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Professionalism | |
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Introduces self/role and preceptor |
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Verbal and non-verbal language demonstrates respect for patient / family |
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Respects patient modesty in child/adolescent |
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Washes hands before examining patient |
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Communication Skills | |
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Uses language that is understood by patient/parent |
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Approach to patient is compatible with developmental level |
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Includes patient in interview to whatever extent possible |
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Uses open-ended questions to elicit information |
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Gathers information in a logical sequence |
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Clarifies responses that are unclear |
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History | |
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Elicits a chief complaint |
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HPI |
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Thorough review of all events leading up to hospitalization |
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Includes pertinent positives and negatives |
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Includes pertinent information from past history, family history, social history and ROS that is relevant to HPI |
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Past History |
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Birth History (prenatal complications, gestational age, type of delivery, birth weight, neonatal complications) |
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Illnesses / Hospitalizations |
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Operations |
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Allergies (food and drugs) |
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Immunizations |
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Medications |
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Diet |
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Developmental Milestones / School Performance |
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Primary Physician |
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Pertinent elements of family history |
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Pertinent elements of the Social History (primary caretaker, members of household, occupations, social support structure, HEADSS for adolescents - home, education, activities, drugs, sex, and suicide) |
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All elements of the review of systems |
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Physical Examination | |
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Observes general appearance for toxicity, distress, irritability, growth/development |
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Head (fontanelles, shape, evidence of trauma) |
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Eyes (pupils, EOMs, red reflex, discs in older child) |
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Ears (canals and tympanic membranes) |
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Nose (turbinates) |
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Mouth / Throat (mucous membranes, pharynx) |
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Neck (thyroid, trachea, movement) |
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Nodes (cervical, axillary, inguinal) |
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Cardiac (rate, rhythm, first and second heart sounds, murmurs, gallops, rubs, symmetry of pulses, capillary refill) |
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Chest (symmetry, breasts, spine) |
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Lungs (respiratory rate, distress, retractions, air entry, wheezing, rales, rhonchi) |
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Abdomen (inspection, bowel sounds, palpation) |
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Genitourinary (inspection, palpation of testes) |
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Extremities (clubbing, cyanosis, edema, symmetry, hips in infants) |
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Neurologic (LOC, cranial nerves, sensory, motor, cerebellar, DTRs, gait) |
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Skin (rashes, lesions) |
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