University of Puerto Rico-School of Medicine

Third-Year Pediatric Clerkship

Patients Work-Ups Evaluation

_____________________________
Student Name

__________________ UPH__SJCH___UPR___MAZ___
Student Number
Institution

Problem Category #
*SCORE

------------------------------------------------------------------------------------------------------------------------------

PATIENT CATEGORY NUMBER

By Presenting Problem

PROBLEM
Category Number

1-

Neonate Respiratory Problem

2-

General Pediatrics - (same day admission)

- (Most Include Radiology

Exercise)
(Include Nutritional Assessment Exercise)

3
4
5
6

Hematology Oncology
Chronic Illness
Health Maintenance (Well Baby)
Emergency Acute Care (Include Managed Care Exercise)

University of Puerto Rico - School of Medicine

THIRD YEAR PEDIATRIC CLERKSHIP
PATIENT WORK-UP EVALUATION

UPH____SJCH____UPR_____MAZ
STUDENT'S NAME

NUMBER

PATIENT'S INITIAL
DATES:

INSTITUTION

DATE ADMITTED
WORK-UP HANDED IN

DATE ASSIGNED

PRINCIPAL DIAGNOSIS

PATIENT

PROBLEM CATEGORY
ITEM

1.
2.

3.
4.

SOURCE OR SITE AND BED NUMBER

*SCORE
(Numerical)

HISTORY: includes relevant positive and negative information

PHYSICAL EXAMINATION: and basic lab tests (results of CBC and urinalysis)
SUMMARY: relevant history and examination findings
SUMMARY: Course of illness follow up information from date admitted to date
Assigned
PROBLEM LIST: Complete and up-dated

6.

DISCUSSION for the presenting problem the logical reasoning (criteria for or against
a given most likely possible, and accurate ranking of other possibilities; psychological
impact included
DISCUSSION for the problems other than the presenting problems. Includes risks
psychosocial problems and impacts of the presenting illness
WRITTEN REPORT Clarity and organization

7.

ORAL PRESENTATION- Quality and verbal communication skills

8.

INITIAL PLAN OF ACTION comprehensive: includes measures for all the problems
identified and utilizes well the resources available; includes motivational and patient
education aspects to ensure compliance, correct selection of diagnostic and therapeutic
measure. PHARMACEUTICAL EXERCISE - (selected drug, dose, route of
administration, toxicity, indication , contraindication and drugs interaction and a written
model of prescription-requisite of approval of case presentation.) Nutritional
Assessment on General Pediatric Case #3 (see instruction )(Manage Care Exercise on
Case #6 - ER- (see instructions). Radiology Exercise on Case #1 (see Resp.Distress)
FOLLOW UP NOTE includes post assignment information: day, hour, problem
number and name, subjective, objective, assessment and plan. (SOAP)
FUND and sound application of medical knowledge.

5.

9.
10.

** Final Score
(Numerical)
INSTRUCTOR'S NAME

SIGNATURE

For non cognitive academic factors (see next page)

*SCORE FOR ITEM
Satisfaction
Excellent - 9-10
Good
- 8-9
Average - 7-8
Unsatisfactory < 7
2004-2005

*SUMMATIVE SCORE
The sum of the 10 item if each item is graded 7 or
more, and has an (S) satisfactory for all the non
cognitive academic criteria (see format page)
INCOMPLETE - Any of the 10 items is less
than 7 and (S) for the non cognitive academic factors
FAILURE - irrespective of final score. If graded
(U) unsatisfactory in the non cognitive academic

University of Puerto Rico

School of Medicine
Medical Sciences Campus

PROFESSIONALISM / NON-COGNITIVE ACADEMIC FACTORS EVALUATION FORM*

STUDENT NAME

STUDENT NUMBER

CLERKSHIP

NUM.HOURS

DEPARTMENT AND
CLINICAL SETTING

Instructions:
The University of Puerto Rico, School of Medicine recognizes and respects the responsibility of the professional medical school faculty to establish
standards for determining the fitness of medical students to participate in the medical profession. Professionalism Academic non-cognitive factors (ANCF)
will be evaluated separately from and in addition to standard academic abilities such as fund of knowledge. Faculty members who have direct contact
with students in the academic setting will determine the final evaluation of students as satisfactory and unsatisfactory with respect to their academic
non-cognitive attributes.
Evaluation of the Professionalism / ANCF will include the following major criteria (See reverse side for explanations): 1) Personal and Professional
Characteristics; 2) Interpersonal Relationships; 3) Ethical Aspects.
Written documentation of events leading to an unsatisfactory evaluation of a student will be required and may be supported by reports of faculty, peers
or other personnel. An unsatisfactory evaluation and written documentation of events should be forwarded to the Dean, or the appropriate Associate Dean,
as soon as possible. Any student receiving an unsatisfactory evaluation for the Professionalism ANCF will be notified in writing as soon as the Associate
Dean will make possible and a review of the evaluation will be available to the student. The course faculty and the appropriate Promotions Committee will
recommend to the Dean the final action to be taken based on their established rules and regulations.
Evaluation Scale Interpretation: The evaluation rating scale should be interpreted as follow:
SATISFACTORY
See back page for criteria
UNSATISFACTORY - The unsatisfactory grade for the Professionalism/ANCF is obtained if the student fails any of the specified criteria or any
other criteria clearly stated and documented by the preceptor.
ACADEMIC NON-COGNITIVE FACTORS
(Must specify if any criteria is found unsatistactory)
y positive or extraordinary aspect of student.
s
vior is:
U
d Professional Characteristics

ty
nd Initiative
t
Image
Authority
Feedback
of Limitations
l Relationships

hers Roles and Rights

cts
ty
tients Vulnerability

_________________________________________________________________________________________________________________________
Date
Academic Period
INSTRUCTOR NAME AND SIGNATURE
Overall Evaluation

*Approved by the School of Medicine Faculty June 5, l989

Revised: May 2004

PROFESSIONALISM SPECIFIC CRITERIAS AS GUIDELINES*

PERSONAL AND PROFESSIONAL CHARACTERISTICS

SATISFACTORY
RESPONSIBILITY
Consistently prompt and prepared at scheduled
conferences, laboratories work-up presentations,
rounds or any academic and professional activity.
Notifies when unable to attend duties or appointments.
MOTIVATION AND INITIATIVE
Hard-worker and an active leader/participant.
Seeks new learning in educating patient. Uses current
medical information and scientific evidence to improve
patient care.
Shows high interest in educating patient.
Quotes relevant updated medical information.
COMMITMENT
Undertaken duties enthusiastically and perseveres until
complete.
Assumes added responsibilities for patient care or
course load.
PROFESSIONAL IMAGE
Maintains and adequate dress code (as described in
official document: Cdigo de Vestimenta, June 6,
1996).
Able to perform duties even under stressful situations.
RESPONSE TO AUTHORITY AND FEEDBACK
Carries out instructions responsibility.
Accepts academic counseling and guidance.
Modifies performance in response to feedback.

UNSATISFACTORY
RESPONSIBILITY
Consistently late and unprepared at conferences, laboratories
work-up presentations, rounds or any academic and
professional activity.
Does not notifies when unable to attend duties or
appointments.
MOTIVATION AND INITIATIVE
A poor worker. Rarely an active leader/participant.
Avoids new learning experiences. Does not or rarely uses
current medical information and scientific evidence to improve
patient care.
Appears disinterested in educating patient.
Rarely quotes relevant updated medical information.
COMMITMENT
Undertakes duties not enthusiastically. Seems uninterested.
Rarely assumes added responsibilities for patient care or
course load.

PROFESSIONAL IMAGE
Does not maintains and adequate dress code.
(as described in official document: Cdigo de vestimenta, June
6, 1996)
Composure under circumstances of extreme stress is poor.
RESPONSE TO AUTHORITY AND FEEDBACK
Shows resentment to directives of superiors. Does not seek
guidance. When guidance received makes poor introspection
of academic recommendations. Rejects changes of judgements
even when guidance show errors.
RECOGNITION AND LIMITATIONS
RECOGNITION AND LIMITATIONS
Recognizes when to seek help and seeks it out from
Does not ask for help even when it is necessary and does not
appropriate persons.
accept help if offered.
INTERPERSONAL RELATION SHIP *

EMPATHY
Emphatic and sensitive toward the emotional and
personal needs of others.

EMPATHY
Discourteous and insensitive in dealing with the emotional and
personal needs of others.

CONSIDERS OTHERs ROLES AND RIGHTS

CONSIDERS OTHERs ROLES AND RIGHTS
Confronts ideas and not people and recognizes the
Confronts people instead of ideas and rarely recognizes the
contribution of others.
contribution of others.
TEAM WORK
TEAM WORK
Contributes to the success of teamwork activities.
Tends to hinder the success of teamwork activities.
ETHICAL ASPECTS *
CONFIDENTIALITY
Respects institutional rules and regulations.
Protects the information trusted to him/her. (HIPPA)
RESPECTS OTHERs VULNERABILITY
Treats professors, patients and their families, and other
persons with respect and dignity both in their presence
and in discussion peers and others.

CONFIDENTIALITY
Omits or disregard institutional rules and regulations.
Does not protect the information trusted to his/her.
RESPECTS OTHERs VULNERABILITY
Does not treat professors, patients and their families, and other
persons with respect and dignity both in their presence and in
discussion with peers and others.

PROBLEM LIST
PREVIOUS ADMISSIONS TO THIS INSTITUTION
(number, date or admission

DATE OF BIRTH:

PROBLEM DESCRIPTION
NO.

APPROX.
ONSET

DATES
ENTERED

RESOLVED OR
INACTIVE

SIGNATURE

PREVIOUS ADMISSION TO THE INSTITUTION

(date of admission and discharge)

DATE OF THE ADMISSION

NAME OF INFORMANT:

Students Name and Signature

RELATION TO PATIENT:

APPARENT RELIABILITY
___ GOOD

___ QUESTIONABLE

____ POOR
A. CHIEF COMPLAINT
(WITH DURATION) _________________________________________________________________________________

B. PRESENT ILLNESS

PRESENT ILLNESS Cont.

Use this column to

specify, clarify or
add any information

C. PAST HISTORY
1. Has your child ever
a. been hospitalized? If yes please list below: ___________________________
b. had an operation? _______________________________________________
c. Non-intentional injuries (specify) __________________________________
d. Hospital
City
Problem
Date
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

No
No
No

Yes
Yes
Yes

Yes
Yes
Yes

No
No
No

No

Yes

No

Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No

Yes

No

Yes

2. Please check any of the following diseases that this child has had.
Chickenpox _____________ Hepatitis
_______________
Mumps
_____________
Whooping Cough _______________
Measles _____________
Rubella (German Measles _____________
Other
_____________
Scarlet Fever
________________
PREGNANCY
3. Is mother Rh negative? ____________________________________________
4. Grava ________ Para ________ Abort _________ Living __________
5. Did she have regular medical care while pregnant with this child? ______
6. Did she have any problems while pregnant with this child (such as excessive
bleeding, kidney or bladder infection, high blood pressure, diabetes or high
blood sugar, any operations, convulsions, weight gain over 30 lbs, German
measles, premature labor, x-rays during the first three months, drug abuse any other
illnesses)?
(If yes, write which and explain)
______________________________________________________________
7. Did she take any of the following medications during this patients pregnancy:
(mark those that apply)
_______ Antibiotics
_______ Birth control pills
_______ Fertility pills
_______ Pills to prevent miscarriage
_______ Aspirin
_______ Illegal drugs
_______ Prenatal vitamins
_______ Any other medicines
_______ Alcohol
_______ Smoking
8. Did she have an unusually long or difficult labor with this child? ________
9. Did the mother had this test done during pregnancy?
________ HIV Test _________ VDRL ________ Heb Surface Antigens
BIRTH
10. Was this child born in a hospital? __________________________________
11. Was this child born by cesarean section? ____________________________
12. How much did this child weight at birth? ________ Lbs. ________ Oz.
13. Were there any problems with this childs delivery? Specify if yes
14. Was this child born with any birth defect?
15. Did this child go home from the hospital at the same time as mother did?
16. Did this child have any unusual problems in the hospital (such as blue spells
(cyanosis), yellow jaundice, trouble breathing, trouble feeding, infection,
convulsions, or any other illness)? (Specify if yes)
____________________________________________________________
17. Did this child need any special treatment while in the hospital (such as
incubator, oxygen, blood transfusion, medicines, feeding with a tube, or any
other unusual treatment)? _______________________________________
ADDITIONS:

Use this column to

specify, clarify or add
any information

D. PERSONAL HISTORY
PATIENT PROFILE
17. Is this child adopted? _____________________________________________
18. If this child goes to school, please give
Name of school __________________________________________________
Town __________________________________________________________
Grade __________________________________________________________
Teachers name __________________________________________________
Grades at last marking period _______________________________________
Trend of performance (improving, stable, deteriorating) __________________
PERSONALITY
19. How would you describe your child?
Happy __________________ Yes
Cooperative ______________ Yes
Usually obedient __________ Yes
Fearful __________________ Yes
Destructive _______________ Yes
Difficult __________________ Yes

No
No
No
No
No
No

Irritable_______________
Too active ____________
Too lazy ______________
Shy __________________
Nervous ______________

20. Does this child

act babyish ______________ Yes No
fight excessively ________
have temper tantrums ______ Yes No
steal __________________
rock back and forth ________ Yes No
have a fear of school _____
have nightmares __________ Yes No
eat dirt or plaster _________
have any sleep problems ____ Yes No
stutter _________________
soil pants with stools ________ Yes No
bite his (her) nails ________
go river bathing and
suck his (her) thumb ______
barefoot walking ___________ Yes No
21. Are you concerned about any of the following:
bedwetting? ______________________________________________________
thumbsucking? ___________________________________________________
masturbation (playing with himself/herself)? ____________________________
biting? __________________________________________________________
lying? ___________________________________________________________
fire setting? _______________________________________________________
other? ___________________________________________________________
22. Has this child ever had
- problems making friends? __________________________________________
- complaints about his/her behavior in school? ___________________________
- medicine to calm him/her down? ___________________________________
23. Are there marriage, drug, drinking or other problems in the family? __________
24. Are you prepare to discuss with this child now or in the future: (mark those that
for which they say yes)
__________ sex
_________ drugs
__________ smoking
__________ drinking
__________ venereal diseases
__________ contraception
__________ marriage
__________ divorce
__________ death
25. Would you like to know how to find out more about any of these topics? ______
ADDITIONS:

No

Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No

Yes
Yes
Yes
Yes

No

Yes

E. FAMILY HISTORY AND SOCIAL HISTORY

FAMILY PROFILE
26. Years at present address ________________ Previous address _____________________________
27. Type of dwelling? _________________________________________________________________
28. Owned or rented? _________________________________________________________________
29. Fathers age? __________________
Education _____________________________________________________________________
Employment __________________________ How long? _______________________________
Previous Marriages ______________________________________________________________
30. Mothers Maiden Name ____________________________________________________________
Age _______________________
Education _____________________________________________________________________
Employment _________________________ How long? ________________________________
Previous Marriages ______________________________________________________________
31. Brothers and Sisters:
Name
Sex
Age
Name
Sex
Age

32. Other People living with Family:

Name
Relationship
Age
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
33. Do any people living in the home have persistent medical problems? Explain
No Yes
______________________________________________________________________
34. How many years have the parents been married? ______________
No Yes
35. Are they separated? ______________________________________________________
No Yes
36. Are there any problems with their present marriage? ____________________________
No Yes
37. Are they satisfied with their present living conditions? __________________________
No Yes
38. Does their health interfere with their ability to perform work? ____________________
39. Do any of the following interfere with any member of the family receiving medical care?
No Yes
Cant pay for it _______________________________________________________
No Yes
Transportation problems ________________________________________________
No Yes
Unattended children at home _____________________________________________
No Yes
No appointments at convenient times ______________________________________
No Yes
Dont like doctors _____________________________________________________
No Yes
Dont like hospitals ____________________________________________________
No Yes
Any other reasons? ____________________________________________________
No Yes
40. Is the family covered by health insurance? ___________________________________
If yes please indicate name of insurer and of coverage if known:
______________________________________________________________________
41. Does this patient have any blood relatives with:
Obesity ___________________________________________________________
No Yes
Short stature _______________________________________________________
No Yes
Thyroid disease _____________________________________________________
No Yes
Diabetes (specify if type 1 or 2) ________________________________________
No Yes
Mental retardation __________________________________________________
No Yes
Deafness __________________________________________________________
No Yes
Chromosomal Disorders (specify) ______________________________________
No Yes
Ophthalmologic Problems
Blindness _________________________________________________________
No Yes
Cataracts __________________________________________________________
No Yes
Glaucoma _________________________________________________________
No Yes
Color blindness _____________________________________________________
No Yes
Detached retina _____________________________________________________
No Yes
Pulmonary Problems
Asthma ___________________________________________________________
No Yes
Emphysema (specify at what age) ______________________________________
No Yes
Chronic pulmonary infections _________________________________________
No Yes
Cystic Fibrosis ____________________________________________________
No Yes

Use this column to

specify, clarify or
add any information

Family History (Cont.)

Cardiovascular
Congenital Heart Disease ________________________________________________
Heart Transplant _______________________________________________________
Rheumatic fever _______________________________________________________
Heart Attack __________________________________________________________
High Blood Pressure ___________________________________________________
Stroke ______________________________________________________________
Gastrointestinal
Inflammatory Bowel Disease _____________________________________________
Sprue or malabsorption _________________________________________________
Rectal polyps _________________________________________________________
Wilsons disease _______________________________________________________
Liver Failure __________________________________________________________
Renal
Nephritis ____________________________________________________________
Nephrosis ___________________________________________________________
Kidney failure ________________________________________________________
Kidney stones ________________________________________________________
Kidney transplant ______________________________________________________
Hematologic
Hemophilia __________________________________________________________
Bleeding tendencies ___________________________________________________
Anemia _____________________________________________________________
Hemolysis ___________________________________________________________
Sickle cell anemia _____________________________________________________
Spherocytosis ________________________________________________________
Musculoskeletal
Arthritis (specify which) ________________________________________________
Muscular dystrophy ____________________________________________________
Muscle diseases _______________________________________________________
Neurologic Diseases
Seizures or epilepsy ____________________________________________________
Chorea ______________________________________________________________
Migraine headache ____________________________________________________
Crippling disease ______________________________________________________
Psychologic Diseases
Depression ___________________________________________________________
ADD or ADHD _______________________________________________________
Breakdown ___________________________________________________________
Mental illness _________________________________________________________
Congenital malformations __________________________________________________
Cancer (specify which) ____________________________________________________
Infectious diseases (specify which besides those mention below) ___________________
Hepatitis B ___________________________________________________________
Hepatitis C ___________________________________________________________
HIV ________________________________________________________________
T.B. ________________________________________________________________
Hepatitis A in the last 6 months __________________________________________

No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No

Yes
Yes
Yes

No
No
No
No

Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Use this column to

specify, clarify or
add any
information

FAMILYGRAM

F. REVIEW OF SYSTEM
GROWTH- ENDOCRINE
42. Was this child born-on time? (specify weeks of gestation) _________________________
43. Have you ever thought that this child was growing too slowly? _____________________
-too rapidly? ____________________
44. Have you ever thought that this child was - too fat? ______________________________
- too thin? _____________________________
45. Has this child lost weight that he/she has not regained? ___________________________
46. Has this child ever had trouble with the thyroid gland? ___________________________
47. Has this child ever taken a thyroid drug? _______________________________________
48. Does a tendency for obesity (being overweight) run in this childs family?
49. Does this child have a blood relative with a sex abnormality? ______________________

No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

SPEECH AND HEARING

54. In the past year has this child
-had more than three ear infections? __________________________________________
-spoken as well as other children who are his/her age? ___________________________
- had trouble hearing? _____________________________________________________
55. Has this child ever had any difficulty with speech? _______________________________
56. Was this childs speech understood by neighbors by five years of age? _______________
57. Does this child have any blood relatives who are deaf? ___________________________
58.Are this childs ear cleaned with sharp objects or Q-tips? _________________________

No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes

VISION
59. Has this child ever
-had trouble seeing? _____________________________________________________
-worn glasses? __________________________________________________________
-had an eye which turned in or out? __________________________________________

No
No
No

Yes
Yes
Yes

DEVELOPMENT
50. Do you think that this childs mental development is normal? ______________________
51. If in school, has this child had trouble keeping up with his/her classmates? ____________
52. Do you think that this child is too clumsy? _____________________________________
53. Did this child a. smile by six weeks of age? ___________________________________
b. sit alone by seven months? ___________________________________
c. walk alone by 14 months? ____________________________________
d. say simple sentences by age of two years? _______________________
e. ride a tricycle by age of three years? ____________________________
f. tie his own shoelaces by age of six years? ________________________
54. Has this child ever had to repeat a school grade? ________________________________

Use this column

to specify,
clarify or add
any information

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A

ADDITIONS:

RESPIRATORY
60. In the past year has this child had
-more than six colds __________________________________________________________
-a persistent runny nose? ______________________________________________________
-a cough that hangs on? _______________________________________________________
-pneumonia? ________________________________________________________________
-an asthma attack? ___________________________________________________________
-wheezing? _________________________________________________________________
-shortness of breath? __________________________________________________________
-frequent sore throats? ________________________________________________________
61. Has this child ever
-had asthma? _______________________________________________________________
-had a positive skin test for tuberculosis (tuberculin or PPD)? _________________________
-been around a person with tuberculosis? __________________________________________
62. Does anyone in the household smoke? ____________________________________________
CARDIOVASCULAR
63. Has this child ever had
-a heart murmur? ____________________________________________________________
-cyanosis (blue spells)? _______________________________________________________
-an extremely rapid or irregular heart beat? ________________________________________
-rheumatic fever? ____________________________________________________________
64. Has this child had a blood relative with
-a heart attack under age 50? ___________________________________________________
-a heart attack over age 50? ____________________________________________________
-elevated blood fats (cholesterol or triglycerides)? __________________________________
-high blood pressure? _________________________________________________________
-a stroke under age 60? ________________________________________________________
-a stroke over age 60? _________________________________________________________
65. Does the child have a throat culture taken when he she has a sore throat to check for a strep
throat? ___________________________________________________________________
GASTROINTESTINAL
88. Has this child ever had
-recurrent stomachaches? ______________________________________________________
-recurrent vomiting? __________________________________________________________
-recurrent diarrhea? ___________________________________________________________
-recurrent constipation? _______________________________________________________
-blood in his/her bowel movement? ______________________________________________
-medicine for stomachaches or constipation? _______________________________________

No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No

Yes
Yes
Yes
Yes

No
No
No
No

Yes
Yes
Yes
Yes

No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes

No

Yes

No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes

Use this
column to
specify,
clarify or add
any
information

89. Has this child ever had x-rays of the stomach or intestines? ____________________________
GENITOURINARY
90. Has this child ever
-had a bladder or kidney infections? ______________________________________________
-had trouble with pain on urination, increased urinary frequency or loss of control? ________
-had trouble with bedwetting? __________________________________________________
-had bloody or smoky-colored urine? _____________________________________________
-had x-rays of the kidney or bladder? _____________________________________________
Girls 10 years or older
91. Does this girl have an excessive vaginal discharge? __________________________________
92. Is this girl having menstrual periods? _____________________________________________
93. Are there problems with her periods? _____________________________________________
94. Does this girl understand menstruation? __________________________________________
95. Does this girl understand contraception? ___________________________________________
96. Does this girl understand sex problems? ___________________________________________
97. Do you want this girl to receive sex education? _____________________________________

HEMATOLOGIC SYSTEM

No

Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes

N/A
N/A
N/A
N/A
N/A

Use this column to specify,

clarify or add any information

Has this child ever

98. been anemic or pale ______________________________________________
99. taken medicines such as iron or folic acid _____________________________
100. seemed to bruise or bleed excessively _______________________________
101. had a blood transfusion ___________________________________________
102. had an operation to remove the spleen _______________________________

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

SKIN
103. Has this child ever had any skin problems? ___________________________

Yes

No

MUSCOLOSKELETAL
Has this child ever had
104. Painful or swollen joints? _________________________________________
105. a broken bone? _________________________________________________
106. a limp? _______________________________________________________
107. treatment for a bone, joint or muscle problem? ________________________

Yes
Yes
Yes
Yes

No
No
No
No

NEUROLOGIC
Has this child ever had
108. troublesome headache, loss of consciousness, a seizure or a convulsion?
109. Does this child eat paint chips, plastes or putty? _______________________

Yes
Yes

No
No

ALLERGY (include penicillin)

Has this child ever had
110. a reaction to a medicine or shot, to a food, hives? (Specify) ______________

Yes

No

COMMENTS AND ADDITIONS:

Use this column to

specify, clarify or
add any information

G. HEALTH MAINTENANCE
HEALTH MAINTENANCE (as applicable for age)
111. Where does this child usually go for medical care? _______________________________
________________________________________________________________________
112. When was this childs last complete checkup and who performed it? _________________
_________________________________________________________________________
113. What did this child eat yesterday (or the last day he (she) was well)?
Breakfast ______________________________________________________________
Lunch ________________________________________________________________
Dinner ________________________________________________________________
Snacks ________________________________________________________________
114. Was (Is) this child breast-fed? ________________________________________________
115. Does this child take vitamins? ________________________________________________
116. Does this child take iron medicine? ____________________________________________
117. Does this child drink more than a quart of milk per day? ___________________________
118. Does this child brush his/her teeth regularly? ____________________________________
119. Does this child use dental floss regularly? _______________________________________
120. Does this child drink fluoridated water or take fluoride supplements? _________________
121. Has this child been to the dentist in the past two years? ____________________________
122. Does this child, if under 4, ride in a safe car seat? _________________________________
123. Do you and your children over 4 use seat belts in the car? __________________________
124. Does this child have a bike? __________________________________________________
125. Does he use a helmet when bike or skate riding? _________________________________
126. Does this child use a lifejacket when boating? ___________________________________
127. Does this child know how to swim? ___________________________________________
128. Do you have firearms at home? _______________________________________________
129. If they; are they kept out of reach of children? ________________________________
130. Does this child operate, play or work with heavy duty machinery? ___________________
131. Do you have a record of immunizations? _______________________________________
132. Please list the dates or approximate ages at which this child received the following
immunizations: (provide dates if known)
DTaP
1 ______ 2 _______ 3 _______ 4 _______ 5 _______
IPV
1 ______ 2 _______ 3 _______ 4 _______
MMR
1 ______ 2 _______
Prevnar
1 ______ 2 _______ 3 _______ 4 _______
Varicella
1 ______ 2 _______
Hibtiter
1 ______ 2 _______ 3 _______ 4 _______
Hepatitis B
1 ______ 2 _______
Influenza
1 ______ 2 _______ 3 _______
Meningococcus 1 ______
Others
1 ______
133. Has this child been tuberculin tested ___________________________________________
If yes, indicate (PPD) date __________________________________________________
and results _______________________________________________________________
134. Does this child get regular physical exercise? ____________________________________
135. Does this child use, or has used in the past, alternative medicine or procedures (Ej.
Santiguo, herbal medicine, naturopathic medicine, etc.)?
ADDITIONS:
A must for patients 12 years or older:
For the adolescent patient add (in an extra paper if necessary) the following essential
information: concerns with the developing body; peer relationship and social interaction;
attitudes towards parental authority; dietary and self care habits; sexual activity and habits;
aggressive or involved in violent acts; affective behavior; suicidal ideation and attempts; habits
to include use of alcohol, cigarettes, illicit drugs and steroids; body and gender image and self
confidence.
For details refer to the Guidelines for Health Supervision for Pediatric Patients ages 0-20
yrs American Academy of Pediatrics.

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Yes

No

Yes
Yes
Yes

No
No
No

Adolescent Essential Information (A must for all patients 12 years or older)

ECOMAPA:

STRENGTH, VULNERABILITIES AND SUPPORT SYSTEM DIAGRAM: LIFE EVENTS, DATES AND
CORRESPONDING PATIENTS AGE

Describe parents and patients (if old enough) ideas and feelings as to nature, cause and diagnosis of the presenting illness. Describe
family conceptions or misconceptions of health problems, procedures and medications. Indicate how these seem to be affected by
cultural patterns.

PEDIATRICS PHYSICAL EXAMINATION

TEMPERATURE _______________ PULSE RATE _______________ RESP RATE ____________
BLOOD PRESSURE ________________________________________________________________
HEAD CIRCUMFERENCE (cm)_______________________ PERCENTILE _________________________________________
LENGTH/HEIGHT (cm) ____________________ PERCENTILE ____________________ HEIGHT AGE ___________________
WEIGHT (kg) ___________ PERCENTILE _______________ WEIGHT AGE ____________ U/L RATIO _________________
BMI ___________________
GENERAL APPEARANCE ACUTELY, CHRONICALLY ILL OR WELL APPERARING, MOTOR AND
PSYCHOLOGIC BEHAVIOR IN RELATION TO AGE, NUTRITIONAL STATUS, STATE
OF CONSCIOUSNESS. SPECIFY WHETHER THE PATIENT IS IN PAIN, VOMITING,
BLEEDING AND DESCRIBE EMANATING ODORS.

FOR EACH SYSTEM CHECK EXAMINED: NORMAL, ABNORMAL NOTE AND DESCRIBE ANY ABNORMALITY IN DETAIL
SYSTEM AND CRITERIA OF NORMALITY

SKIN
Color: clear, no jaundice, pallor, cyanosis, rashes or abnormal
pigmentations, petechiae, purpuras.
Texture and Feel: normal
Good Turgor: no edema or nodules.

LYMPH NODES describe nodes as to location, size and

tenderness
HEAD
Size and Shape: normal
Palpation: no areas of tenderness. Fontanelle not bulging or
sunken.
Hair: normal texture or distribution.

EYES
Sclerae and Conjunctiva: clear. No jaundice injection or
exudates.
Pupils: round, equal, reactive to light.
Media: comes clear, no cloudiness nor cataracts.
EOM: intact.
Fundi: discs sharp, normal in color. Retinal arteries and veins
normal. No hemorrhage or exudates.

EARS
External ears and canal: clear shape normal
TM: clear, normal gray color with landmarks visible. No bulging,
perforation, scarring.
Hearing: grossly normal.
Mastoid: no tenderness or swelling.

Specify, clarify or add any positive or

negative pertinent findings

SYSTEM AND CRITERIA OF NORMALITY

NOSE no obstruction, normal shape, no discharge
MOUTH AND THROAT
Lips: color normal, no asymmetries, sores.
Gums and Mucous Membrane: intact.
Tongue: normal papillae, adequate moisture, function.

Teeth: correct number for age (describe), no caries, malocclusion.

Posterior pharynx: clear, no exudates, injection, enlarged tonsils, post nasal drip
NECK
Inspection: supple, trachea in midline.
No deformity, no masses.
Palpation: good carotid pulses. No abnormal pulsations.
No tenderness, no enlarged nodes, distended vessels or abnormality of
position.
Thyroid: normal in size and consistency.
THORAX normal shape and circumference for age. Symmetrical expansion, no
retractions or other evidence of respiratory distress: sternum no abnormality
LUNGS
Inspection: normal rate for age, no tachypnea, hyperpnea, respiratory distress, nasal
flaring, retractions, expiratory grunting, stridor, hoarseness or cough.
Percussion: no dullness or hyperresonance.
Auscultation: clear, broncho vesicular breath sounds, well aerated no decreased
breath sounds, wheezes, rales, rhonchi, rubs.
Normal voice sounds and fremitus.
Transmitted upper respiratory tract sounds.
BREASTS normal development fir age, symmetrical, no heat, tenderness, masses or
hyperpigmentation of areola.
Describe tanner staging.
HEART AND CARDIOVASCULAR SYSTEM
Inspection: no precordial asymmetry or hyperactivity.
Palpation: quiet, no thrills or hyperactive impulse, abnormal pulsations. :PMI in
normal position.
Good and equal pulses in all extremities describe.
Specify femoral pulses.

Auscultation: clear, crisp sounds, regular rhythm, no murmurs, extra sounds,

irregular rhythm, tachycardia, bradycardia. No pericardial friction rub
Describe S, S, (S, S if present).

Specify, clarify or add any

positive or negative pertinent
findings

SYSTEM AND CRITERIA OF NORMALITY

ABDOMEN
Inspection: normal contour, not distended, no peristaltic waves, umbilical
or other hermiations.
Palpation: soft, no tenderness, no abnormal masses or fluid waves. Liver
not tender not more than 2 cm below RCM, spleen nor felt.
Auscultation: normal bowel sounds, no bruits.

Percussion: normal.
GENITALIA Describe Tanner Staging
Male: normal development for age. Penis, scrotum and testicles are normal.
No epispadias, swelling, phimosis or discharges.

Female: normal development for age. Normal vaginal opening without

discharges.

Urinary Meatus: clear and normally patent.

Pelvic examination adolescent girls (where indicated)

ANUS AND RECTUM no fissures, prolapse.
Rectal (where indicated normal sphincter tone, no tenderness,
masses).
MUSCULOSKELETAL
Shape, Symmetry and Development: normal.

Tone and Function: normal.

Palpation: no abnormal masses, tenderness or pain in motion.

Lower and Upper Extremities: no abnormalities, no clubbing or cyanosis

of fingers and toes.
JOINTS normal range of motion, no heat, tenderness, swelling, redness.

Infant Hips: (normal abduction, no pain, no clicks).

SPINE straight, with normal thoracic and lumber curves good posture, no
tenderness or masses.

Specify, clarify or add any

positive or negative pertinent
findings

SYSTEM AND CRITERIA OF NORMALITY

Specify, clarify or add any positive

or negative pertinent findings

* NEUROLOGICAL
Cerebral Function: mental status and development for age.
(See instructions)
Meningeal: signs not present (neck supple, no Kernig, Brudzinski, tense
fontanel).

Cerebellar: good coordination and gait for age, no ataxia or tremors.

Cranial Nerves: (I-smell; II-vision, visual fields, fundi; III, IV, VI-extra
ocular muscles; V-jaw, corneal reflexes; VII-facial;
VIII-hearing; IX-X-palate, gag, swallowing; XI-spinal
accessory, neck; XII-tongue) intact.

Muscle Tone, Strength and Bulk: normal.

No gross motor deficit.

Reflexes: DTR: (Knee, ankle, triceps, radial brachial) present,

symmetrical, normal activity. No clonus. Superficial:
present with normal activity.
Other: Babinski not present after 18 months. Mass
reflexes: (note: Moro, step, suck, tonic neck reflex,
grasp in infants).

Normal Sphincters
Sensory: no deficits.
* MENTAL SCREENING AND DEVELOPMENT FOR AGE EXAMINATIONS
Record findings objectively following the guidelines for persons ages 0-6 yrs, or the one for persons > 6 yrs.

MENTAL SCREENING AND DEVELOPMENT FOR AGE EXAMINATIONS

SUMMARY: HISTORY ON ADMISSIN, PHYSICAL EXAMINATION (include vital signs and percentiles) AND
PRIMARY LABORATORY FINDINGS (CBC AND URINALYSIS)

DISCUSSION
1. DISCUSS DIFFERENTIAL DIAGNOSIS OF PATIENTS PRESENTING PROBLEM (AT LEAST 3 IN ORDER
OF PROBABILITY).

PLAN OF ACTION OF THE PRESENTING PROBLEM:

1. FOR THE PROBLEM IDENTIFIED DISCUSS PLAN OF ACTION.
2. PLAN OF ACTION MUST INCLUDE: DIAGNOSTIC PLAN, THERAPEUTIC PLAN (MOST INCLUDE
APPROPIATE DOSAGES FOR AGE AND PROBABLE CONDITION) AND EDUCATIONAL PLAN

OTHER PROBLEMS LISTED IN THE PROBLEM LIST:

1. DISCUSS WITH A SHORT NARRATIVE ALL OTHER IDENTIFIED PROBLEMS IN LIST.
2. INCLUDE FOR EACH PROBLEM THE PLAN OF ACTION THAT CORRESPONDS.

FOLLOW UP NOTE (FROM DATE ASSIGNED TO DATE PRESENTED)

Patient Initials: _____________________________
Date: _______________________________

S:

O:

A:

P:

PHARMACEUTICAL EXERCISE: (TO BE DUE IN ALL 6 CASES)

1. SELECT ONE MEDICATION, IVFS OR ANY OTHER THERAPEUTIC PROCEDURE FROM THIS PATIENT.
2. DISCUSS, FOR THE ONE SELECTED, DOSING, ROUTE OF ADMINISTRATION, TOXICITY,
INDICATION, CONTRAINDICATION, AND DRUG INTERACTION WITH OTHERS YOUR PATIENT IS
RECEIVING.
3. WRITE A PRESCRIPTION FOR THIS SELECTED DRUG FOR YOUR PATIENT CONSIDERING THE
MEDICAL CONDITION HE/SHE HAS.
4. WRITE THE COST OF THIS PRESCRIPTION FOR YOUR PATIENT.

PRESCRIPTION (To be done in all 6 cases)

MD Name: ______________________________________________________________
MD Address: ____________________________________________________________
____________________________________________________________
MD telephone #: _________________________________________________________
Patients Initials: __________________________________________________________
Patients Address: _________________________________________________________
Patients Age: ____________________________ Patients Weight: _________________
Date: ___________________________________________________________________

Rx:

Sig:

Disp:

_____________________________
MD Signature

_____________________________
MD State License

______________________________
BNDD
(To use for narcotics and other restricted drugs)

_______________________________
DMD
(To use for narcotics and other restricted drugs)

Nutritional Assessment Exercise (Case #3)

Patients Initials: ________
Patients Age: ________

Date:
____________________
Diagnosis: ____________________
____________________
Infant (0 2 y/o) Child (3 11 y/o) Adolescent (12 y/o)

Problems:
Nausea

Chewing difficulties
Swallowing difficulties
Diarrhea

Vomiting
Anorexia

Abdominal Pain
Constipation
Others:_____________________
_____________________

Screening:
1. Assess familys sociocultural factors linked to excess weight.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Assess family history of excess weight. _________________________________________
___________________________________________________________________________
3. Assess hours per day of T.V. viewing, video games or computers (child or adolescent only).
___________________________________________________________________________
4. Assess hours per day of physical activities, and what kind.
___________________________________________________________________________
5. Was patient born prematurely? Yes: ______weeks (gestational age)
6. Illness: Acute

No

Chronic

Nutritional History:
1. Diet (0 2 years):
Breast Milk:
feeds/day________________ duration of each feed:_______
Formula: ________________ ounces per day: ____________

Milk ounces per day: _______

Whole Milk Low-Fat Milk
2. Use of additional foods (which and quantity) (0-6 mo):
__________________________________________________________________________
__________________________________________________________________________

3. Diet diary (>6 mo): Breakfast __________________________________________

Lunch
__________________________________________
Dinner
__________________________________________
Snacks __________________________________________
4. Use of vitamins Yes: ______________________________ No
5. Use of Iron: Yes No
6. Medications: _______________________________________________________
7. Food allergies: _____________________________________________________
8. Appetite:
Finicky eater Adequate Always Hungry
9. Stools per day________ consistency of stools: ____________________________
Classification:
a. Birth weight:_______Ptile:_________________
c. Head circum. ______Ptile:_________________
d. Birth length:_______Ptile:_________________
f. Current Weight for age, Ptile: _______________

b. Current weight:_______Ptile:_________
e. Current length or height: ____Ptile: ____
g. Current height for age, Ptile: __________

h. Current Wt for Ht/Ptile: ___________________ i. Mid arm circumference: ______________

j. % Weight change in last week: ______________
k.Triceps skin fold: _________________________
l. Body Mass Index (BMI): ___________________
m. Resting energy expenditure (REE): _________
n. Body energy expenditure (BEE): ___________
Vital signs: HR: _______

RR: ________

Laboratories:
a. Hgb: ______________
d. Total protein: _______
f. Total Cholesterol: ____
j. Triglyceride: _________
m. Other: _____________

BP:________

b. Hct: ______________
e. Albumin: __________
g. HDL: _____________
k. BUN: _____________

c. MCV: ____ MCH: ____ MCHC: ____

h. LDL: ________ i. VLDL___________
l. Creatinine: _____________________

Assessment:
a. Nutritional Risk (explain below): Yes No
________________________________________________________________________________
b. Estimated nutrient requirement (kcal/day):_______________________
c. Estimated desirable body weight: ______________________________
Recommendations (Plan):

NUTRITIONAL ASSESSMENT (To be done in case #3 Ped Gen)

Hispanic Center of Excellence/Department of Pediatrics

School of Medicine
University of Puerto Rico Medical Sciences Campus

Managed Care Applications in Pediatric Care

Emergency Care/Acute Care Case Study Questions, Case #6

Answer the questions below using the following managed care principles:

Risk distribution

Catastrophic coverage

Stop loss

Case management

Utilization review and claims analysis concepts

Emergency vs. urgent care criteria

HIPAA, EMTALA, HEDIS

1.

What is the patients principal diagnosis? Identify and copy the ICD9 codification for this
diagnosis.

2.

Select a treatment or diagnostic procedure, identify and copy its CPT4 codification (e.g.,
ABGs, Veni-puncture, Bone Marrow, or any other procedure performed on the patient).

3.

What are the managed care implications of correctly identifying and recording the
patients principal diagnosis in the medical record? Explain briefly in a short narrative.

4.

Why is it important to send a summary to the patients primary physician? What are the
implications of not sending the summary?

5.

What information should be included in the summary? Write an outline of what must be
included in this kind of summary.

6.

Who assumes the financial risk of managing this patient? Why?

7.

What criteria should be utilized and steps followed to enroll this case in the proper
healthcare coverage within the government health plan (i.e., regular orcatastrophic
coverage)? (Do the exercise even if the patient already has the coverage)

MANAGE CARE EXERCISE (To be done in case #6 ACUTE CARE/ ER)

RADIOLOGY EXERCISE
This exercise must be done in the work-up presentation of the newborn patient with respiratory
difficulty or problem. Case #1
1-

Mention specific history findings and criteria that contributes to define the most probable
diagnosis in this patient
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________

2-

Mention specific physical exam findings and criteria that contributes to define the most
probable diagnosis in this patient include vital signs and O2 saturation.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________

34-

Discuss chest X rays of assigned patient with neonatology faculty, pediatric faculty or
resident.
Discuss chest X rays with assigned hospital radiologist
Radiologist signature:_______________________________________________

5-

Describe patient X rays findings

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________

6-

Mention at least 3 most probable diagnosis

___________________________________
___________________________________
___________________________________

7-

Mention the most likely diagnosis for this patient taking into account history , physical
exam and radiologic findings:
__________________________________________________________________