Pediatric Pulmonology New Patient Consultation Note

Patient: [Patient name], [DOB], [Age (years; months)], [MRN]

Date/Time: [Encounter date and time]

Location: [clinic / telehealth]

Clinician: [Clinician name, credentials]

Accompanied by: [Parent/guardian/patient present and relationship] | Interpreter: [language / none]

Referring Clinician: [Name, practice]

PCP: [Name, practice]

Referral Reason: [Verbatim referral question if available] (If absent or nonspecific, state this.)

Records Reviewed: [List records reviewed by source and date] (If records requested but not yet received, note this with date requested.)

Chief Complaint

[Primary symptom or concern in caregiver or patient words with duration and/or severity context]

Reason for Consultation

(Use 1 short paragraph or 2–4 bullets summarizing the consultation questions, what has been tried, why referral now, and any urgent issues. If referral letter is absent or nonspecific, document this.)

• [Specific question(s): diagnosis / management / second opinion / pre-op clearance]
• [Prior treatments or evaluations already completed and response]
• [Reason for referral at this time]
• [Urgent issues requiring same-day guidance]

History of Present Illness

(Write 2–4 concise paragraphs. Distinguish reported history from clinician interpretation using phrases such as "Family reports..." and "My interpretation is...". Tailor depth to the referral question.)

[Onset and course of presenting symptom(s); cough characterization (dry vs wet/productive, nocturnal pattern, triggers, post-tussive emesis); wheeze (audible vs clinician-diagnosed, bronchodilator response); dyspnea or exercise intolerance; noisy breathing or stridor; chest tightness, chest pain, hemoptysis. Impact on sleep, school attendance, and activities.]

[Treatments attempted and response: bronchodilators, inhaled corticosteroids, antibiotics, reflux therapy, airway clearance, other.]

[Exacerbation history: ED visits, hospitalizations, ICU admissions, intubations, supplemental oxygen use, systemic steroid courses (approximate counts/dates). Infectious patterns including recurrent pneumonia frequency and organisms if known. Red flags: aspiration/choking, cyanosis, failure to thrive, recurrent focal pneumonias, chronic wet cough, hemoptysis, hypoxemia.]

(Tailor depth: for suspected asthma, emphasize triggers, controller use, and objective testing; for chronic cough, emphasize duration, cough pointers, and prior workup; for recurrent pneumonia, emphasize radiographic confirmation, lobe distribution, and immune/aspiration evaluation; for sleep concerns, emphasize snoring, witnessed apneas, and prior sleep studies. For home respiratory support, include oxygen settings, NIV parameters, tracheostomy details, and airway clearance regimen only when applicable.)

Past History

• Birth history: [Gestational age, NICU course, intubation/ventilation, O2 at 36 weeks, BPD diagnosis] (Document unknown if not available.)
• Growth/feeding: [Growth trajectory, feeding method and tolerance]
• Immunizations: [up to date / not up to date / unknown]
• Chronic diagnoses: [Asthma, eczema, allergic rhinitis, GERD, neuromuscular disease, congenital heart disease, other]
• Surgeries/procedures: [Airway procedures, bronchoscopy, adenotonsillectomy, other respiratory-relevant procedures]

Medications & Respiratory Therapies

• Controller medications: [Name – dose – route – frequency – device (MDI with spacer / nebulizer / DPI)]
• Rescue medications: [Name – dose – route – frequency – device]
• Airway clearance: [Device and schedule] (Only include if applicable.)
• Home equipment: [Oxygen, suction, pulse oximeter, nebulizer compressor, NIV] (Only include items that are used.)
• Technique/adherence: [Method assessed and findings] (Only include if assessed.)

Allergies

• [Substance] – [Reaction] – [Severity]

Family History

• [Asthma, atopy (eczema, allergic rhinitis)]
• [Cystic fibrosis or CFTR-related disease]
• [Primary ciliary dyskinesia]
• [Immunodeficiency]
• [Bronchiectasis, early emphysema, other relevant pulmonary or genetic conditions]

Social & Environmental History

• Household: [Household members], [Pets], [Daycare/school attendance]
• Exposures: [Tobacco smoke, vaping, wood stove, indoor allergens (pets, pests, mold), air quality concerns]
• Adolescent risk assessment: [Personal vaping/substance use] (Include only if assessed; note confidentiality approach.)
• (If exposure history not assessed, state this rather than implying negative.)

Review of Systems

(Brief and focused on pulmonary differential. Omit if comprehensively addressed in HPI.)

• Constitutional: [Fever, weight loss, fatigue]
• ENT: [Nasal congestion, rhinorrhea, sinus symptoms, snoring]
• Respiratory: [Cough, wheeze, dyspnea, stridor, chest pain, hemoptysis]
• Cardiac: [Palpitations, murmur history, cyanosis]
• GI: [Reflux, emesis, aspiration concerns]
• Skin: [Eczema, rash]
• Neuromuscular: [Hypotonia, coordination, developmental concerns]

Vitals & Growth

Temp: [Value] HR: [Value] RR: [Value] BP: [Value] SpO2: [Value] [room air / supplemental oxygen]

Weight: [Value, percentile] Height/Length: [Value, percentile] BMI: [Value, percentile]

Physical Exam

• General/Work of breathing: [Appearance and respiratory effort]
• HEENT: [Nasal congestion, nasal polyps, tonsil size, oropharynx]
• Neck: [Stridor, lymphadenopathy]
• Chest wall: [Shape, deformities, tenderness]
• Lungs: [Aeration, wheeze, crackles, prolonged expiration, focal vs diffuse findings, transmitted upper airway sounds]
• Cardiac: [Rate/rhythm, murmur, perfusion/capillary refill]
• Abdomen: [Findings] (Include if relevant.)
• Skin: [Eczema, clubbing, cyanosis]
• Neuromuscular: [Tone, strength] (Include if relevant.)
• (If exam is limited, document the reason.)

Data Reviewed

(List with dates and source; include key findings and brief interpretation. Note pending or unavailable data separately.)

• Pulmonary function testing: [Spirometry date, source – FVC, FEV1, FEV1/FVC, FEF25–75, pre/post bronchodilator – quality/acceptability – bronchodilator responsiveness interpretation]; [FeNO date, value, interpretation]
• Imaging: [CXR date, source – key findings – interpretation]; [Chest CT date, source – key findings – interpretation]
• Laboratories/Microbiology: [CBC with eosinophils, IgE, immunoglobulins, cultures, viral testing – dates, key values, interpretation]
• Sleep studies: [Polysomnography date – AHI, oxygen nadir, CO2 data – interpretation]
• Procedures: [Bronchoscopy date – airway findings, BAL results – interpretation]
• Other testing: [Swallow study, pH-impedance, allergy testing, sweat chloride, CFTR genetics – dates, key findings, interpretation]
• Pending/Requested: [Items pending or requested with date ordered]

Assessment

[2–4 sentence synthesis answering the referral question, summarizing key history and objective findings, and stating the primary working diagnosis or diagnostic uncertainty.]

1. [Problem 1]: [Working diagnosis or symptom label], [status/severity]

   • Differential: [Focused differential with brief rationale linked to findings]
   • Risk factors: [Factors increasing urgency or complexity]

2. [Problem 2]: [Working diagnosis or symptom label], [status/severity]

   • Differential: [Focused differential with brief rationale]
   • Risk factors: [Factors increasing urgency or complexity]

Plan

(Problem-oriented; match the order and titles of the Assessment problem list.)

1. [Problem 1]:

   • Diagnostics: [Tests ordered today with rationale; contingent testing if initial results nondiagnostic or symptoms persist]
   • Therapeutics: [Medications started/changed/stopped – name, dose, route, frequency, duration, device, purpose]; [Technique/adherence interventions]; [Environmental control recommendations]; [Airway clearance instructions]
   • Education: [Counseling provided]; [Caregiver understanding/teach-back]; [Shared decision-making and alternatives considered for significant interventions]

2. [Problem 2]:

   • Diagnostics: [Planned tests with rationale]
   • Therapeutics: [Treatment plan details]
   • Education: [Counseling and shared decision-making]

Follow-up & Safety-Netting

• Follow-up: [Interval] [in-person / telehealth]; [Data expected by next visit]
• Communication: [Plan to update referring clinician and PCP]
• Return Precautions: [Specific signs/symptoms warranting urgent evaluation: increased work of breathing, persistent hypoxemia, dehydration, hemoptysis, apnea] – [Action: call clinic / go to ED]
• Contingency: [Instructions if child worsens before scheduled follow-up]

(Omit sections not applicable to the encounter. Use brief placeholders when expected information is missing but clinically meaningful. Do not infer information that was not explicitly obtained. For spirometry, include test quality when available. Keep note focused on answering the referral question.)