What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
HPI: 3 yo African American M here for Well Care visit . Mother reports pt. stools only 2 times per week. BMs described as hard, brown, and round. Has noticed this infrequent stooling pattern since began potty training at 2.5 yo. Pt. often cries and strains when trying to pass bowel movement. Pt. a “picky” eater who avoids fruits and vegetables. Mother has not tried any treatments and is unsure what makes better or worse.
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•Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
•Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Make sure you include Review of System for age appropriate
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
•Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
References
Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
◦Review: “Promoting Healthy Nutrition” (pp. 121–145)
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
◦Chapter 26, “Recording Information”
