rash and nothing was noted to worsen the rash
besides the passing time. Both mother and grandmother did not note any changes in Cortez's
temperature, stool or urine quality or quantity, or appetite. In addition, there were no
symptoms of increased work of breathing, cough, or lethargy. However, grandmother did say
that Cortez was slightly more irritable today. This was Cortez's first medical visit following
discharge after birth. Patient's family denies any illness within their current household and
visiting relatives. The patient does not attend daycare.
ROS:
CONSTITUTIONAL: No fever, weight loss. Grandmother reported increased irritability.
EYES: Seems to have difficulty focusing at distances
EARS, NOSE, MOUTH/THROAT: No otorrhea, no congestion, Mom noticed a white dot on the
roof of his mouth since birth
CARDIOVASCULAR: No history of heart murmur, no cyanosis.
PULMONARY: No cough or increased work of breathing, but mom did notice that he
occasionally breathes fast then stops for a few seconds, then starts up again. It’s most
noticeable when he sleeps.
GI: Mom says Cortez passes a lot of gas. When he was breast-fed, he had a soft stool after every
feed – sometimes 8-10 a day. He has only had two stools in the last 24 hours. His umbilical cord
fell off three days ago.
GU: Cortez displays a strong stream of urine when he voids.
NEUROLOGICAL: Cortez was very shaky after birth but that’s slowly resolved.
MUSCULOSKELETAL: No edema or trauma
HEMATOLOGY: No ecchymosis or bleeding.
DERMATOLOGY: see HPI
, Birth History: Cortez was born at 40 weeks gestation via normal spontaneous vaginal delivery
(NSVD) to 16yo mother G1P1 whose first prenatal visit was in the second trimester. His
mother’s prenatal screen revealed a negative Hepatitis B antigen, negative HIV screen,
nonreactive RPR, Rubella immune, and GBS negative according to the OB discharge papers from
the hospital; however, vaginal cultures came back positive for Chlamydia. This was treated in
the second trimester, with repeat test coming back negative. She was never diagnosed with
genital herpes and denies ever having symptoms of this condition. His birth weight was 3.0 kg
(Mom doesn’t remember length). There were no complications at delivery. APGAR’s are
unknown but mom says Cortez did breathe spontaneously at birth. Both mother and baby were
discharged after a two-day hospital stay. Cortex did not require any respiratory support or
phototherapy while in the nursery. Newborn screen was performed prior to discharge, but the
results are not known.
Past Medical History: No past medical history to date. Mother denies any accidents and
injuries. Mother has not established her pediatrician and Cortez did not receive his two-week
well child check-up.
Past Surgical History: Circumcision, no complications
Immunizations: Hepatitis B vaccine was given in the nursery.
Medications: No medications
Allergies: No known allergies
Family History:
Paternal Grandfather - Unknown
Paternal Grandmother - Unknown
Maternal Grandmother - Healthy with no known medical problems
Maternal Grandfather - Unknown
Mother - Healthy with no known medical problems
Father - Unknown
There is no family history of diabetes, seizures, cancer, heart disease, hypertension or sickle cell
on the maternal side. However, very little is known about the paternal side.
Social History: Patient lives with his unmarried mother and grandmother plus a maternal cousin
with her 1 year old baby in a Memphis apartment. Mother has not graduated from high school
at this time. She is not currently working outside of the home. The patient's father is uninvolved
with the care. The family subsists on SSI and AFDC. Their residence contains no pets. No one in
the home smokes.
Diet: Cortez was breast-fed exclusively until one day prior to admission. Since then he has
received Similac, 3-4 oz. every 3-4 hours. He receives occasional water.
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