History of Present Illness (HPI) Template for Infant Colic
Chief Complaint Documentation
Document the exact crying pattern using the "Rule of Three": crying episodes lasting >3 hours per day, occurring >3 days per week, for >3 weeks in an otherwise healthy infant. 1, 2
Essential History Elements
Crying Characteristics
- Onset and duration: Peak age is 6 weeks, with resolution expected by 3-6 months 1
- Time of day: Note if worse at night (typical pattern) 1
- Quality: Paroxysmal, inconsolable crying with agitated status 3
- Frequency: Document specific hours per day and days per week 1, 2
Red Flags to Exclude (Colic is a Diagnosis of Exclusion)
- Fever: Any fever requires immediate evaluation for infection or incomplete Kawasaki disease, particularly in infants <6 months 4
- Vomiting: Bilious emesis suggests malrotation requiring urgent imaging 4
- Poor feeding or weight loss: Suggests organic pathology rather than benign colic 1
- Lethargy between episodes: May indicate metabolic emergency 4
- Abnormal movements: Could represent seizures rather than colic 5
- Recent trauma or fall: Peak age for abusive head trauma, with crying as the most common trigger 4
Feeding History
- Type: Breast vs. formula (incidence equal between both) 1
- Technique: Assess for poor feeding technique as contributing factor 1, 3
- Maternal diet (if breastfeeding): Document dairy, caffeine, cruciferous vegetables intake 1
- Formula type (if formula-fed): Current formula brand and preparation 1
- Feeding frequency and volume: Rule out overfeeding or underfeeding 5
Maternal and Environmental Factors
- Maternal smoking or nicotine replacement therapy: Established risk factor 1, 3
- Allergen exposure: Pets, dust, tobacco smoke at home or daycare 4
- Parental anxiety level: Important for management planning 5, 2
- First-time parents: Higher anxiety and need for reassurance 3
Birth and Medical History
- Gestational age: No correlation with colic, but document for completeness 1
- Sex: Equal incidence, document for records 1
- Previous medical conditions: Rule out organic causes 5
- Medications: Any current medications or supplements 5
Physical Examination Template for Infant Colic
Vital Signs (Critical for Exclusion of Serious Pathology)
- Temperature: Any fever requires evaluation for infection or Kawasaki disease 4
- Weight: Plot on growth curve; normal growth supports benign colic diagnosis 1, 5
- Heart rate and respiratory rate: Document baseline 5
General Appearance
- Between crying episodes: Infant should appear well, alert, and consolable 1, 5
- During examination: Note if infant can be consoled or remains inconsolable 2
- Hydration status: Assess mucous membranes, fontanelle, skin turgor 5
Head, Eyes, Ears, Nose, Throat (HEENT)
- Fontanelle: Should be soft and flat (bulging suggests increased intracranial pressure) 4
- Eyes: Assess for conjunctival injection (Kawasaki disease) 4
- Oral mucosa: Check for thrush, oral lesions, or signs of dehydration 5
- Ears: Examine tympanic membranes to exclude otitis media 5
Cardiovascular
- Heart sounds: Regular rate and rhythm, no murmurs 5
- Pulses: Equal in all extremities 5
- Capillary refill: Should be <2 seconds 5
Respiratory
- Breath sounds: Clear bilaterally, no wheezing or crackles 5
- Work of breathing: No retractions, grunting, or nasal flaring 5
Abdominal Examination (Critical to Rule Out Surgical Emergencies)
- Inspection: Flat, no distension (distension suggests obstruction or malrotation) 4
- Palpation: Soft, non-tender, no masses or organomegaly 5
- Bowel sounds: Present and normal (absent suggests obstruction) 5
- Inguinal region: Check for hernias bilaterally 5
Genitourinary
- Testicular examination (males): Rule out testicular torsion or incarcerated hernia 5
- Diaper area: Assess for rash, signs of irritation 5
Musculoskeletal and Neurological
- Extremities: Palpate all long bones to exclude fractures (especially if trauma history) 4
- Range of motion: Move all extremities; pain suggests fracture or injury 4
- Tone: Normal for age; hypotonia or hypertonia suggests neurological pathology 5
- Reflexes: Age-appropriate primitive reflexes present 5
- Fontanelle: Recheck for signs of increased intracranial pressure 4
Skin
- Rashes: Document any rashes (consider Kawasaki disease if present with fever) 4
- Bruising: Any bruising requires evaluation for non-accidental trauma 4
- Hair tourniquet: Check fingers, toes, and penis for hair tourniquets 5
Immediate Laboratory/Imaging Considerations
When to Obtain Testing (Only if Red Flags Present)
- Serum glucose, calcium, magnesium: If lethargy, poor feeding, or abnormal movements present 4
- Urinalysis: If fever present to exclude urinary tract infection 5
- Abdominal imaging: Only if bilious vomiting, distension, or concerning abdominal findings 4
When NOT to Obtain Testing
Do not obtain routine laboratory testing or imaging in well-appearing infants with typical colic presentation and normal physical examination. 1, 5, 2
Documentation Pitfalls to Avoid
- Never dismiss prolonged fever with irritability as viral illness without considering incomplete Kawasaki disease, especially in infants <6 months 4
- Never attribute all irritability to normal crying without examining for fractures, as this is peak age for abusive head trauma 4
- Never prescribe proton pump inhibitors for uncomplicated colic, as they are ineffective and carry significant risks 4, 1
- Always document that physical examination was completely normal to support diagnosis of benign colic 5, 2