HPI Templates

Well Child

Patient had normal prenatal course.
Patient born at full term by NSVD.
UTD vaccinations.
Patient continues to have normal feeding patterns. No emesis.
Patient has no changes to stooling or urination frequency or consistency.
Child is active/interactive at home.
Family has good access to pediatrician.

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PEARLS and mini-macros

Normal I/O Patterns

Newborn Intake: Goal ~16 ounces/day. Should feed every 2-4 hours even if you have to wake. Should take in 1-2cc per feed (about the size of your thumb DIP to tip). Formulas should contain iron and vitamin D. No bottle of water, may cause hyponatremia. Best test for hydration status: Serum Na+.

Newborn Output: Should have 4-6+ wet diapers per day. More than three bowel movements per day is normal in breastfed infants. Bottle-fed infants may have fewer bowel movements. Constipated: 1 oz of sorbitol-containing juice (e.g., prune, pear, apple). Low output increases risk for hyperbilirubinemia.

Weight change: Newborn: Okay to lose up to 10% of body weight in first few days. Back to normal weight by: Day 10 bottlefed. Day 14 Breastfed (given increased time for milk letdown). Infant: 15-30g/day or 1lb q2weeks for first three months of growth velocity.

Vaccines and Milestones

2mo: Patient received initial newborn Hep B as well as 2mo vaccines (rotavirus, DTaP, Hib, PCV, polio). And continues to be UTD on vaccinations.

Milestones:
2mo: smiles responsively, lifts head, vocalizes in play
4mo: babbles & coos, rolls front to back, controls head well
6mo: rolls over, transfers small objects, vocal imitation
12mo: Cries when mom or dad leaves, Says “mama” and “dada”, Copies gestures (waves “bye bye”), May stand alone
18mo: Says several single words, walks on stairs, “runs”

Consent

Emergency exception rule: Treat pain and other emergencies in children with implied consent.
General Conditions okay in most states with Child Only consent: pregnancy-related conditions, mental health issues, sexually transmitted diseases, substance abuse.

Difficult dispositions

Parents very uncomfortable going home: “This is a child with a chronic medical condition for which this child’s caretakers are likely best able to assess the capabilities they have at home and do not feel safe being discharged. For this reason, for social work evaluation and continued medical monitoring this patient should be admitted.”