Paeds Clerking

Patient’s identification

 Name :

Registration no :

Date of birth:

Bed no :

Age :

Ward no :

Sex :

Date of admission :

Religion :

Date of examination :

Race :

Informant :

Address :

Others :

Chief complaints

(Problems with dration! •

1.

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2.

•

3.

History of present illness

Systemic enquiries

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Res"i # $ogh %aemo"t&sis S"tm (color amont and smell! whee'ing Sob D&s"nea

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$S # Pal"itation Shortness of breath $hest "ain )eg swelling Poor feeding $&anosis *rine tract + D&sria %aematria Noctria Incontinence *rine color  ,I- + )oss of a""etite Nasea and .omiting $onsti"ation Diarrhea Abdominal "ain $NS + ision %earing Nmbness Di''iness Sei're /aints 0emor& 1 $oncentration 0S2 # )etharg& 0scle "ain 3oint "ain Stiffness Immobilit& S4in # Itchiness Swelling Rashes %istor& of s4in allerg& Bleeding 5ndocrine # $old or heat intolerance $hange in sweating 5N- # 5ar or nose discharge

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History of past illness •

0edical:

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Srgical:

Birth history •

Antenatal:

Reglar attended antenatal clinic (AN$! In67 a-- gi.en An& fe.er with rash dring "regnanc& ("articlarl& in the first trimester! Serolog& tests8 %e" B9 %e" $9 DR) 1 %I 0edications for crrent "regnanc& $hronic illness or An& trama

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 Natal:

,estational age

0ode of deli.er& with "resentation Prolonged labor and ox&tocin sed PRO0if &es offensi.e li;or or meconim staining li;or  0aternal fe.er with lower abdominal tenderness (chorioamnionitis! $
•

Postnatal:

$ried well<.igorosl& immediatel& after birth Birth weight (gm or 4g!  Neonatal 6andice Se"sis 1 meningitis Pnemonia %&"ogl&caemia $on.lsions

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 Neonatal:

An& significant illness ex": "nemonia9 meningitis or asthma /irst rine ot"t and meconim (=> hrs! When start breastfeed ?? %ow long ??

Feedin and dietary history

Breastfeeding amont 1 fre;enc& of mil4 offered :

/ormla feeding : Prelacteal feeding:

$om"lementar& feeding (Start time 1 food offered! :

$rrent dietar& inta4e:

!mmuni"ation history

0ala&sian national 5PI schedle +

#e$elopmental history •

,ross motor:

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ision 1 fine motor:

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%earing9 s"eech 1 langage:

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Social9 emotional 1 beha.ioral:

%reatment & allery history

Drg reaction or allerg& :

/ood allerg& :

Family history

$onsanginit& of marriage Siblings: nmber9 age 1 sex9 their health

/amilial illness

0aternal illness %istor& of miscarriage9 abortion9 I*D9 still birth and neonatal death

Socio'economic history

Ade;ate basic facilities (ade;ate water s""l&9 "ro"er sanitation9 good .entilation! ,ood sorce of light7 %ose is located in a hosing area and not near highwa& or factor& Pets and car"et

0other wor4s (salar&! /ather wor4s (salar&! Smo4e??? Alcohol??? O$ "ills ???

Personal history

Summary and #!)*+S!S