Form a case sheet of a child who is four years and 11 months old, date of birth 12th August 2022, who presented to pediatric OPD with complaints of throat pain since two days and, uh, runny nose and cough since two days. Um, um, may also record, uh, birth history. Uh, the patient is the second child, birth order is two, and, uh, the patient... Was born via LSCS. Um, and, uh, there were no complications during birth. Um, the mother, uh, compl- uh, mother said that she used to suffer from heart problems during the pregnancy and was admitted in the ICU. She had, he has a elder sister who's of 11 years age and was, uh, delivered normally. Developmental milestone was all a- were all achieved according to age, um, all five domains. And there is no significant family history.
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Here is the completed pediatric OPD case sheet based on the information provided:
PEDIATRIC OPD CASE SHEET
Date: 23 July 2026
OPD No.: _______________
IP No.: _______________
I. PATIENT IDENTIFICATION
| Field | Details |
|---|---|
| Name | _____________ |
| Age | 4 years 11 months |
| Date of Birth | 12 August 2022 |
| Sex | Male |
| Weight | _____ kg |
| Height | _____ cm |
| Address | _____________ |
| Father's Name | _____________ |
| Father's Occupation | _____________ |
| Mother's Name | _____________ |
| Mother's Occupation | _____________ |
| Contact No. | _____________ |
| Informant | Mother |
| Reliability of History | Good / Fair / Poor |
II. CHIEF COMPLAINTS
- Throat pain - 2 days
- Runny nose (rhinorrhoea) - 2 days
- Cough - 2 days
III. HISTORY OF PRESENTING ILLNESS
The patient, a 4-year 11-month-old male child, presented to pediatric OPD with complaints of throat pain, rhinorrhoea, and cough since 2 days. History to be elaborated regarding:
- Throat pain: Onset (sudden/gradual), character, severity, associated difficulty in swallowing (dysphagia/odynophagia), drooling, change in voice (muffled/hoarse)
- Rhinorrhoea: Character of discharge (watery / mucoid / mucopurulent / blood-stained), unilateral or bilateral, associated nasal block, sneezing
- Cough: Character (dry / productive), nature (barking / whooping / brassy), associated breathlessness, wheeze, stridor
- Systemic: Fever (onset, duration, pattern, severity), ear pain/discharge, eye discharge, rash, vomiting, loose stools, reduced oral intake, reduced urine output
- Exposure history: Sick contacts at home or school, recent travel
IV. PAST HISTORY
- Similar complaints in the past: Yes / No
- Recurrent respiratory infections: Yes / No
- Hospitalisation: Yes / No (if yes, details)
- Known allergies: Yes / No
- Bronchial asthma / Atopic dermatitis: Yes / No
- Surgical history: Nil significant
- Immunisation history: To be verified (as per National Immunisation Schedule)
V. BIRTH HISTORY
| Parameter | Details |
|---|---|
| Birth Order | 2nd child |
| Period of Gestation | _____ weeks (Term / Preterm / Post-term) |
| Mode of Delivery | LSCS (Lower Segment Caesarean Section) |
| Indication for LSCS | Maternal cardiac complications |
| Place of Delivery | _____________ |
| Birth Weight | _____ kg |
| APGAR Score | _____ / 10 (at 1 min and 5 min) |
| Cry at birth | Immediate / Delayed / Absent |
| Complications (Neonatal) | None reported |
| NICU Admission | No |
Antenatal History:
- Mother suffered from cardiac problems during pregnancy
- Mother was admitted to ICU during pregnancy (details of cardiac condition, trimester of ICU admission, management received - not available at time of history; to be clarified)
- Regular antenatal check-ups: Yes / No
- TORCH infections screening: Done / Not done
- GDM / PIH / Anaemia: _____________
VI. FEEDING HISTORY
- Breastfeeding: Initiated at birth / Delayed - Duration: _____ months
- Exclusive breastfeeding: Up to _____ months
- Complementary feeding: Started at _____ months
- Current diet: Mixed diet / vegetarian / non-vegetarian
- Appetite: Good / Fair / Poor
VII. DEVELOPMENTAL HISTORY
Developmental milestones achieved appropriately for age across all five domains:
| Domain | Expected Milestone | Achieved |
|---|---|---|
| Gross Motor | Runs, climbs stairs alternately, hops | Yes |
| Fine Motor | Draws a person, copies shapes, uses scissors | Yes |
| Language | Speaks in sentences, tells stories, vocabulary >1000 words | Yes |
| Social / Personal | Plays with peers, dresses/undresses, toilet trained | Yes |
| Cognitive / Adaptive | Names colours, counts objects, understands concepts | Yes |
Global developmental delay: Absent
Regression: None reported
School attendance: Yes / No - Performance: _____________
VIII. FAMILY HISTORY
- Sibling 1: Elder sister, 11 years old, healthy, delivered via normal vaginal delivery, no significant medical history
- Parents: Father - healthy; Mother - history of cardiac illness during pregnancy (nature of illness to be clarified - valvular disease / cardiomyopathy / arrhythmia / other)
- Family history of: Tuberculosis: No | Asthma / Atopy: No | Congenital heart disease: No | Malignancy: No | Consanguinity: No
- Significant family history: Nil (as reported)
IX. SOCIOECONOMIC AND ENVIRONMENTAL HISTORY
- Socioeconomic status: _____________ (Modified Kuppuswamy / BG Prasad Scale)
- Type of house: Kutcha / Pucca / Semi-pucca
- Overcrowding: Yes / No
- Ventilation: Adequate / Inadequate
- Drinking water source: Tap / Well / Borewell / Packaged
- Sanitation: Adequate / Inadequate
- Pets at home: Yes / No
- Passive smoke exposure: Yes / No
X. IMMUNISATION HISTORY
(As per National Immunisation Schedule - India)
| Vaccine | Due | Given | Remarks |
|---|---|---|---|
| BCG | Birth | ||
| OPV 0 | Birth | ||
| Hep B (Birth dose) | Birth | ||
| DPT 1, OPV 1, Hep B 1, Hib 1 | 6 weeks | ||
| DPT 2, OPV 2, Hep B 2, Hib 2 | 10 weeks | ||
| DPT 3, OPV 3, Hep B 3, Hib 3 | 14 weeks | ||
| IPV | 14 weeks | ||
| Measles / MR 1 | 9 months | ||
| Vitamin A (1st dose) | 9 months | ||
| DPT Booster 1, OPV Booster | 16-24 months | ||
| MMR / MR 2 | 16-24 months | ||
| Typhoid conjugate vaccine | 9-12 months | ||
| DPT Booster 2 | 5 years | Due |
Immunisation status: Up-to-date / Incomplete / Unimmunised (to be verified from card)
XI. GENERAL PHYSICAL EXAMINATION
| Parameter | Finding |
|---|---|
| General appearance | Active / Ill-looking / Toxic |
| Consciousness | Alert and oriented |
| Cry | Normal |
| Nutrition | Adequate / Moderate / Severe acute malnutrition |
| Hydration | Well hydrated / Mildly / Moderately / Severely dehydrated |
| Pallor | Absent / Present |
| Icterus | Absent / Present |
| Cyanosis | Absent / Present |
| Clubbing | Absent / Present |
| Lymphadenopathy | Absent / Present (site, size, consistency, tenderness) |
| Oedema | Absent / Present |
| Temperature | _____ °F / °C |
| Pulse Rate | _____ /min, regular, volume _____ |
| Respiratory Rate | _____ /min |
| Blood Pressure | _____ / _____ mmHg |
| SpO2 | _____ % (room air) |
| Weight | _____ kg (_____ centile) |
| Height | _____ cm (_____ centile) |
| Head Circumference | _____ cm |
XII. SYSTEMIC EXAMINATION
ENT:
- Throat: Erythema / Tonsillar enlargement (Grade ___) / Exudate / Membrane
- Tonsils: Normal / Enlarged (grade I / II / III / IV)
- Anterior pillars: Congested / Normal
- Posterior pharyngeal wall: Congested / Granular / Normal
- Nasal mucosa: Congested / Pale / Normal; Discharge: Watery / Mucoid / Purulent
- Ears: TM intact / Congested / Dull; NAD
Respiratory System:
- Shape of chest: Normal
- Movements: Equal / Unequal; Retractions: Absent / Present (subcostal / intercostal / suprasternal)
- Auscultation: Air entry - Equal / Reduced; Added sounds - Wheeze / Crepitations / Rhonchi: Absent / Present
Cardiovascular System:
- S1, S2 heard; No murmur / Murmur (if present - describe)
Abdomen:
- Soft, non-tender; Liver / Spleen: Not palpable
Nervous System:
- Higher functions: Age-appropriate; Tone / Power / Reflexes: Normal
XIII. PROVISIONAL DIAGNOSIS
Primary: Acute Pharyngitis / Acute Tonsillitis (viral vs bacterial - to be determined clinically; consider Centor / McIsaac scoring)
Differential Diagnoses:
- Acute viral upper respiratory tract infection (URTI)
- Streptococcal pharyngotonsillitis (Group A beta-haemolytic Streptococcus)
- Infectious mononucleosis (if exudative tonsillitis with lymphadenopathy)
XIV. INVESTIGATIONS (If Required)
- Throat swab for culture and sensitivity (if bacterial aetiology suspected)
- Rapid Strep Antigen Test (RSAT)
- Complete Blood Count (CBC) with differential
- C-Reactive Protein (CRP) - if sepsis / systemic illness suspected
- Monospot test / EBV serology (if mononucleosis suspected)
XV. MANAGEMENT PLAN
(To be filled by treating physician after examination)
Symptomatic:
- Antipyretic / analgesic: Paracetamol 15 mg/kg/dose 4-6 hourly PRN
- Saline nasal drops / nasal wash
- Adequate oral hydration
- Steam inhalation
Antibiotic (only if bacterial aetiology confirmed / strongly suspected):
- Amoxicillin 40-50 mg/kg/day in 2-3 divided doses x 10 days (for Group A Strep)
- Alternatives: Amoxicillin-clavulanate / Azithromycin (if penicillin allergic)
Advice:
- Adequate rest and oral fluid intake
- Return if: high-grade fever persists > 48 hrs, difficulty breathing, drooling, refusal of feeds, ear pain, neck stiffness
- Follow-up: After 3-5 days / as needed
XVI. NOTES / REMARKS
- Mother's cardiac history during pregnancy should be documented clearly (likely valvular heart disease / peripartum cardiomyopathy) - relevant for any future anaesthetic / surgical planning for the child and for genetic counselling.
- Immunisation card to be verified at this visit; DPT Booster 2 due at 5 years of age.
- Growth parameters to be plotted on WHO / IAP growth chart.
Signature of Resident/Intern: _____________
Signature of Senior Resident / Consultant: _____________
Date & Time: 23/07/2026, 15:39
Note: Fields marked with blanks (___) are to be completed after physical examination. History regarding the mother's specific cardiac diagnosis (e.g., valvular disease, cardiomyopathy, arrhythmia) should be obtained and documented as it has potential implications for the child's genetic and cardiac risk assessment.
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