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    Pediatric Caseheet PDF

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    Aparna Devi
    This document contains a paediatric case sheet template that collects information about a child's medical history, including their chief complaints, history of present illness, past medical history, antenatal history, natal history, postnatal history, immunization history, family history, socioeconomic history, physical examination findings organized by body system, differential diagnosis, recommended investigations, treatment, and plans for follow up. The case sheet guides the clinician to gather comprehensive clinical information to evaluate and manage the child's health issues.

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    Pediatric Caseheet PDF

    Uploaded by

    Aparna Devi
    91 views23 pages
    This document contains a paediatric case sheet template that collects information about a child's medical history, including their chief complaints, history of present illness, past medical history, antenatal history, natal history, postnatal history, immunization history, family history, socioeconomic history, physical examination findings organized by body system, differential diagnosis, recommended investigations, treatment, and plans for follow up. The case sheet guides the clinician to gather comprehensive clinical information to evaluate and manage the child's health issues.

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    Pediatric-Caseheet.pdf

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    This document contains a paediatric case sheet template that collects information about a child's medical history, including their chief complaints, history of present illness, past medical history, antenatal history, natal history, postnatal history, immunization history, family history, socioeconomic history, physical examination findings organized by body system, differential diagnosis, recommended investigations, treatment, and plans for follow up. The case sheet guides the clinician to gather comprehensive clinical information to evaluate and manage the child's health issues.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    91 views23 pages

    Pediatric Caseheet PDF

    Uploaded by

    Aparna Devi
    This document contains a paediatric case sheet template that collects information about a child's medical history, including their chief complaints, history of present illness, past medical history, antenatal history, natal history, postnatal history, immunization history, family history, socioeconomic history, physical examination findings organized by body system, differential diagnosis, recommended investigations, treatment, and plans for follow up. The case sheet guides the clinician to gather comprehensive clinical information to evaluate and manage the child's health issues.

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    PAEDIATRIC CASE SHEET

    1
    PAEDIATRIC CASE SHEET

    Name:                           Age:                   Sex:
    Address :
    Date of admission:      Date of examination:   
    Informant:                    Reliability:   

    Chief complaints:
    1.                                     2.
    3.                                     4.

    2
    PAEDIATRIC CASE SHEET

    History of present illness:

    Past history:

    Antenatal history:

    Natal history:

    Postnatal history:

    3
    PAEDIATRIC CASE SHEET

    AGE  GM FM Social  Language  Vision  Hearing 

    Inference 

    4
    DIETETIC HISTORY

    • Exclusive BF & Complementary feeding
    • 24 hr dietary recall
                                             Calories                       Protein
    • Total:
    • Expected (ICMR):                                                     
    • Inference:
    • Dietary restriction :
    • Dietary advice :

    5
    IMMUNIZATION HISTORY

    • National schedule 

    • BCG scar

    • Optional vaccine 

    • AEFI

    • Advise on further vaccination 

    6
     Family history
    • Pedigree chart
    • Hereditary illnesses 
     Socio‐economic history:
    • Socio economic class 
    • Indoor and outdoor  pollution  
    • Sanitation 

    7
     General appearance:

     Vital signs:   Temp:                   PR:
                               RR:                       BP:
                               CRT                      SPO2

     General physical examination:
    PICCLE 

    8
    ANTHROPOMETRY
                                                                  
    Actual           Expected        Inference 
    Weight 

    Height 

    Weight for height

    Head circumference

    Chest circumference

    Mid arm circumference

    Upper segment/ lower segment ratio
    9
    HEAD TO FOOT  EXAMINATION

    Head
    Face
    Eyes
    Ears
    Nose
    Mouth & oral cavity
    Neck 
    Chest
    Abdomen
    External genitalia
    Skin
    Extremities
    Back & spine
    SMR stage (if required) 
    Developmental age assessment(if required):

    10
    SYSTEMIC EXAMINATION‐RESPIRATORY SYSTEM
    •  Upper RT: 
    • Lower RT:
    •Inspection
    Flaring of nose:                      trachea:                    Shape of chest:
    Accessory muscles:                                                  Chest wall retraction:
    Movement of chest:                                                 Apex beat:
    Bony cage:
    •Palpation:
    To confirm inspection  findings:                      Tenderness:
    Tactile vocal fremitus:                                       Friction rub:
    •Percussion: 
    •Auscultation:
     Breath sounds 
    Adventitious sounds                                       
     Vocal resonance
    11
     CARDIO VASCULAR SYSTEM
    • Inspection:
          Pulse:                       BP:                        JVP:
          Precordium:            Apex beat:           Pulsations:
    • Palpation 
          Confirm inspectory findings:              Apex beat:                                 
    Heart sounds:
          Parasternal heave:                                        Epigastric 
    pulsation :          Thrill:
    • Percussion:
    • Auscultation:
         Heart sounds:        Added sounds:                      
    Murmurs:

    12
    GIT EXAMINATION 

     Upper GIT :
     Per abdomen:
    • Inspection:
    Shape:                                Movement: 
    Visible peristalsis:             Pulsation/veins:
    Hernial orifices:                 Ext. genitalia:
    • Palpation: 
    Confirm inspection findings
    Tender:                    Liver:                     Spleen:
    Kidneys:                  Bladder:                Any other mass:
    Renal angle:           Ext. genitalia:

    13
    GIT EXAMINATION 
     Percussion:

    Liver span:                          Shifting dullness:

    Fluid thrill:

     Auscultation: 

     BS 

    Bruit 

     Rectal examination(if required):
    14
    CENTRAL SYSTEM EXAMINATION

    Higher mental function:

    Conscious:               Orientation:        Emotional status:

    Memory:                  Speech:     

    Delusions/Hallucinations:

    15
    • Cranial nerve examination:                                          
                          Right                                 Left

    • Motor system:
                           Upper Limb                             Lower Limb
                      Right                   Left           Right                  Left
    Bulk 
    Tone 
    Power

    16
     Reflexes                         Right                              Left
    Superficial reflex
    Deep tendon reflex
    ‐Biceps
    ‐Triceps
    ‐Supinator
    ‐Knee jerk
    ‐Ankle jerk
    ‐Clonus 
    Primitive reflex (if required)

    17
     Abnormal movements:

    Tremor:                 Chorea:              Athetosis:

    Hemiballismus:                 Dystonia:

    Any other:

    18
     Sensory system:
                           Upper Limb                    Lower Limb
                            R                L                      R              L
    Touch 
    Pain
    Temperature
    Pressure  
    Position
    Vibration
    Cortical sensation

    19
    Cerebellar signs:
    Nystagmus:                   Speech:                Finger nose test:

    Dysdiadochokinesia:     Tremor:            Knee to heel test:        

    Romberg’s sign:          Tandem walking:                     Gait

    20
     Signs of meningeal irritation:
    • Neck rigidity:                                  
    • Kernig’s sign:
    • Brudzinski’s sign‐ neck/leg sign
     Skull &spine 
    • Mac Ewan’s sign
    • Cranial bruit/carotid bruit
    • Transillumination of skull
    • Tenderness over spine, gibbus, tuft of hair, 
    kyphoscoliosis

    21
    Differential diagnosis:

    Investigation:

    Treatment:

    Follow up:

    22
    THANK YOU 

    23

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