Paediatrics cash sheet

Department of Paediatrics
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM.
Name : Informant :

Age / Sex : Reliability :

Place : Date : Time :

Case Sheet Written by Dr.

Chief Complaints :-

History of presenting illness :-

Past History :-
H/O similar illness in past : Yes / No
H/O hospitalization : Yes / No (If Yes Details)

Blood Transfusion : Yes / No (If Yes Details)

Treatment H/O :

For ________________________________________
On any long term medications ? : Yes / No (If Yes : details)

Any Surgery? : Yes / No (If Yes : details)

Antenatal History :-

Married at _______ years of age : P____L____A

Conceived at _______ years of age
Registered : - Yes / No

Hyper emesis gravidarum H/O quickening -----Month H/O anemia - Yes / No

H/O pregnancy induced

Fever with rash H/O Blood Transfusion - Yes / No
Hypertension - Yes / No

Gestational Diabetes mellitus

Drug Intake H/O Bleeding for vagina - Yes / No
Yes / No

H/O of any other Medical

Irradiation - Yes / No H/O Hypothyroid - Yes / No
or surgical - Yes / No

If yes, details

Natal History :
Preterm/Term/Post term Birth weight :
Natural labour/assisted delivery/caesarian section Place of delivery :

Cried immediately after birth - Yes / No

If No, Rescustication details:

Neonatal history :
H/o admission in NICU : Yes / No
H/o jaundice : Yes / No
H/o seizures : Yes / No
H/o respiratory distress : Yes / No
H/o feeding difficulty : Yes / No
H/o cyanosis : Yes / No
Developmental History :
Gross Motor - months Fine Motor - months
Milestone Age Milestone Age
Neck holding Reaching for objects
Rolls over Bidextrous grasp
Sits with support Unidextrous/palmar grasp
Sitting without support Pincer grasp mature
Stands with support Imitates scribbling; tower of 2 blocks
Stands without support Scribbles; tower of 3 blocks
Creeping
Walks with support
Walks without support Tower of 6 blocks; vertical and circular stroke
Runs; explores drawers Tower of 9 blocks; copies circle
Walks up and downstairs; Jump Copies cross; bridge with blocks
Rides tricycle; alternate feet going upstairs Copies triangle; gate with blocks
Hops on one foot; alternate feet going Copies square/rectangle
downstairs
Skipping Copies diamond

Social and adaptive Language

Milestone Age Milestone Age
Social smile Alerts to sound
Recognize mother; anticipates feeds Coos
Recognizes stranger, stranger anxiety Laugh loud
Waves “bye bye” Monosyllables
Comes when called; Plays simple ball game Bisyllables
Jargon 1-2 words with meaning
Copies parents in task 8-10 word vocabulary
Asks for food, drink, toilet; pulls people to 2-3 word sentences, uses pronouns
show toys ”I”, ”me”,” you”
Shares toys; knows full name and gender Asks questions; knows full name and gender
Plays cooperatively in a group; goes to Says song or poem; tells stories
toilet alone
Helps in household tasks, dresses and Asks meaning of words
undresses

Bowel control __________ years : Bladder control ___________ years :

Development quotient : gross motor :_____ % fine motor :_____% language:_____% socioadaptive :_____%

Impression : Developmental delay Regression Normal

DIET HISTORY :
Pre lacteal feeds - yes/no
Breast feeding initiated within ___________ hours after delivery
Exclusive Breast feeding given for ___________ months
Complementary feed started by ___________ months
Breast feed continued upto ___________ years of age
24 hours dietary recall

Diet Quantity Calorie protein

Morning

After Noon

Night

TOTAL

Calories required __________________kcal/day Protein required ___________________ gms/day

Calories taken ____________________kcal/day Protein taken ______________________gms/day
Calorie deficit______________________kcal/day Protein deficit_______________________gms/day

Immunisation History

Immunised upto the age according to National immunised schedule - Yes / No

(If no, details of missing immunisation)
Optional vaccine - Yes / No
Pulse polio vaccine - Yes / No

Last date of Immunization :

Family History:
Age of Father pedigree chart

Age of Moher
Consanguinity – No.1°/2°/3°
Previous sibling death – Yes / No
Previous abortion – Yes / No

H/O similar illness in the family:

Socio EconomicHistory:
Modified Kuppuswamy scale : _____________score
Socio economic status : Lower /upper lower/ Lower Middle / Upper Middle/middle
Types of house : pucca house / kutcha house
No of rooms :
Water supply :
Latrine facility - Yes / No
Garbage disposal - Yes / No
Mosquito breeding - Yes / No
Animal inside house - Yes / No

History of allergy :
Contact History
History of exposure to tuberculosis - Yes / No
If yes : details

PHYSICAL EXAMINATION
A.
GENERAL HEAD TO FOOT EXAMINATION

Awake/ conscious Head :

Alert/oriented Face :
Pallor - No / Yes Eyes :
Icterus - No / Yes Ears :
Cyanosis - No / Yes - central/peripheral Lips and Palate :
Clubbing of fingers - No / Yes____________grade Chest :
Lymphadenopathy - No / Yes Abdomen :
Generalised/significant______group of lymphnodes Genitalia :
Oedema (pedal/pre sacral) - No / Yes Spine/back :
Pitting /non pitting edema Limbs :
Dehydration - No / Yes Skin :
BCG scar -yes/no Neuro cutaneous markers :
Others :
PAIN SCACE :

VITAL SIGNS
1. Temperature
2. Pulse Rate
3. Respiration (Count for a full min. )
4. Blood pressure:
5. SPO2 at Room air

ANTHROPOMETRY :
Anthropometry Actual Value Inference (percentile)
Weight (kg)
Height / Length (cm)
Head circumference (cm)
Chest circumference (cm)
Mid upper arm circumference (cm)
(plotted in growth chat)

NUTRITIONAL STATUS :
Normal SAM MAM Undernourished over weight obese

Normal Stunted Short Stature

SYSTEMIC EXAMINATION :
PROVISIONAL DIAGNOSIS :

Note : 1. Please with GENERIC NAME Preferably 2. Please write in CAPITAL LETTERS Only.
3. Do Not user abbreviation – MS, MSO, U, IU, QD, QQD, Trailing Zero.
'CONFIDENTIAL'

Date : Consultant Signature: