Last Updated on August 19, 2026
Clerking a new case
Admission Clerking If child is less than 2 years old and born preterm, please check for corrected gestational age or corrected age e.g. 2nd hospitalization At home? At babysitter’s house? At hometown? Asking about history related to asthma for respiratory cases. Patient should be more than 10 months old, and previously not diagnosed with asthma. If patient has underlying asthma, ask regarding asthma control instead. Personal history of atopy Personal history of atopy Family history of atopy EMLSCS / ELLSCS / SVD Antenatal issues e.g. IUGR, GDM on diet control, asthma during pregnancy etc. Postnatal issues e.g. Neonatal jaundice requiring phototherapy ED / KK e.g. Alert, AFNT, pink, warm peripheries, CRT less than 2 seconds, good pulse volume ======
Name
Age
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 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?
–
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:
=====
UPON ARRIVAL TO WARD
On examination:
General condition
Not tachypnoeic, RR 20, No chest recessions
**Anterior fontanelle should be examined if child less than 2 years old
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 [tooltips keyword =’BP Percentile for age & height‘ content=’Recommended app for quick check in BP percentile:
– Ped(z) – Pediatric Calculator (App Store) (Google Play Store)’] 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.