Paediatric Clerkship
Date:
1. ID: Name
a. Age; in days/weeks (if neonate; <1month); in months (if infant 1mth –12mths); in years
& months (if toddler 1yr–3 yrs); in years (if ≥5 years)
b. Sex (M/F)
c. Address
d. Birth; place, method of delivery (SVD / C-Section: if so, why?)
e. Informant (relation to child)
f. Self-referral from home/referred from hospital (+ reason for referral)
g. Known chronic illnesses (for how long) ± medication (regular/irregular) ± clinic attendance
(regular/irregular)
h. If IDS (for how long, baseline CD4 count & current CD4 count, ART regimen?, TMP-SXT
prophylaxis?)
j. Ask for any documentation (e.g. discharge summaries, CTC card)/medication that the relative
has with them
k. When the patient admitted
History:
2. Chief Complaint (C/C)
a. SOCRATES; Site, Onset, Character, Radiation,
b. Associated factors, Timing (duration, periodicity,
frequency), Exacerbating/alleviating factors, Severity
3. History of Presenting Illness (HPI)
a. DOPPARA; Duration, Onset, Periodicity, Progression,
b. Associated factors, Relieving factors, Aggravating
factors
4. Review of Systems (ROS)
a. HEENT; Head, ears, eyes, nose and throat
i. Pain
ii. Bleeding
iii. Lumps
iv. Discharge
v. Sneezing
vi. Mouth breathing
vii. Snoring
b. Central Nervous System
i. Fever
ii. Loss of consciousness (LOC)
iii. Seizures/Collapse /blackouts/dizziness/loss of balance
iv. Headache
v. Problems in vision/hearing
vi. Tingling (paraesthesiae)
vii. Spasms and involuntary movements
c. Cardiovascular System
i. Awareness of heartbeat (palpitations)
ii. Shortness of breath (SOB, dyspnoea)
iii. Difficulty in breathing on lying flat (orthopnoea)
iv. 'Air-hunger' at night (paroxysmal nocturnal dyspnoea, PND)
v. Lower limb, ankle swelling/facial puffiness
vi. History of bluish discolouration? (cyanosis)
d. Respiratory System
i. Chest pain
ii. Difficulty in breathing (rapid breathing?, mouth-breathing?)
iii. Nasal discharge? (rhinorrhoea), Ear discharge (otorrhoea?)
iv. Cough ± sputum
v. Haemoptysis
e. Gastrointestinal
i. Abdominal pain
ii. 'Heart-burn' (dyspepsia)
iii. Difficulty swallowing (dysphagia); of solids ± liquids?
iv. Painful swallowing (odynophagia); of solids ± liquids?
v. Nausea ± vomiting
vi. Change in appetite
HOODA, Faisal Hasnain
②
vii. Weight loss / gain
viii. Bowel pattern and any change; constipation, diarrhoea
ix. Bloody stools; streaks/gross blood, fresh/digested
x. History of yellowish discolouration (jaundice)?
f. Genitourinary System
i. Painful urination (dysuria)
ii. Blood in urine/bloody urine (haematuria)
iii. Waking up to urinate at night (nocturia)
iv. Frequency
g. Musculoskeletal System
i. Weakness
ii. Pain in limbs and back
iii. Joint pain/stiffness/swelling
h. Haematopoietic System
i. Easy bruising
ii. Bleeding tendencies
b. Gross motor; prone, lifts head clear of ground/ sits with support/ sits on own/ crawling/ walks
alone/hops/skips
c. Fine Motor & Vision; looks at toy mid-line/watches hands, tries grasping objects/ transfers
objects from hand to hand/ building a tower of cubes/ copies drawn shapes
d. Hearing & Speech; Vocalises with gurgles/ turns head to sound, vocalises appropriately/
says small words/ 1 meaningful word/ 2-3 meaningful words/ joining 2 words together/
N.B: 1 year: single words, walks | 2 years: 2 word sentences, understands 2-step commands|3 years:
3 word combos, repeats 3 digits, rides tricycle (3 wheels)| 4 years: draws square (4 sides), counts 4 objects
Physical Exam
10. General Exam
a. Consciousness; alertness/ lethargic/ irritable/ unconscious
b. Orientation to people, place and time
c. Physique & nutrition (obesity/wasting/abnormal fat distribution)
d. Hair; colour, distribution (normal/sparse), texture (soft, silky/ coarse, dry)
e. Head; size? (normal/ microcephaly/ macrocephaly), shape? (normal/abnormal)
12. Vitals;
a. Temperature: °C
b. Pulse;
i. Rate: beats per minute
ii. Rhythm: (regularly regular, regularly irregular, irregularly irregular)
iii. Synchronicity; (synchronised/de-synchronised) with (contralateral limb/femoral pulse)
c. Respiratory rate; breaths per minute
d. Blood pressure; mmHg (sitting, standing, MAP =1/3 SBP + 2/3DBP)
e. O2 saturation; % in room air/ x lts of O2
16. Investigations:
a.
b.
17. Management:
a. Non-pharmacologic
b. Pharmacologic
18. Prognosis:
a.
b.
20. Prevention:
a.
b.