Pediatrics Clinical Case Proforma

For Ward Presentation — Department of Pediatrics
 |  Date:

1. Identification & Presenter Details

Patient Name
Age / Sex
IPD / Bed No.
Occupation
Address
Date of Admission
Presenting Student & Roll No.
History given by

2. Chief Complaints

Tick all that apply. For infants/young children, complaints may be reported by caregiver.
✓Chief ComplaintSideSiteDuration (since)
Fever
Cough and cold
Diarrhea
Vomiting
Poor feeding / failure to thrive
Respiratory distress
Skin rash
Seizures
Delayed developmental milestones
Abdominal pain
Other:

3. History of Present Illness

Mode of Onset

Character of Pain / Key Symptom — SOCRATES

To be filled whenever pain is a chief complaint (verbal/older child) or inferred from behaviour (infant).
S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)
Associated symptoms

4. Past, Personal, Family & Treatment History

Past History

Family History

Personal History

Treatment / Drug History

5. Antenatal, Natal, Postnatal, Immunization, Development & Nutrition

A. Antenatal History

Booked / Unbooked, ANC visits
Illness / medication during pregnancy
Gravida / Para

B. Natal History

Term / Preterm
Mode of delivery
Birth weight
Cry at birth / resuscitation needed

C. Postnatal History

D. Immunization History

As per National Immunization Schedule — tick vaccines received.

E. Developmental Milestones

DomainAchieved milestoneAge at achievement
Gross motor
Fine motor
Language
Personal / social

F. Nutritional / Feeding History

Exclusive breastfeeding duration
Weaning — age & foods started
Current diet (24-hr recall)

6. General Physical Examination

Build
Nutrition
Consciousness
SignAbsentPresentDetails (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

Vitals

PR (/min)
BP (mmHg)
RR (/min)
Temp
SpO2 (%)
RBS
GCS
Weight (kg)
Height/Length (cm)
Head circumference (cm)

7. Systemic Examination

A. Respiratory System

B. Cardiovascular System

C. Per Abdomen

D. Central Nervous System

Overall System AssessmentNormalAbnormalSummary detail
Respiratory System
Cardiovascular System
Per Abdomen
Central Nervous System

8. Investigations

✓InvestigationFindings
Complete blood count
CRP
Blood culture
Urine routine & microscopy
Stool routine & microscopy
Serum electrolytes
Chest X-ray
Random blood sugar
Malaria antigen/smear
Widal / dengue serology (if indicated)
Other:

9. Diagnosis

Provisional Diagnosis
Differential Diagnosis

10. Treatment Plan

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.
Presenting Student's Signature
Countersigned by Faculty / Resident
Pediatrics Clinical Case Proforma — for teaching purpose · not a legal medical record