HISTORY:
for
, up to °, over
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Mouth:
Neck:
Heart: ,
Lungs: ,
Chest: on
Abdomen: , , ,
Genital: , testicles , penis , Tanner stage
Extremities: , , cap refill
Skin:
Musculoskeletal: joints ,
ASSESSMENT:
DDx:
PLAN:
- Urinalysis
- Urine culture
- Blood work: ,
- Renal ultrasound
- Voiding cystourethrogram
- DMSA scan
-
-
-
- Encourage fluids
- Avoid constipation
- Avoid bubble baths
- Avoid scented soaps
- Avoid holding urine
- Referral to pediatrician
- Follow-up in
- Return if symptoms worsen or if new symptoms develop