Pediatrics — Sick Visit Template

Visit Information

Date: [Date]
Time: [Time]
Age: [X] years [X] months / [X] weeks
Chief complaint: [Primary symptom]

Historian

Information provided by: Mother / Father / Guardian / [Other]
Patient present: Yes
Interpreter needed: No / Yes — Language: [X]

Chief Complaint

[Primary concern]
Duration: [X] hours/days
Onset: [When started]

History of Present Illness

Symptom Details

[Detailed narrative of illness]

For Fever:

Temperature: Max [X]°F — Method: [Rectal, oral, axillary, temporal]
Fever pattern: Intermittent / Continuous
Duration: [X] days
Response to antipyretics: Yes (breaks fever) / Partial / No response
Associated symptoms: [List]
Sick contacts: Yes / No — [Who, illness]
Recent travel: No / Yes — [Where]
Immunization status: Up to date / Behind / Unknown

For Respiratory Symptoms:

Cough: Yes / No — [Dry, wet, barky, whooping]

• Duration: [X] days
• Timing: [Constant, nocturnal, with feeds]

Congestion: Yes / No
Runny nose: Yes / No — [Clear, yellow, green]
Sore throat: Yes / No
Difficulty breathing: Yes / No

• Retractions: Yes / No
• Wheeze: Yes / No
• Stridor: Yes / No

Feeding difficulty (infants): Yes / No
Ear pulling/pain: Yes / No

For GI Symptoms:

Vomiting: Yes / No

• Frequency: [X] times in [X] hours
• Character: [Non-bilious, bilious, bloody]
• Projectile: Yes / No

Diarrhea: Yes / No

• Frequency: [X] stools in [X] hours
• Character: [Watery, mucoid, bloody]

Abdominal pain: Yes / No — Location: [X]
Appetite: Normal / Decreased / Refusing
Oral intake: [Amount in last 24 hours]
Urine output: Normal / Decreased — Last wet diaper: [X] hours ago
Bloody stool: Yes / No

For Rash:

Location: [Body areas]
Onset: [X] days ago
Evolution: [How it has changed]
Associated fever: Yes / No
Pruritus: Yes / No
Preceding illness: [Recent URI, etc.]
New exposures: [Medications, foods, soaps, contacts]

Hydration Assessment

Oral intake: Normal / Decreased / Poor / Refusing
Last meal: [Time]
Last wet diaper/urination: [X] hours ago
Tears with crying: Yes / No
Activity level: Normal / Decreased / Lethargic

Red Flag Screening

[ ] Ill-appearing / Toxic
[ ] Lethargy / Difficult to arouse
[ ] Inconsolable crying
[ ] Bulging fontanelle (if applicable)
[ ] Petechial/purpuric rash
[ ] Signs of dehydration (sunken eyes, dry mucous membranes, decreased skin turgor)
[ ] Respiratory distress
[ ] Abdominal distension / Bilious vomiting
[ ] Fever in infant <3 months
[ ] Seizure
[ ] Neck stiffness
Red flags present: No / Yes — [Specify]

Past Medical History

Birth history: Full-term / Preterm — [X] weeks

• Birth complications: None / [Details]
• NICU stay: No / Yes — [Duration, reason]

Chronic conditions: None / [List]
Prior hospitalizations: None / [Details]
Prior surgeries: None / [Details]
Medications: None / [List]
Allergies: NKDA / [Allergies with reactions]
Immunizations: Up to date / Behind — [Missing]

• Recent immunizations: [Within 48-72 hours if relevant]

Family History

Sick contacts at home: Yes / No — [Illness]
Daycare/school exposures: Yes / No — [Known illnesses]
Recent travel: No / Yes — [Location]
Immunocompromised household member: No / Yes

Social History

Lives with: [Family structure]
Daycare/school: Yes / No — [Name]
Siblings: [Ages, health]
Smoke exposure: No / Yes
Pets: No / Yes — [Type]

Vital Signs

Weight: [X] kg ([X] lbs) — [% of last recorded weight]
Temperature: [X]°F / [X]°C — Method: [R/O/Ax/T]
HR: [X] — [Normal / Tachycardic / Bradycardic for age]
RR: [X] — [Normal / Tachypneic for age]
SpO2: [X]% on [RA / O2]
BP (if applicable): [X/X]

Age-Specific Vital Sign Interpretation

[Compared to normal ranges for age:

• Infant: HR 100-160, RR 30-60
• 1-3 years: HR 90-150, RR 24-40
• 3-6 years: HR 80-140, RR 22-34
• 6-12 years: HR 70-120, RR 18-30
• >12 years: HR 60-100, RR 12-20]

Physical Examination

General

Appearance: Well / Mildly ill / Moderately ill / Toxic
Activity: Active / Quiet / Lethargic / Unresponsive
Consolability: Easily consoled / Difficult to console / Inconsolable
Interaction: Age-appropriate / [Concerns]

Hydration Status

Mucous membranes: Moist / Dry / Very dry
Tears: Present / Absent
Skin turgor: Normal / Decreased / Tenting
Fontanelle (if open): Flat / Sunken / Bulging
Capillary refill: <2 seconds / 2-3 seconds / >3 seconds
Eyes: Normal / Sunken
Hydration assessment: Well-hydrated / Mildly dehydrated / Moderately dehydrated / Severely dehydrated

HEENT

Head: Normocephalic / [Findings]
Fontanelle (if applicable): Flat / Sunken / Bulging / Closed
Eyes:

• Conjunctivae: Clear / Injected / Discharge [type]
• Pupils: PERRL
• Periorbital: Normal / Swelling / Erythema

Ears:

• Right TM: Clear / Erythematous / Bulging / Retracted / Effusion / Perforation
• Left TM: Clear / Erythematous / Bulging / Retracted / Effusion / Perforation
• Canals: Clear / [Findings]

Nose: Clear / Congested / [Discharge type]
Throat:

• Pharynx: Clear / Erythematous / Exudate
• Tonsils: [Grade 1-4] / Erythematous / Exudate / [Asymmetric]
• Uvula: Midline

Neck: Supple / Stiff / Lymphadenopathy [location, size]

Respiratory

Work of breathing: Normal / [Increased — specify]

• Retractions: None / Subcostal / Intercostal / Suprasternal
• Nasal flaring: Absent / Present
• Grunting: Absent / Present
• Head bobbing (infants): Absent / Present

Breath sounds: Clear bilaterally / [Wheezes / Rales / Rhonchi / Decreased — location]
Stridor: Absent / Present [Inspiratory / Expiratory / Biphasic]
Air entry: Good / Diminished

Cardiovascular

Heart rhythm: Regular / Irregular
Heart sounds: Normal S1, S2 / Murmur [grade, location]
Perfusion: Normal / Delayed capillary refill
Pulses: Strong / Weak / Thready

Abdomen

Inspection: Flat / Distended
Bowel sounds: Present / Hypoactive / Hyperactive / Absent
Tenderness: None / [Location]
Guarding: Absent / Present
Rebound: Absent / Present
Masses: None / [Findings]
Hepatosplenomegaly: Absent / Present

Genitourinary (if applicable)

[ ] Not examined
[ ] Normal external genitalia
[ ] [Findings]

Skin

Color: Normal / Pale / Mottled / Cyanotic / Jaundiced
Rash: None / [Description — type, distribution, blanching]
Turgor: Normal / Decreased
Warmth: Normal / Cool extremities
Petechiae/purpura: Absent / Present

Neurological

Alertness: Alert / Drowsy / Lethargic
Tone: Normal / Increased / Decreased
Activity: Moving all extremities symmetrically
Meningeal signs: Absent / Present

Point-of-Care Testing

[ ] Rapid strep: Negative / Positive
[ ] Rapid flu: Negative / Positive (A / B)
[ ] Rapid RSV: Negative / Positive
[ ] COVID rapid: Negative / Positive
[ ] Urinalysis: [Results]
[ ] Fingerstick glucose: [X] mg/dL
[ ] Other: [Specify]

Assessment

1) [Primary diagnosis]
Severity: Mild / Moderate / Severe
2) [Secondary diagnoses]
3) Hydration status: [Well-hydrated / Mildly dehydrated / etc.]

Plan

Treatment

Medications:

• [Medication] [Dose] [Route] [Frequency] — Duration: [X] days
• Dispense: [Quantity]

OTC Recommendations:

• Acetaminophen: [Dose] mg every [X] hours PRN fever/pain (max [X] doses/day)
• Ibuprofen (if ≥6 months): [Dose] mg every [X] hours PRN fever/pain
• [Other OTC recommendations]

Supportive Care:

• Encourage fluids: [Specific recommendations]
• Rest
• Humidifier: [If applicable]
• Saline drops/suction (infants): [If applicable]
• Honey (if ≥1 year): [For cough]

Activity

School/daycare: May return when [fever-free 24h, etc.]
Activity restrictions: None / [Specify]

Follow-up

Return to office: [X] days if not improving / Sooner if worse

Return Precautions — Seek Care If:

• [ ] Fever >3-5 days or new fever after being afebrile
• [ ] Difficulty breathing or fast breathing
• [ ] Not drinking or decreased wet diapers
• [ ] Excessive sleepiness or difficult to wake
• [ ] New rash (especially petechiae)
• [ ] Worsening symptoms despite treatment
• [ ] [Condition-specific warning signs]

When to Go to ED:

• Difficulty breathing
• Blue lips or face
• Unable to keep any fluids down
• No urine in 8-12 hours
• Inconsolable
• Lethargic or difficult to arouse
• Bulging soft spot (infants)
• Seizure

Communication

Discussed diagnosis and plan with: Mother / Father / Guardian
Questions answered: Yes
Written instructions provided: Yes