Case Recording Format

Department of Pediatrics.

1. Name , Age, Sex, Address, Phone no. Bed No. Regd. No. Date of Admission:

2. Chief complaints with durations

a.

b.

c.

3. History of present illness:

4. Past history:- Measles / Pertussis / ARI / AGE / Seizures / Contact with PTB / Allergy / Dog bite / ARV /
Similar attack / Hospitalization / Blood transfusion.
5. Perinatal history (under 5 children, especially infants )
Antenatal (Maternal diseases…………………../ Medications……………………………/ TT/Td………….)
Intra-natal (Place & mode of delivery)
Post-natal (First cry, birth asphyxia, jaundice, birth weight, any other illness, prelacteal feeds,
Breastfeeding/ Top feeding).
6. Development history:
Social smile-----------Head control------Rolling over------Sitting-------Standing--------------
Walking------
Speech-----------------Bladder control-------- Self feeding & dressing--------academic
performance------

7. Family&sibling history:-consanguineous marriage/similar illness/Allergy/Chronic illness/TB/

seizure disorder/BT/sibling death/ unexpected death in the family.

8. Medication history:

9. Social history:- S.E class, Nuclear / joint family, Working mother, Overcrowding, Sanitation & personal
hygiene, Passive smoking, Mosquito coils, Talcum powder, pets ( Animals & Birds )

10. Nutrition history:- Breastfeeding ( onset & total duration of exclusive breastfeeding-----months)
Prelacteal feed/ Top feed. Time of weaning………….. months.
Daily calorie & protein intake (24 hours recall) – Actual / Expected……………….

11. Immunization history:- BCG/ OPV / IPV / DPT / HB/ Hib / Rota / Measles /MR/MMR/ Typhoid / DT/ TT. BCG
scar- present/ absent. Fully immunized/ Partially immunized / Unimmunized.
12. General physical examination:-
Vitals : Pulse ………………..Temp………….BP…………….RR…………………SpO2……………..CRT…………….
JVP…………….
Anthropometry – Height/ Length……………….Wt…………………..Wt/Ht………………(Z score )
HC…………..CC………………Visible severe wasting- present/absent.
MUAC……………. Span length………………..US/ LS Ratio………………………BMI…………………….
Nutritional Status: Normal/MAM/SAM (Severe Acute Malnutrition)
Pallor / lcterus/ Cyanosis/ Clubbing/ Lymphadenopathy/ Edema
Thyroid swelling/ Skin condition/ Facial dysmorphism/ Eyes- Xerosis / Conjunctivitis/ Bitot’s spots/
Cataract

13. Systemic examination:-

A. CVS:- Pulse…………………….BP……………… JVP—Normal/raised; Pulsatile/non-pulsatile
Precordium……………….Apex beat……………………Parasternal heave / thrill. Cardiac dullness
extending beyond
Apex-Yes/ No. PercussionofLt.2nd ICS- resonant/dull. Heart sounds/ Murmurs/ Rubs in Mitral
Area…………………..Pulmonary area………………………Aortic Area………………………..2nd Aortic
area……………………..Tricuspid area
B. Respiratory system:-RR……………………Chest in
drawing…………………….Trachea………………………..Chest
Expansion ………cm. Percussion note…………………………..Breath sounds & added
sounds…………………………………..
VF & VR------------------------Coin test / Succussion splash……………………..Intercostal tenderness-
present/absent.
C. G.I System:- Oral Cavity ( Teeth & Gum )……………………..Abdomen-Umblicus/ Visible Peristalsis/
Visible
Veins, Rigidity/ Tenderness/ Rebound Tenderness/ Fluid Thrill/ Shifting dullness………………………
Liver…………………………Liver span……….cm, Spleen……………Renal angles……………....Kidneys: ballotable/
not
Any other mass…………Bowel Sounds………………Hernial Orifices……………………….
D. Genito-Urinary System:- Phimosis (in boys)…………………./Testes…………….Bladder……………/
Renal Lump……………….
E. Nervous System:- Higher Functions- Consiousness, Handedness (after 3 Yrs), Attitude,
Intelligence, Memory, Emotions, Delusion, illusion, Hallucination, Sleep, Speech & Gait.
Cranial Nerves:- CN I. Sense of smell………………..CN II-Acuity & field of vision, accommodation
Light reflex (Direct & consensual )…………………Fundoscopy……………………………
CN III. IV & VI-Movements of eye ball…………………Squint……………………CN V-Sensation over face,
Muscles of mastication CN VII- Muscles of facial expression:-
CN - VIII. Hearing, tinnitus, vertigo. CN IX, X, XI. Position of uvula, Palatal reflex & pharyngeal reflex.
CN XII. Position of tongue/ Tremor/ Fasciculation/ Atrophy.
Motor system: Bulk ………………… Tone ………………… Power …………………… in each group of
muscles
Deep Jerks: Ankle Knee Biceps Triceps Supinator Jaw ( N/brisk)
 Superficial reflexes:- Corneal, Cremasteric, Abdominal, Babinski sign ( Plantar ) –Flexor/
extensor
Co-ordination-------- Involuntary movements:

Cerebellar signs:-Tremor/Ataxia/Nystagmus.
Sensory system:- Pain/Temp./Touch……………………………Vibration / Position…………………………………
Topognosis/ Stereognosis …………………Sensory Level……………………….Skull & Spine: ………..
Fontanellae……………….. Macewen’s sign………. Signs of Meningeal irritation……………………
Gibbus/Kyphosis/ Scoliosis………….. Peripheral nerves: Thickening/ Tenderness
Autonomic Nervous System:
F. Musculoskeletal System:- Joints/ Muscles / Bones.

14. Summary of the case:-

15. Provisional diagnosis:-Points in favour Points lacking

16. Differential Diagnoses:- Points in favour Points against

1.

2.

3.

17. Investigations:-

18. Final Diagnosis:-

19. Treatment & Outcome:-

20.Days of hospital stay:

Food groups & Diet Audit

1.Cereals : Wheat, Rice, Jowar, Bajra, Maize, 2. Pulses (Legumes) : All types of Sprouts & Dal, Beans
potato & Nuts
Steam Rice/Khichadi/Pulav/Biryani etc Dal fry/ Tadka Dal
Roti /Bhakri Zunka ( Besan)
Puri/ Thepaia/ Paratha Usal (Sprouts)
Rawa: Sheera/ Upma Almonds, Walnut, Cashew etc

3. Vitamin A 4. Others Veg/ Fruits 5.Milk/ Dairy products

Veg: Drumsticks Leaves, Green Leafy Veg, Ripe Make variety daily Veg: Diary products:
Mango, Carrot, Orange, Papaya, Onion Stalks, Wild Cabbage, Cauliflower, white Paneer, Home made
yam, Cowpea pods, Pink Beans Giant Chillies, pumpkin, snake gourd, Giant butter, Ghee, Curd,
Tomato, Elephant yam, Kankoda, Rasberry chillies, Butter milk lasi,

6.Egg: Boiled egg Omlet, 7. Mutton, Chicken,

Burji Fish

8. Vitamin c 9. Iron 10. Vitami

nD
Amla, Drumstik, Leaves, Cashew fruit, Garden cress seeds, Lotus stem, shepu, Mustard Leaves, Sun light
Cabbage, Green Chillies, Tamrind, Bara Koli Mint, Betel Leaves, Green colocasis (Alu) and Mayalu, Bathua
Sweet Lime, Papaya, Strawberry, pineapple, leaves (Chandan Batwa), Amarnath, Palag, Jeggery, Dates
Custeredapple, dried, Cashew, Almond, Food cooked in Iron vessels
Litchi, Orange, Jamb, tomato, Muskemelon,
Date: Children’s Name
When food started What food How many Look for deficiency
? offered? times/24hrs

Before 6 months/in 10 food groups Also discuss

7thmonth / (24 hours) menu

in 8th month /in Yesterday- Today What time?

9thmonth/ morn
1.
after completing 9 Cereals
months. Pulses 2.

Vit- A Veg 3.
Dairy 4.

Egg Non-veg Food specially

prepared for
Vit-C Iron baby:
Vit-D Dal water / Rice
Calcium water/Khimti/Nar
chani satwa
How food is How mashed?
offered: With
Hand/Spoon hands/spoon/
Mixer grinder
Mashed
with:Dal/Breast
milk/
Milk/Curd
Illnesses : in last 3 months
& diet management
Junk food:
Biscuits/Kahri/Butter/Toasts/Colddrinks/waters/Chi
ps/Chocolates/Cadbury/
 Noodles/Corn flakes
Baby foods:
Cerelac,Farex,Nestum etc
Others: Pediasure, Complan,Bournvita,Horlicks etc
How Food
offered?
With family
Yes/No
With songs / stories
Yes/No
With TV-Mobile etc
Yes/No
Force feeding
Yes/No
Sitting at one place
Yes/No
Who gives?:
Cleanliness:
Check nails &
dental
Hygiene (Child
&Caregiver)
How much:
Quantity How much -- Quantity:
Katories/meal?
1. 2.
3. 4.