PEDIATRIC ATTENDING NOTE ___Admit ____Subsequent Day DATE: TIME: History as documented by Dr. _______________________ reviewed with patient and resident. It is noted that: Review of Systems NEG POS (positive findings detailed in narrative note) General HEENT Respiratory Cardiovascular Gastrointestinal Genitourinary Neurological Musculoskeletal Hemat/Lymph Allergic/Immuno Psych/Mental Endocrine Skin PAST MEDICAL HISTORY: _____ No pertinent changes from admit FAMILY HISTORY: _____ No pertinent changes from admit SOCIAL HISTORY: _____ No pertinent changes from admit Ancillary tests (Lab/Xray/Others): -----------CONTINUED----------- PHYSICAL EXAM WNL Exceptions PHYSICAL EXAM EXCEPTIONS AND/OR CONSTITUTIONAL ____ _____ POSITIVE FINDINGS Vital Signs (BP, Pulse, RR, Temp) ____ _____ General Appearance ____ _____ EYES Inspection of conjunctivae and lids Exam of pupils and irises ENT External exam ears and nose Otoscopic Exam Oropharynx Exam NECK Exam, neck Exam, thyroid RESPIRATORY Respiratory Effort Auscultation of Lungs CARDIOVASCULAR Auscultation of Heart Extremities for Edema GENITOURINARY Exam, abdomen Exam, liver and spleen Exam, Scrotal contents Exam, Penis Exam, external genitalia GI/ABDOMEN LYMPHATIC Palpation, Neck Palpation, Axillae Palpation, Groin ASSESSMENT AND PLAN MUSCULOSKELETAL Inspection of digits and nails Muscle Strength and Tone Range of Motion (note pain,crepitation,etc) Note Musculoskeletal Area(s) Examined: Head and Neck Spine, ribs and pelvis Right upper extremity Left upper extremity Right lower extremity Left lower extremity SKIN Inspection of skin and subq tissue Palpation of skin and subq NEUROLOGIC Exam, deep tendon reflexes Exam, sensation PSYCHIATRIC ___________________________ Orientation to time, place & person PHYSICIAN SIGNATURE Mood and affect ASSESSMENT AND PLAN PHYSICIAN SIGNATURE