Date:
Infant:
Reason for Visit: Evaluation for suspected Sudden Infant Death Syndrome (SIDS)
History of Present Illness:
Briefly document the circumstances surrounding the infant’s death, including:
Age at death
Scene investigation findings (sleeping position, bedding materials, presence of illness)
Timeline of events leading to discovery of the infant
Any previous illnesses or concerns about the infant’s health
Information from parents/caregivers regarding the infant’s sleep habits and last feeding
Past Medical History:
Prenatal history (prematurity, complications during pregnancy)
Birth history (weight, gestational age)
Immunization history
History of any previous illnesses or hospitalizations
Family History:
Sudden unexplained infant deaths (SIDS) in siblings or first-degree relatives
History of genetic disorders in the family
Social History:
Living situation (parents, siblings, daycare)
Smoking history in the home or around the infant
Substance use by parents/caregivers
Physical Exam:
This will not be possible due to the post-mortem nature of the visit. Document that an external examination was not performed.
Autopsy/Investigations (if performed):
Document if an autopsy was performed and the preliminary findings (organ weights, histology, toxicology).
Mention any investigations conducted by law enforcement or social services.
Diagnosis:
This is a provisional diagnosis and requires autopsy and investigation to confirm.
State: “Sudden unexpected infant death, pending investigation/autopsy for SIDS determination”
Management:
There is no medical management for SIDS after death.
This section should focus on supporting the family:
Provide emotional support and grief counseling resources to the parents/caregivers.
Offer information about SIDS and risk reduction strategies for future pregnancies (safe sleep practices, avoiding smoking exposure).
Connect the family with support groups or social services as needed.
Plan:
Outline the next steps:
Await autopsy and investigation results.
Schedule a follow-up appointment with the family to discuss the final determination and provide continued support.
Prognosis:
Unfortunately, this is not applicable in a SIDS case.
Additional Information:
Document any concerns raised by the family or investigators.
Include details regarding any reports filed with authorities.