Paediatric assessment sheet

Identification data:
Name Age/Sex. C.R.No. .

Ward /Bed no. D.O.A D.O.D .

Address Informant .

Diagnosis/Surgery Consultant Incharge .

Chief complaint at admission:

History of present illness:

History of past illness:

 Medical:

 Surgical:

Antenatal history of mother and delivery

 Immunization (TT)-
 Gravida-
 POG at delivery-
 Type of delivery-
 Birth weight-
 CSAB/ any complications

Immunization status: Immunized for age or not

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Nutrition and Dietary history: Exclusive Breast feeding or weaning started

Family health history: maternal / paternal side any hereditary disease

Consanginous marriage / Non consanginous marriage

Socio economic status:

Education/Occupation (father):
Education/Occupation (mother):
Family type/No. of family member and Pedigree:

Laboratory investigation:
CBC
LFT
RFT
Serum electrolytes
Usg
CT
Xray
Any specific blood test / investigation

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Treatment:
In emergency :

In continuation:

General physical examination:

Vital sign:

Temp(°c/°f) Pulse(per min.) Resp.(per min.) B.P.(mmHg) SpO2(%)

Anthropometry :

Height
Weight
Head Circumference
Chest Circumference
Mid Arm Circumference
Head: Ear:

 Shape Discharge
 Hair distribution Placement
 Any surgical scar
 Fontenelles Nose
DNS
Eyes:
Discharge

 Colour Patency
 PEARLA
 Pallor / icterus
 discharge Throat:
 Conjunctiva Uvula
 Sclera Tonsillitis
 Strabismus
 Ocular movements CMF:
if present, then specify

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Lips:

 Colour
 Hydration
 Any cracks
 Cleft lip / palate Lymph nodes:
Neck: Submental

 Web neck
 Neck rigidity Submandibular:
 Lymph node Preauricular
 Neck folds Postauricular
 Range of motion Supraclavicular
Sabclavicular
Axillary

Systemic examination:
Integumentary system `(pallor, cyanosis, clubbing, edema, koilonychia)
1. Skin
 Odour
 Color
 Texture
 Integrity
 Cyanosis/ icterus / Pallor
2. Hair
 Color
 Texture
 Distribution
3. Nails
 Shape
 Nailbed color
 Texture
 Cyanosis

Gastrointestinal system
1. Oral cavity caries
2. Abdomen
 Inspection: any mass / lesion
Peristaltic movements
 Auscultation: Bowel sounds

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  Palpation: any mass / tenderness
Soft to touch / hard to touch
Abdominal girth
Any surgical scar
 Percussion: Tympanic / Dullness

Cardiovascular system:
 Inspection:
 Palpation:
 Auscultation:

Respiratory system:
 Inspection:
 Percussion:
 Auscultation:

Nervous system:
 GCS:
 Speech and articulation
 Cranial nerve:

 Muscle power:
-Coordination
 Sensory system:

 Reflexes:

Musculoskeletal system:
 Spinal curve
 Upper extremity
-Range of motion
-Polydactyly/syndactyly
 Lower extremity

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 -Range of motion
-Polydactyly/syndactyly
-Knock knee
-Flat foot
 Gait

Endocrine:
 Thyroid gland
 Body built
 DM

Genitourinary:
Male genitalia

 Epispadiasis/hypospadiasis:
 Testes and scrotum:
Female genitalia

 Labia majora/minora:
 Any fistula:

Remarks
Signature