Last Updated on February 5, 2023
Clerking a new case
Admission Clerking
Name
Age + Gender
Any underlying medical illness
Any food / drug allergy
__ hospitalization
Date of admission: ____
Day __ of illness
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Underlying Medical Illness
1. ____
2. ____
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Previous Hospitalizations
1. ___
2. ___
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History of Presenting Illness (HOPI)
Any sick contact? Any closed contact with COVID 19?
Any recent traveling?
Asthma profile
– History of nebulization: When was first neb? how frequent is the neb? When was last neb? Whether caretaker knows it’s neb saline or neb salbutamol? Any Syr Salbutamol taken?
– Frequency of daytime symptom
– Frequency of nocturnal symptom
– Any cold induced symptom (air condition, cold weather, cold drink)?
– Any exercise induced symptom?
– Any early morning sneezing? Does the symptom disturb daily life? Any ENT referral or follow up?
– Any eczema?
– Any pet at home?
– Any carpet at home?
– Is house near to construction site?
– Does father / mother / sibling have asthma, eczema, allergic rhinitis?
Birth History
Term or preterm at how many weeks? Born at which hospital? Mode of delivery?
Birth weight
ANC
PNC:
Developmental History
Gross motor:
Fine motor:
Speech:
Social:
Immunization History
Up to age?
Any missed immunization?
Any additional immunization?
Diet History
Exclusively breastfeeding for ___
Weaning at __
Breakfast:
Lunch:
Dinner:
Still taking formula milk or breastfeeding on demand?
Picky eater?
Family & Social History
Father (__ years old), underlying medical illness / working as ___
Mother (__ years old, underlying medical illness / working as __
Siblings’ details:
Main caretaker?
Babysitter / nursery?
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UPON ARRIVAL AT __
On examination
Impression:
Management:
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UPON ARRIVAL TO WARD
On examination:
General condition
Ear examination:
Throat examination:
BP:
HR:
T:
SPO2:
Lungs:
CVS:
Abdomen:
Investigations:
Impression:
Management:
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PLAN
Ventilation
Feeding / Fluid
Investigation
Medication
Others
Name & MMC Number // Sign and stamp
💡Tips
• 3 golden questions — (i) Active as usual? (ii) Oral intake as usual? (iii) Diapers change / Passing urine as usual?
What ‘s next after clerking a new case?
• Fill in Investigation Summary
• Fill in inpatient Prescription Slip (PS)
• Plot growth chart (Growth chart is a must in Paediatric Department!)
• Whenever possible, have a look at child’s Rekod Kesihatan Bayi dan Kanak-Kanak e.g. immunization, growth
• If child is haemodynamically unstable / requires BP monitoring / requires resuscitation, you can write down the BP Percentile for age & height near vital signs chart for quick reference later on
Example:
5th centile – 80 / 60
50th centile – 95 / 65
90th centile – 100 / 71
95th centile – 105 / 83
99th centile – 112 / 85
• Start managing the patient e.g. blood taking (if indicated), MDI/Neb Salbutamol, suction etc.