①

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
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 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

5. Past Medical History (PMHx)

a. Previous admissions; number, time, cause
b. History of trauma/surgical intervention; number, reason, when
c. History of blood transfusions; number, reason, when
d. Medications; what (herbal medication), route, duration, compliance
e. Allergies; food/drugs
f. Obs/Gyn Hx; in girls
i. Age at Menarche
ii. LNMP
iii. Duration of menstrual cycle
iv. Duration, amt of bleeding menstrual periods
g. Chronic illnesses; DM, HTN, TB, SCD

Antenatal History; health of mother during pregnancy

a. ANC (antenatal clinic); date of first visit at ANC, age of pregnancy at first visit to ANC,
frequency of attendance
b. Illnesses during pregnancy; febrile?, vomiting?, bleeding?, complications?
c. Any tests during pregnancy; (PITC?, VDRL?), when?, repeated later?
d. Medication use during pregnancy (which?, duration?), radiation exposure

Natal History; all events during childbirth and delivery

a. Duration of pregnancy; pre-term (<37wks), term (38-42 wks), post-term (>42 wks)
b. Duration of labour (normal is <8hrs)
c. Type of birth; SVD/C-section; if so, why?
d. Birth-weight; (normal: 2.5-3.5kg, low: 1.5-2.5kg, very low: 1.5-1.0kg, extremely low <1.0kg)
(At 6/12: x2bwt, at 1year: x3 bwt, at 2years: x4 bwt)
e. State of neonate at birth; any problems during newborn period; jaundice?,
breathing problems?, feeding difficulties?
f. Resuscitation; required? , how long resuscitated?
g. Onset of first cry
h. Place of delivery

Neonatal History; regards all events up to 1/12 after delivery

a. Serious illnesses after birth; congenital malformations?, pallor?, jaundice?, convulsions ?,
b. Difficulty in sucking, feeding difficulties?, weight loss?
c. Rashes TORCHES; Toxoplasma, Other (Plasmodia, Listeria,
Gonococci, Chlamydia, Candida), Rubella, Cytomegalovirus,
HErpes simplex & varicella zoster, HIV, HBV, Human
parvovirus B19, Human T-lymphotropic virus, Syphilis
6. Immunisation History; according to the national Immunisation and Vaccines Development (IVD) schedule
The previous immunisation schedule (Expanded programme of immunisation: EPI) was launched in December 2012,
launching additional vaccines Rotarix (rotavirus vaccine) and PCV-13 (Pneumococcal conjugate vaccine, 13 most
common serotypes).
The current schedule (Immunisation and Vaccines Development: IVD) scheme was introduced 2014 – whereby the booster
measles dose was added at 18 months.

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 ③
a. Day 0:
i. Oral Polio Vaccine (OPV)0; given as PO drops
ii. Bacille Calmette-Guerin (BCG); given on Rt shoulder SubQ, leaves a mark.
If not given at birth, give as soon as the baby presents to hospital
b. Week 6: (2 oral vaccines + 2 IM injections)
i. Oral Polio Vaccine (OPV)1; given as PO drops
ii. Pentavalent Vaccine1; given on Lt shoulder IM. Consists of 5 components
DPT (diphtheria, pertussis, tetanus)
HiB (Haemophilus influenzae-B)
HBV (Hepatitis B)
iii. PCV-131; given on Rt thigh IM
iv. Rotarix1; given as PO drops
c. Week 10: (2 oral vaccines + 2 IM injections)
i. Oral Polio Vaccine (OPV)2; given as PO drops
ii. Pentavalent Vaccine2; given on Lt shoulder IM
iii. PCV-132; given on Rt thigh IM
iv. Rotarix2; given as PO drops
d. Week 14:
i. Oral Polio Vaccine (OPV)3; given as PO drops
ii. Pentavalent Vaccine3; given on Lt shoulder IM
iii. PCV-133; given on Rt thigh IM
e. Month 9:
i. Measles Vaccine; given on Lt shoulder IM
ii. Vitamin A; then every 6 months for 5 years (often Jun, Dec of every year)
f. Month 18:
i. Measles Booster; (also contains rubella) given on Lt shoulder IM?
(vitamin A, albendazole every 6 months)

7. Dietary History: (conclude about adequacy of quantity & quality)

a. Breast-feeding; (recommended for 6/12 – >2years)
i. Duration; exclusive breastfeeding (strictly breast milk only: atleast 6/12 )/
mixed breastfeeding (breast + bottle feeding <6/12).
ii. Problems; ↓suckling?, ↓maternal milk?
iii. Formula; type, duration, major formula changes
b. Weaning; complementary food (↓breast , ↑bottle feeding, other sources >6/12),
what age?, type of food given?,
c. Current diet; what? amount ?, no. of meals per day?
feeding habit: themselves?/ sharing(with whom)?

8. Developmental History; (chronologic history of developmental milestones)

a. Status: Normal for age/delayed for age/ regressed (backward progress) for age

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/

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 using phrases/ speaks 3-word sentences/ counts to 10 ④
e. Behaviour & Social Skills; smiles spontaneously/ recognises mother/ finger or object feeds/
drinks from cup/ takes-off clothes/ clean and dry but occasional accidents/ brushes teeth,
washes hands/ co-operative play

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

9. Family Social History (FSHx)

a. Primary care-taker; (who the child lives with)
b. Who takes care of the child when the mother is away
c. Occupation, age of parents
b. Number of siblings; sex?, alive?, well?
c. Home; water source (boiled water?), toilets?, insecticide-treated nets?, ventilation?
d. Chronic familial illnesses; DM, HTN, SCD, haemophilia, thalassemia, heart problems

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)

i. Anterior fontanel; (closes at 9 –18 months max

If still open: if bulging = ↑ICP, if depressed = dehydration)
ii. Posterior fontanel; (closes at 2 –3 months)
f. Face;
i. Shape: normal/ ‘moon’-shaped (kwashiorkor: generalised oedema)/
‘old-man’s face (marasmus: loss of subcutaneous fat)
ii. Abnormalities; forehead, epicanthic folds?, ears (small?), upward sweeping
palpebral fissures?, nasal bridge?
g. Eyes;
i. Position: (straight/ slanted)
ii. Obvious discharge; (single/both eye(s), amount, colour, smell, texture)
iii. Normal/ sunken
iv. Scleral jaundice?
v. Conjunctival pallor: mild/ moderate/ severe (less accurate in younger children)
vi. Cataract? (associated with TORCHES)
vii. Features of vitamin A deficiency: Bitot spots?, keratomalacia?, xerophthalmia?
h. Nose; obvious discharge, shape, position, abnormality
i. Mouth;
i. Angular cheilosis (stomatitis)? (iron, vitamin B deficiency)
ii. Cyanosis; of lips (inaccurate when child is crying/active)
iii. Dry, cracked lips?
iv. Tongue; (atrophic) glossitis?, rash?, hairy leukoplakia?
v. Oral cavity; thrush?, cleft-palate?
vi. Inflammation (reddening, swelling) of throat?, tonsillitis?
j. Ear; setting (normally set/ low-set), obvious discharge (otoscope: tympanic memb. exam)
k. Neck; size (normal/ shorter/ longer), webbing?, masses?, lymph nodes?
l. Extremities; skin texture, warm/ cold, dry/sweaty, capillary refill (<3 seconds), clubbing,
splinter haemorrhages, palmar creases, palmar pallor?, syndactyly? (fusion of ≥2 digits) ±
polydactyly (6 toes on one foot/hand)?, clinodactyly? (turning of digits)
m. Oedema; pitting/non-pitting, location (pedal/ pre-tibial/ sacral/ anasarca)
n. Superficial lymph node enlargement

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 i. Site, Size ⑤
ii. Discrete (solitary) /matted (joined)
iii. Tenderness
iv. Surface, edge, consistency (hard/s oft/rubbery, irregular/regular,
nodular/smooth, round)
v. Mobility (usually mobile)
o. Back; normal/kyphosis? (forward bending)/ scoliosis? (lateral bending) /kyphoscoliosis?
p. Dehydration status; none/some/severe (impairment of ≥2 of the following)
i. Level of consciousness: alert/ irritable/ lethargic
ii. Eyes: normal/sunken
iii. Drinking ability: normally/ eagerly/ unable to
(test: give ORS with water, even to children <6 months)
iv. Skin turgor; normal/ skin pinch goes back slow (<2 secs)/
skin pinch goes back very slow (>2 secs).
(pinch anterior abdomen skin laterally right to umbilicus)
11. Anthropometric Measurements;
a. Body weight; on admission, current
b. Height (≥2 years, can stand unsupported)
Length (<2 years, or ≥2 years but can’t stand unsupported)
(2 ppl needed to accurately measure: in exam, request examiner to help!)
c. Head circumference (<3 years); (>3SD= hydrocephalus)
d. Mid-upper arm circumference (MUAC); (>6 months, measure of wasting)
i. 6-59 months: >11.5 cm
ii. 5- 9 years: >13.5 cm
iii. 10-14years: >16.0 cm
N.B: WFL; is a measure of acute wasting in children <2 years of age
WFH; is a measure of acute wasting in children 2-5 years of age
WFA; is a measure of being underweight for children <5 years
BMI-for-age; is a measure of being underweight for children >5 years

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

13. Systemic Exam Alert

a. Central Nervous System: Response to voice (lethargic)
i. Higher Centres Response to pain (obtunded)
1) Mental State Unconscious
2) Level of Consciousness; AVPU/ GCS/ Blantyre
Glasgow Coma Scale Blantyre Coma Scale
Paediatric Scale Infant Scale (Less than 2 years)
Eye Opening Eye Movement
4 Spontaneously Spontaneously 1 Follows eye movement
3 To voice To voice 0 Fails to follow eye movement
2 To pain To pain
1 None None
Best Verbal Best Verbal Response to Pain
5 Oriented Coos and babbles 2 Appropriate cry
4 Confused speech Irritable cries 1 Moan/abnormal cry
3 Inappropriate response Cries to pain 0 No vocal response
2 Incomprehensible sound Moans to pain
1 None None
Best Motor Best Motor Response to Pain
6 Obeys command Spontaneous movement 2 Localises pain
5 Localises to pain Withdraws from touch 1 Withdraws from pain
4 Withdraws from pain Withdraws from pain 0 No response
3 Flexes to pain Abnormal flexion
2 Extends to pain Abnormal extension
1 None None

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 3) Orientation (person, place, time) ⑥
4) Speech
5) Memory (short-term and long-term)
ii. Cranial Nerves

Cranial Nerve Newborns & Infants Early & Late Childhood

I (Olfactory) Difficult to test Testable in older children. Observe grimacing
when a pungent odour is brought under
nostril
II (Optic) Have baby regard your face and look for facial Use snellen chart after 3 years
response, tracking Test visual fields (parent may need to hold
Also use light to test for optic blink reflex child’s head)
(blinking in response to light). Use
ophthalmoscope to assess papillary response
III, IV, VI Observe tracking as the baby regards your Have child track light/object/toy (parent may
(Oculomotor, smiling face move side-to-side. Use light if need to hold child’s head)
Trochlear, Abducens) needed
V Rooting reflex, sucking reflex (breast, pacifier) Sense: test sensation by moving soft cotton
(trigeminal) ball
Motor: have the child clench teeth,
chew/swallow food.
VII Observe crying, smiling and note symmetry of Have the child make ‘faces’/imitate you and
(facial) forehead, face, nasolabial folds observe symmetry and facial movements
VIII Test acoustic blink reflex (blinking of both Perform auditory testing after 4 years
(vestibulocochlear) eyes to a loud noise) Whisper a word/command behind the child’s
Observe tracking in response to sound back and have the child repeat it
IX, X Observe co-ordination during swallowing Have the child say ‘ah’. Observe movement of
(glossopharyngeal, Test for gag reflex uvula, soft palate
vagus) Test gag reflex
XI Observe symmetry of shoulders Have child push your hand away with his
(accessory) head, have the child shrug his shoulders while
your hands to ‘see how strong you are’
XII Observe co-ordination of swallowing, sucking, Ask the children to ‘stick out your tongue all
(hypoglossal) tongue thrusting the way’
Pinch nostrils, observe reflex opening of Note any wasting, fasciculation, tremors of
mouth with tip of tongue to midline tongue

iii. Meningeal Signs

1) Neck stiffness
2) Kernig's sign
3) Brudzinski's sign
iv. Motor/Reflexes;
1) Bulk: (normal/wasted)
2) Tone: (normal/increased/decreased/rigid/spastic)
3) Power: (grade 0 - 5)
a) Upper limbs
b) Lower limbs
4) Reflexes:
Superficial; (present/absent)
a) Pupillary Light Reflex; (CN II, III) observe direct and consensual
constriction of pupils as light is shone into eye(s).
b) Occulocephalic Reflex; (CN III, VI, VIII) movement of the eyes in an
opposite direction to head movement.
c) Corneal Reflex; (CN V, VII) blinking of eyes on contact with cotton
d) Gag Reflex; (CN IX, X) gag/choking induced as tongue is depressed
using tongue spatula.
e) Apnoea Reflex; for a ventilated patient, switching-off ventilator
evokes a gasping response.
f) Abdominal Reflex; stroke abdomen gently from flanks → inward.
Observe the contraction of the abdominal muscles resulting in
deviation of umbilicus towards the area stimulated.
g) Cremasteric Reflex; stroking inner aspect of thigh causes reflex
contraction of scrotum on the same side
h) Anal Reflex; reflexive contraction of the external anal sphincter
upon stroking of the skin around the anus

HOODA, Faisal Hasnain

 i) Babinski Reflex; (down-going/up-going/equivocal) ⑦
Deep; (grade 0-4)
a) Biceps (C5, C6)
b) Brachioradialis (C5, C6)
c) Triceps (C6, C7)
d) Finger (C8)
e) Adductor (L2, L3)
f) Knee (L3, L4)
g) Ankle (S1)
5) Sensory System;
a) Pin-prick
b) Temperature
c) Light touch
d) Vibration sense
e) Joint position sense
f) 2-point discrimination
v. Co-ordination, Gait & Balance;
1) Co-ordination:
a) Finger-to-nose
b) Rapid alternating movement of the hand
c) Heel-shin test
2) Gait
3) Balance/Stance
a. Cardiovascular System; (inverted J)
i. Hand/palm;
1) Warmth of extremities
2) Cyanosis: at rest? (check nail-bed, circumorally, tongue)
3) Digital (finger/toe) clubbing
4) Capillary refill (<3 secs)
5) Signs of Infective endocarditis; (dermal infarcts, Janeway lesions :painless
haemorrhagic cutaneous lesions on the palms and soles, Osler's nodes:
painful subcutaneous lesions in the distal fingers, Roth's spots: on the retina)
6) Arterial Pulses;
a) Radial
b) Brachial
c) Carotid
d) Femoral
e) Popliteal
f) Pedal (dorsalis pedis)
g) Middle maleolar
a) Rate: bpm
b) Rhythm: (regularly regular/ regularly irregular/irregularly irregular)
c) Character: (good/poor volume)
d) Synchronicity: with contralateral limb

ii. Arm; blood pressure

iii. Neck;
1) Jugular Venous Pressure: (normally <4cm)
2) Hepatojugular reflux
iv. Precordium;
1) Inspection
a) Traditional marks/surgical scars
b) Precordial bulging (protrusion of the chest around heart)
c) Precordial hyperactivity
d) Difficulty in breathing (easy fatigability, pausing often during
breastfeeding, sweating during feeding, inability to suckle)
2) Palpation
a) Thrills (palpable murmurs in all 4 areas of auscultation)
b) Heaves (indicative of chamber enlargement:
Apical/ Rt parasternal/ Lt parasternal)
c) Apex beat (<5 yrs: 4th ICS lateral to lt. MCL)
(>5 yrs: 5th ICS along lt MCL)

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 3) Auscultation: (4 areas of auscultation. apex area: mitral area, lower left
⑧
sternal edge: tricuspid area, upper left sternal edge: pulmonary area,
upper right sternal edge: aortic area)
a) Heart Sounds
a) S1, S2
b) Extra heart sounds (gallop rhythm: S3/S4)
c) Murmurs
One. Loudness; grade (1-6)
Two. Quality; pitch(low/medium/high)
Three. Location; best heard at
(aortic/pulmonary/tricuspid/mitral) area
Four. Timing; (systolic/diastolic/ continuous)
v. Other areas (report only if necessary)
1) Lungs; bibasilar crackles (≡pulmonary oedema)
2) Liver; enlarged, tender, hepatojugular reflux (≡hepatic congestion)
3) Oedema; pitting/non-pitting (periorbital, lower limb)
b. Respiratory System;
i. On inspection;
1) Respiratory rate
a) Rate (breaths per minute, dyspnoeic)
b) Rhythm (regular/ irregular)
2) Respiratory distress; nasal flaring, mouth-breathing, use of
accessory muscles of respiration, head-nodding
3) Skin; (scars/lesions/lumps)
4) Spine; (normal/kyphosis/scoliosis)
5) Ribcage: (normal/barrel-shaped/ pigeon-chest /sunken-chest)
6) Movement
a) Expansion
b) Symmetrical movement:
c) Intercostal recessions
d) Lower chest wall in-drawing
ii. On palpation;
1) Lymph node enlargement:
2) Swelling/tenderness
3) Position of trachea (deviated/centrally-located)
4) Asymmetry during chest expansion
5) Tactile vocal fremitus (normal/ increased /reduced)
iii. On percussion;
1) Resonance; (normal/ increased /reduced)
iv. On auscultation;
1) Breath sounds
a) Intensity; (normal/loud/diminished)
b) Quality; (vesicular/bronchial/bronchovesicular)
c) Added breath sounds; (wheezes, crackles, stridor, pleural rub)
2) Vocal resonance; (increased/normal/reduced)
c. Per Abdomen;
i. On inspection
1) Shape; (scaphoid/ flat/distended: generalized/local, symmetric/asymmetric
or sunken)
2) Umbilicus (inverted/everted)
3) Movement of abdominal wall; (diminished, aortic pulsation, peristalsis)
4) Skin; (scars, stretch marks/shininess)
5) Veins; (caput medusae)
ii. On palpation
1) Superficial: tenderness?
2) Deep: tenderness?
a) Left kidney
b) Spleen; (palpable, span below costal margin)
c) Right kidney
d) Liver;
i) Span
ii) Surface; (soft/firm/hard, regular/irregular,
tender/non-tender, nodular/smooth)

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 ⑨
e) Gallbladder (murphy’s sign?)
f) Urinary bladder
g) Aorta
h) Rectus abdominis muscle
i) Abdominal mass(es)
i) Site
ii) Size & shape
iii) Surface, edge, consistency (hard/soft, irregular/regular,
nodular/smooth, round, tender/non-tender)
iv) Mobility
v) Pulsation
j) Guarding / rebound tenderness
iii. On percussion; tympanic note/dullness
1) Liver; span
2) Spleen; span
3) Urinary Bladder
4) Other masses
5) Ascites; chest-knee position dullness/ shifting dullness/ fluid thrill
iv. On auscultation;
1) Bowel sounds
2) Vascular bruits
14. Summary :

15. Provisional Diagnosis & Differentials:

a.
Rule out:
b.
Rule out:

16. Investigations:
a.
b.

17. Management:
a. Non-pharmacologic

b. Pharmacologic

18. Prognosis:
a.
b.

19. Follow-up & Other Remarks:

a.
b.

20. Prevention:
a.
b.

HOODA, Faisal Hasnain