Paediatrics clerking format Patient details: Name: Dos: Hospital Age: DOA: Hosp No: Sex: Ward: Consultant Race: Historian (age): Relationship: Presenting complaint Systemic enquiry: -General: Fever Dnightsweats GLOW LOA Clethargy Dirritability Resp: Ceough Clwheeze C1S08 Dfastbreathing Csnoring Cichest indrawing Capnoea CVS: chest pain Dfatigue Cileg swelling C'syncope O08 PND Corthopnoea CO sweating/fatigue during feed Ceyanosis during feeds -GIT: QDiarrhoea 0 Vomiting Cjaundice CLOW/LOA Cabdominal distention 7 Abdominal pain CNS: Dseizures Clweakness OLOC Dheadache CINecksstiffness -MSK: Djointpain Gjoint swelling movement -GUS: Cdysuria GHaematuria Clenuresis Cifrequency -ENT: Osore throat Clearpain Cleardischarge Cinasal discharge -Skin: Crashes Gitching Oburing Ceczema Ghairloss - Danger signs: vomiting everything Dilethargy/unconscious Ci convulsions during present illness Cinot able to feed Past medical history: - Known medical conditions (when was it diagnosed, treatment, response to treatment) Previous hos} | admissions/surgery(C0 TB + diagnosed when and how: oT Duration: -CHIV + diagnosed when and how: cepa: ov: -CHIV exposed Mothers CD4: Mothers VL: (Mothers last PCR -0 Allergies Perinatal history - Pregnancy: - Mothers name = Mothers age: - PG OMiscarriages = Age of other children = Pregnancy of patient Age: Planned/unplanned: ANC initiation: RVD status: Initiation of PMTCT: + During pregnancy: Ciinfections: Resolution: Contact (if so, who): oT Compliance: 0 Mothers Tx: (Mothers Compliance: Stillborn 0 Other: Healthy complications: DM GHPT DEpilepsy Smoking DAlcohol GDrugs CSober habits C Medications 0 Supplements 0 X-rays/investigationsLabour and delivery Place: GNVD OCIS GWhy? Duration: Complications Gestational age:__weeks Birth weight:__kg birth Iength:_cm birth OFC:_om APGAR 1min:____ Smin: 40min: - Neonatal period: (i Cried immediately Cjaundice Ceyanosis Odifficulty est. feed Ciseizures Ciassisted vent blood transfusion CInfection Cother: - Duration in nursery: Nutritional history Breasted Dformuta (name): - how often: how long: - weaning oft: how often: - solids: - side effects: - weaning off: - sterilization practices: - Preparation: - Current diet: Protein rich Genergy rich Any nutritional abnormality CO Vitamins/iron supp Citolerating feeds history of PEM Ciweight gain (double by 6m, triple by tyr) LOW Dood allergy: Family history Mother and parents: First degree relatives: Father and parents: Siblings: - Inherited/congenital/chronic conditions: Drug history - Past (ARV at birth): - Present (OTC, herbal) Social history Lives in with, ~ Type of housing No of rooms: - Amenities: C water (Citap inside, O tap outside) Celectricity Csanitation - Mother: Clemployed: (unemployed Level of education: Cisocial grant ( c Mother, ci Child)- Father: employed: Glunemployed Financial assistance - Nearest clinic/ hospital: Mode of transport: - TB contact: Pets CAir pollution -Schooling of child ~ Caregiver: Child health record -Immunisations: Cup to date Cmissed—why? Next due: Adverse reactions: Dvitamin A GDeworming Next due = growth charts © growing well Losing weight -WFA: Dunderweight (-2) Diseverely underweight (-3) - WFH: wasting (-2) Cisevere wasting (-3) Cloverweight (+2) Cobese ( +3) - HFA: Cistunted (-2) Ciseverely stunted (-3) -MUAG: (ISAM (<11.5) MAM (11.5-12.4) Cmild (12.5-13.5) Gnormal (>13.5) - OFC: Cmicrocephaly Cmacrocephaly - History of malnutrtion/abnormal classification health care/ chronic visits: Development History ‘Assessment Gross motor Fine motor (vision) Speech (hearing) Personal/social Schooling ~ Age appropriate? Why? -Red flags not smiling at 8 wk Cot sitting at 9m Cot standing supported at 12m not walking at 15m not babbling at 12m_Cinot using at least 3 words by 15m no reaction to sound (all ages) Cino reaction to light all ages)Examination Anthropometry: -Weight:___kg WFA: * WFH: + ~Height:___em HFA: -OFC:__em OFC for age: - MUAC: om Nutritional assessment: = Skin: PEM:C]_desquamating, pigmented dermatosis Vit A: Dfollicular hyperkeratosis Cxerosis 0 acneiform lesions Vit: O perifolicular haemorrhages Clecchymoses Zine: C perioral and perianal (acral) erythematous easily denuded plaques Vit C/K: Dintradermal petechiae © purpura Chaematomas Niacin (B3): erythema Cihyperpigmentation -Hair:PEM~ brittle Ccopper Dalopecia Ceasily plucked - Nails: PEM/Ca ~ 0 brittle/thin Iron Def =a koilonychia - Eyes: Vit A0Bitot's spots CDkeratomalacia Cicomeal clouding/ulceration CO xerosis, Iron def—cblue sclera Cpallor - Mouth: angular stomatitis (PEM/B2/B6/B12) atrophic glossitis and mucosa (PEM/B2/Niacin) Obleeding gums (Vit) C/Magenta coloured tongue (82) Ciscarlet tongue (niacin) CiCheilosis (B2/B6) - Extremities: Cloedema (visible wasting Drickets (Vit D/Ca) - Organomegaly: Ciliver (PEM) Dthyroid (iodine) - Mental state: PEM/Ironiniacin~ Diirritable C apathetic Assessment: J] Macronutrient Ci micronutrient Dysmorphologies General inspection Diawake Clalert Ciresponsive Ciwell-hydrated Cwellpertused Ccooperative irritable Crespdistress normal body posture OIVline Ceding tube Cisupplemental 2 (Cinasal prongs, C1 mask) General examDJaundice Canaemia Ceyanosis clubbing Coedema Cilymphadenopathy Ddehydration~Cpulse Ceapillary refill Csunken eyes Cidry mucosa DBCG scar (R arm) Mantoux (L arm) als ~Pulse:___bpm= - BP: mmHg > Pulse BP RA Birth—3m: 120-160 O-3yr: 110/65 Neonate: 40-50 tyr) 80-140 3-7yr: 120/70 Infant: 25-40 2yr 80-130 7-Noyr: 120/75 1-5yr: 20-30 Byrn: 80-120 10-13yr: 140/80 <10yr. 15-25 Older: 75-115 >1oyr: 15-20 ~BR: bpm= “Temp cs Systems exam Resp exam -Resp distress: Ctachypnoea Clalarflaring Cuseof acc muscles Ciintercostal/subcostal recessions Cyanosis grunting - Resp failure: Type 1+ Cicyanosis Type 2~ C bounding pulse Ciconfusions Clwarm peripheries Ciflapping tremor = Chronic lung dz: stunted Clubbing Ccor pulmonale -Dangersigns: Cistridor Calter LOC CSAM GHIVand notontx = Inspection: Shape: Clnormal_Gabnormal: scars Cideformities symmetry Pattern of breathing: -Palpation: Trachea~ Ghormal Odeviated Ctug ApexCpalpable character: Chest expansion: Anterior: Vocal fremitus Diver ptosis - percussion: 1D resonant Chyperresonant: Deardiac dullness Ciliver dullness ~ Auscultation: Posterior: Ddult Nose~ Lungs ~ air entry: wheeze:Derackles (0 fine; C coarse) 0 Stridor Gadded sounds: Vocal resonance: CVS exam - Cardiac failure: Citachypnoea Dtachycardia Cicardiomegaly Clhepatomegaly - Infective endocarditis: Cfever Clanaemia Ceardiacfindings Clubbing Csplinter haemorrhages O Janewaylosler nodes - Rheumatic fever: Citever Gnodules © erythema marginatum [1 Sydenham’s chorea Inspections: (1 JVP Ovisible pulsations Cideformities Ciprecordial bulge C asymmetry Cisurgical scars -Palpation: ‘Apex beat: Cipalpable Location Character: CiLeft parasternal heave C)Palpable P2 Clepigastric pulsation Dithrills Citrachea: - auscultation: LHF: RHF: ‘Sympt:0 dyspnoea ‘Sympt:0 anorexia/FTT O weakness 0 fatigue 0 oedema Signs:0 tachycardia 0 $3/S4_ 0 crackles Signs: tenderHSM (Hepa Ooedema 0 |JVP 0 SM os! os2 0 ss Os4 Murmurs ~ site: radiation: intensity: character: timing: GIT exam: =Cisigns of CLD -Cisigns of liver failure -Cisigns of portal HPT = Inspection Cidistention (visible peristalsis Cpulsations Cimasses Ciscars (distended veins shape of umbilicus: palpation Ditenderness Drigidity guarding Cmasses ~ size: surface: consistency: tenderness: edge: pulsatile: Cahepa + size surface: consistency: tenderness: edge: pulsatile: Spleen Okidneys - percussion Dascites Cifluid thrill Cishitting dullness auscultationbowel sounds Gbruit Grubs - inspect ~ Groin, genitalia, anus Neuro exam GCS normal values -LOC: Gawake Dalert Dresponsive Giirritable Cunconscious 0-6m9 -Gcs: 612m 11 4-2yr12 = Eyes open: none (1) Cito pain (2) Cito speech (3) Cispontaneously (4) 25yr-13. = Verbal: none (1) Deries (2) Cvocal sounds (3) Owords (4) Cloriented (5) = Motor:Cinone (1) Gextension to pain (2) ciflexion to pain (3) withdraws (4) Glocalises pain (5) obeys commands (6) - General Posture: normal Clabnormal movements: normal Cabnormal wasting Citasciculations Cmoving limbs Ciealthypertrophy Gait: Gnormal Cabnormal (Ghemiplegic:__) ___dysmorphic features: Cneurofibromas Cituberous sclerosis, head: OFC +) macro/cmicro/normal C bulging 1 fontanelles~ 0 open ci closed (post: 3-6m, ant: 18m) OVP shunt (G asso meningomyelocele) CAV matformation bruit = meningism: Cineck stiffness C1Kemig’s Brudzinski Raised ICP ~ Cbulging fontanelle Cheadache Cvomiting Cbradycardia Cisystolic HPT Dirritable high pitch cry Clabnormal resp - Cranial Nerves CN 1 —nottested CN2- Cisee if child fixes eyes and follows movement CNS, 4,6- Ciptosis CIPEARL movement in all directions CN 5—comeal reflex not tested CN7- C symmetry of face Cismile/tory Clwrinkle forehead Ciclose eyes tightly CN8— Ghearing (without seeing) jangle keys outside child's vision CN9, 10, 12— Ciswallow Cidrooling CN 11 - shrug shoulders (if old enough) = Long tracts = Tone:Cinormal hypo Ohyper truncal tone (pullto sit) Clhead lag Civentral suspension Dilimb tone = Power: spontaneous movements Csymmetrical movements grade:_____Cifasciculations wasting + Reflexes: C moro Ograsping Ostepping Casymmetric tonicneck (fencer) Cirooting Deep~Dbiceps RL Citriceps R/L Cisupinator R/L Oknee R/L ClankleR/L Celonus R/L Superficial > 0 Babinski Cabdominal Coremasteric = Sensation: check for clues of | sensation (pressure sores)Dlighttouch Cipain Ovibration ci rhombergs cerebellar signs: Young child~ Dataxia when sitting Cnystagmus Older child + Cdysdiadokokinesis Cifinger—nose heel to knee intention tremor - Developmental assessment (brief) = Motor: = Fine motor: = Personalisocial: = Speech: _ MSK exam - General: Cimalarrash (i subraorbital rash (dermatomyositis) Cisigns of ARF - Joint examination: Dtender Cwarm Cswelling Cisynovial thickening CROM Cideformities Abnormal joint description: Spine: Overtebrae aligned Cigibbus Cscoliosis Ckyphosis Cimeningocele ENT exam = Copharynx: Ddischarge: 0 other: Summary: DDx: