This is a presentation that will help a clinician develop information by asking questions. Ultimately, the answers will give the clinician an idea of what could be wrong with his/her patient

1. Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. Page 1
PAEDIATRICS CLERKING SHEET
A. HISTORY TAKING
Identity:
- Name:
- Age:
- Sex:
- Tribe:
- Religion:
- Residence:
- Informants: ?pt/parent
- Date of Clerking (DOC):
- Language of interview:
- Referral/Not and frm where and for what?
Presenting complaint:
- What do parents think or fear is the problem?
Development of Symptoms:
- Detailed info about child’s illness
- It shd be recorded systematically to give separate paragraphs and headings to each
new dateline, rather than giving the whole hx in essay form
- Days of wks shd not be written in hx since they don’t indicate duration of disease
Review of Systems:
a) CVS;
- Easy fatigability
- Palpitations
- Swelling of legs
b) RS;
- Chest pain
- Cough
- Dyspnoea
- Wheeze
- Haemoptysis
- Sore throat
c) GIT;
- Appetite
- Vomiting
- Diarrhoea
- Constipation
- Abd pains
d) MSS;

2. Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. Page 2
- Skin rash
- Joint/bone pains
- Joint swellings
- Yellowing of eyes/palms
e) GUT;
- Frequence
- Haematuria
- Dysuria
- Nocturia
- Incontinence
f) CNS;
- Headache
- Weakness/paralysis
- Seizures
- Abnormal movements
Past Medical Hx:
- Hospital admissions
- Hx of similar illness
- Operations
- Accidents, injuries
Drug Hx:
- Past and present medications
- Allergies
Birth Hx:
- Place of birth
- Gestation age at birth, method of delivery, duration of labour, birth wt.
- Perinatal problems and method of feeding
Immunisation Hx:
- Under 5 card
- Immunisations given
Nutrition Hx:
- Breast feeding
- When other feeds started?
- ?Type of feeds and how much daily
Developmental Hx:
- Smile
- Head support
- Sit

3. Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. Page 3
- Stand
- Walk
- Talk
- ?is pt at school
Family Hx:
- ?Parents alive
- Siblings and their ages
- Deaths incl miscarriages, stillbirths, terminations
- Family illness and allergies
- Family tree (asthma, TB, HTN, DM, epilepsy)
Socio-economic Hx:
- Occupation of parents
- Housing
- Relationship of parent
- Smoking
- Water source
- Toilet
Summary of Hx:
Differentials/Impression:
B. PHYSICAL EXAMINATION
B1. GENERAL EXAMINATION:
- Obtain a child’s cooperation
- Be sensitive when undressing child, and make sure yr hands are warm!
- If child appears very ill, first assess: Airway, Breathimg, Circulation, Disability,
Exposure (ABCDE)
- P, J, C
- Lymphadenopathy
- Oral cavity – ?membrane lesions

4. Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. Page 4
- Teeth - ?carries
Vitals:
- Temp
- Respiratory rate
- Pulse: ?regular, full volume, RR and RF delay
- BP
Anthropometric Measurements:
a) Weight;
- Initially 12% loss
- Regains birth wt by 10th
day
- Then gains 30g/day
- Wt doubles by 5 mo
- Wt trebbles by 1 yr
b) Height;
- 50cm at birth
- 75cm at 1 yr
- 100cm at 4 yr
- Then gains 5cm/yr
c) Head circumference (Occipito-frontal);
- 35cm at birth
- 40cm at 3 mo
- 47cm at 1 yr
- 0.5cm/yr btn 2-7 yr
- 0.3cm/yr btn 8-12 yr
d) Mid- upper arm circumference (MUAC);
B2. SYSTEMATIC EXAMINATION
RS:
- chest; ?symmetrical, deformities
- scars; ?tatooes, surgical
- tenderness
- trachea; ?central
- chest mvts
- percussion
- breath sounds; ?bronchial, vesicular
- added sounds
- vocal resonance
CVS:

5. Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. Page 5
- Distended neck veins
- Precordium
- Apex beat
- S1, S2
- Added sounds
Per Abdomen:
- Inspection; ?skin, inverted umbilicus, scars, dilated vessels
- ?moving with respiration
- Liver/spleen
- Abd masses
- Ballotable kidneys
- Renal angle tenderness
- Shifting dullness
- Bowel sounds
CNS:
- ?pt conscious – interacting with environment and cooperative
- ?talk and answer questions
- ?crainal nerves intact
- ?gait
Urinalysis: e.g.
- SG: 1.020
- Leukocytes: 500/Ul
- Nitrites: -ve
- Bilirubin: -ve
- Glucose: normal
- pH: 5
- blood: -ve
- ketones: -ve
- proteins: 15mg/dl
Summary of Examination:
Differentials/Impressions: