PEDIATRIC CASE SHEET

Bed No……………… IPD No…………………………

Name……………………………………………………………….. Age & Sex…………………………………….
Parents…………………………………………………. Address……………………………………………………
Date of Admission………………………………… Date of Examination………………………………..
CHIEF COMPLAINTS:

HISTORY OF PRESENT ILLNESS:

PAST HISTORY:

PERINATAL HISTORY:
a) Pregnancy:
Antenatal check-up: Drugs:
Maternal disease: Vaccines:
Complications:
b) Delivery:
Place of delivery: Type of delivery:
c) Baby:
Gestational age: First cry:
Birth weight: APGAR score:
d) Post natal:
NUTRITIONAL STATUS:
Structure: Members:
Sibling: Diseases:
SOCIOECONOMIC HISTORY:
Rural/ Urban background: Parental occupation:
Family income:
DEVELOPMENT HISTORY:
a) Gross motor: b) Fine motor:
Head control(3m): Reach out of objects(5m):
Turnover(5-6m): Crude palmar grasp(7m):
Sittiing(6-8m): Pincer grasp(9m):
Standing(10-12m): Hand to hand transfer(10m):
Walking(11-13m):
c) Personal Social: d) Language:
Social smile(2m): Monosyllables(Ba/Da)(6m):
Recognise mother(3m): Disyllables(Baba/Dada)(9m):
Smiles at mirror images(6m): Two words speech(12m):
Stranger anxiety(8m): Sentences(24m):
e) Recent status:
Regression of milestones/school performances
TREATMENT HISTORY:
 CLINICAL EXAMINATION
GENERAL CONDITION: Consciousness: Look:
Posture: Build:
ANTHROPOMETRY:

Actual Expected Percentage

a) Weight (Kg) :
b) Height/Length (cm) :
c) Head of circumference (cm) :
d) Mid arm circumference (cm) :
e) Chest circumference (cm) :
f) Upper/Lower segment ratio :
VITAL SIGNS:
Temperature: Site…………………………………….. Degrees………………………………………..
Pulse: Site…………………. Rate……………… Rhythm……………….Character………………………..
Volume……………….. Symmetry…………………… Other pulses……………………………..
Respiration: Rate………………. Rhythm…………………… Type………………………………………….
Blood Pressure: Site…………………….. Posture……………………… mm Hg…………………………
HEAD TO TOE GENERAL EXAMINATION:
Pallor: Icterus: Clubbing:
Cyanosis: Lymphadenopathy:
Oedema- Face: Pedal: Presacral:
Head- Shape: Swelling: Structures: Fontanelle:
Xeropthalmia: Avitaminosis features: Koilonychia:
Facies: Ears: Nose: Throat:
Thyroid/Other midline swellings:
Deformities: Skin/Nails: Limbs:
Others:
 RESPIRATORY SYSTEM
Inspection: Shape of chest……………………………………………………………………………………..
Symmetry of chest……………………………………………………………………………….
Deformity of chest……………………………………………………………………………….
Harrison sulcus…………………………………………………………………………………….
Drooping of shoulder……………………………………………………………………………
Movements of chest wall with respiration……………………………………………
Crowding of ribs……………………………………………………………………………………
Flattening of Chest wall...……………………………………………………………………..
Widening of intercostal spaces…………………………………………………………….
Position of trachea-
Any visible pulsations-
Palpation:

Trachea position…………………………………………………………………………………..
Expansion of chest wall……………………….
Vocal fremitus……………………………………..
Tenderness of ribs…………………………………………
Percussion:
Resonance: Increased…………………………..
Decreased………………………
Impaired……………………….
Dull………………………………
Stony dull………………………..
Left second space anteriorly
Shifting dullness:
Auscultation:
Breathe sounds…………………………………. Vesicular………………………………….
Bronchial…………………………………………... Tubular……………………………………
Cavernous…………………………………………. Amphoric…………………………………
 Adventitious sounds:
Dry (Rhonchi)………………………………………………………
Moist (Rales) Fine……………………………………………….
Coarse…………………………………………..
Vocal Resonance:
Pleural Rub:
Whispering pectoriloquy:

Succussion splash:

CARDIOVASCULAR EXAMINATION:
Pulse: Rate:
Rhythm: Character:
Volume: Symmetry:
Delay: Peripheral Pulse:
Blood Pressure: Posture: Site:
Method: mm Hg:
Jugular Venous Pulse: Pressure: Pulsation:
Inspection: Precordial bulging/ Deformities:
Any visible pulsation:
Palpation: Apex beat:
Parasternal impulse (grade):
Palpable sounds: P2:
Thrill:
Percussion: Cardiac dullness:
Left 2nd Intercostal space:
Auscultation:
Mitral area: 1st sound: Intensity: Type:
3rd sound: Opening snap: Rub:
Murmurs: Phase: Character:
Grade: Conduction:
Radiation: Change with Posture:
Change with respiration:
Pulmonary area: 2nd sound (P2): Intensity: Split:
Murmurs: Click:
Aortic area: 2nd sound (A2): Intensity:
Murmurs: Click:
Tricuspid areas: 1st sound:
Murmurs: Gallop:
Left parasternal border:
Murmurs:
Others: Neck:
Back:
GASTROINTESTINAL SYSTEM EXAMINATION:
Oral cavity: Teeth: Gum:
Mucosa: Hygiene:
Tongue: Others:
Abdomen:
Inspection: Shape: Swelling:
Movement: Umbilicus:
Peristalsis: Venous Engorgement:
Scars: Pigmentation:
Any visible pulsation:
Hernial Orifice:
Palpation: Feel: Tenderness:
Liver: Size: Surface:
Margin: Consistency:
Tenderness: Movement:
Span:
Spleen: Size: Surface:
Margin: Consistency:
Tenderness:
Kidney: Palpability:

Ballotability: Surface: Consistency:

Tenderness: Renal
angle: Any other mass:
Hernial sites: Genital sites:
Percussion: Fluid thrill: Shifting dullness:
Paddle sign: Note over mass:
Auscultation:Bowel sounds: Bruits:

CENTRAL NERVOUS SYSTEM EXAMINATION:

Higher functions:
Consciousness: Orientation:
Speech: Memory:
Intelligence: Emotions:
Sleep: Gait:
Handedness:
Appearance:
Behaviour:
 Cranial Nerves Left Right
First-

Second-
Acuity of vision:
Colour vision:
Field of vision:
Fundoscopy:
Third/Fourth/Sixth-
Pupil size:
Pupil reaction:
Ocular movement:
Fifth-
Ophthalmic:
Maxillary:
Mandibular:
Motor(5th)-
Muscles of
Mastication:
Temporalis:
Jaw
Movement:
Seventh:
Wrinkling of forehead:
Eye Closure (Spontaneous):
Eye closure(against resistance):
Nasolabial fold:
Angle of mouth:
Whistling:
Taste (Ant. 2/3rd tongue):
Others:
Eighth-
Hearing test:
Calory test:
Nineth-
Taste Post. 1/3rd
tongue:
Gag reflex:
Vagus-
Gag reflex:
Eleventh-
Sternomastoid:
Trapezius:
Twelfth-
Tongue movement:
 Left Right
Deviation of tongue:
Motor system
1. Bulk:
2. Tone:
3. Involuntary movement:
4. Power:
5. Reflexes(deep):
Jaw jerk
Biceps jerk:
Supinator jerk:
Knee jerk:
Ankle jerk:
6. Reflexes (superficial):
Glabellar tap:
Conjuctival:
Abdominal:
Cremasteric:
Scapular:
Anal:
Bulbocavernosus:
Plantar:
7. Co-ordination:
Finger nose test:
Adiadochokinesia:
Heel knee test:
Others:
SENSORY SYSTEM:
Special sensation:
Fine touch: Pressure:
Temperature: Pain:
Deep sensation:
Position: Vibration:
Joint sensation:
Cortical sensation:
Tactile localisation: Tactile discrimination:
Stereognosis: Sensory in attention:
Graphaesthesia:
Abnormal sensation:

Signs of meningeal irritation:

Neck rigidity: Kernig’s sign:
Brudzniski(leg): Brudzniski(neck):
Tripod sign: Others:
Skull & Spine:
Deformities: Tenderness:
Cerebellar sign:
Autonomic function:
Change of pulse rate with respiration: Sphincter control:
Change of blood pressure with posture: Sweating:
Skin temperature change: Others:

LOCOMOTOR SYSTEM EXAMINATION:

Bones: Swellings: Deformity: Tenderness:
Joints: Swellings: Tenderness: Effusion:
Movement: Deformities:

CASE SUMMARY:
PROVISIONAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS
Differential diagnosis Points in favour Points against

INVESTIGATIONS:
FINAL DIAGNOSIS:

TREATMENT:

OUTCOME/ FOLLOW-UP: