Final answer:
To write a pediatric history and physical for a 4-year-old with fever, gather information about the child's medical history, current symptoms, and potential exposures. Document the chief complaint, conduct a thorough physical examination, and create a problem list summarizing the child's medical issues.
Step-by-step explanation:
How to Write a Pediatric History and Physical with a Problem List for a 4-year-old with Fever
When writing a pediatric history and physical for a 4-year-old with fever, it is important to gather information about the child's medical history, current symptoms, and any potential exposures or risk factors. Begin by documenting the chief complaint, which is the reason for the visit, such as fever. Include details about the onset, duration, and pattern of the fever. Ask questions about associated symptoms, such as cough, sore throat, or rash. Inquire about the child's vaccination history, medication use, and any recent travels or exposures.
During the physical examination, assess the child's vital signs, including temperature, heart rate, respiratory rate, and blood pressure. Conduct a thorough head-to-toe examination, paying attention to any specific symptoms mentioned during the history. Look for any signs of illness or abnormal findings, such as rash, enlarged lymph nodes, or abnormal lung sounds.
Based on the gathered information, create a problem list that summarizes the child's medical issues. This may include conditions like fever, cough, and potential exposures to infectious agents. Use clear and concise language to describe the problems, and consider prioritizing them based on the severity or urgency of each issue