Identification Data

Name of the child- Aniket Ghosh

Mother's name- Papiya Ghosh
Father's name- Gopal Ghosh
Age of the child- 14 years
Sex- male
Address- Horapur, Habra, West Bengal
Chief complaint
The boy came in the adolescence clinic with her father. He has aggressive behaviour with
lack of social activity. She also has decreased interest in study
History of present illness:-
Medical- aggressive behaviour, lack of social activity, decreased attention and concentration.
Surgical- nothing significant
Past history
Medical- nil
Surgical- nil
Birth history:-
Prenatal history
 Age of mother- 20 years
 Years since marriage- 2 years
 height- 157 cm
 Health problems during pregnancy- nothing significant. There was no history of
diabetes, hypertension, and thyroid disorder or any systemic disease of mother.
 History of folifer consumption- tablet ferrous sulphate was taken by mother in
antenatal period regularly.
 History of addiction- no such addiction was present in mother.
 Antenatal check up- two antenatal check up were done
 Immunization- two doses of injection tetanus toxoid where given to mother.
Intranatal:
Date of birth- 7/04/2005
Time of birth- 2:30 p.m.
Type of delivery - normal vaginal delivery
Breathing problem - nil
Birth weight- 2.2 kg
Cry- baby cried immediately after birth
Postnatal:
 Initiation of breastfeeding- started within one hour of delivery
 History of top feed- no
 Meconium and urine passed- within 24 hours of birth
 Cord- healthy
 Activity - active
 Jaundice - nil
 Bleeding history - nothing significant
 Congenital malformation-not present

Developmental history-
Physical Motor Cognitive Psychological Moral Spiritual
 Body  Motor  Abstract  Preoccupied Understand  Compare
weight- function is thinking with rapid duty & the religious
48kgs comparable developed body changes. obligation. standards of
 Height- 159 to adult  Thoughts  Measure parents with
cm  Eye hand co- are attractiveness those of
 Secondary ordination is influenced by acceptance others.
sexual at adult level by logical or rejection of  Compare
character principle peers. religious
appeared. rather than  Conform to standards
 Visual own group norms. with
acuity- perception  Strong desire scientific
20/20 and to stay viewpoint.
thoughts dependent on
 Capable of parents while
logical trying to
reasoning detach.
& formal  Seeks peer
logic. attention.

Immunization history -
The boy got all immunization up to date

Personal history -
 General personal hygiene - well maintained
 Dressing - perform independently
 Bathing - taken
 Number of Bawal elimination - average one time per day
  Number of urine elimination - 7 to 8 times per day
 Sleeping - sleep amount is more than normal. He sleeps approx and average of eight
hours all total
 Habits or behaviour he has aggressive behaviour
 Schooling - reads in class 8
 Play and exercise - interested in football. But now I just I don't like to go to outside
for playing
Dietary history -
 The child is non vegetarian.
 No of meal- 5 ( breakfast, lunch, tiffin, evening snacks, dinner)
 Food allergy- nothing significant
Family History:-
 Type of family:-
 Consanguine marriage-
 Religion:-

 Family Chart:-
Sl Age Name of the Relationship Education Occupation Income Health
no family with the head status
members of the family
1 39 Gopal Ghosh Head of the Higher Service 12000/- Healthy
years family Secondary
2 34 Papiya Wife Higher Housewife Nil Healthy
years Ghosh Secondary
3 14 Aniket Son Class 8 Student Nil Healthy
years Ghosh

 Family genogram:-
Index
- male member

Female member

Affected person

Environmental history
 Type of home - pucca
 Number of room - 3
 Kitchen – separate kitchen is present
 Lighting - adequate
 Ventilation – well ventilated
 water supply - tube well
 Waste disposal - dumping
 Pet animal - nil
 Sanitary latrine - present

Physiological history
 Blood group – A+
 Blood group of mother – A+
 Physical examination on 5.01.2019

General appearance
 Consciousness - conscious
 Posture - normal
 Looks - normal
 Colour - pink
 Activity - lethargic
Vital sign
 Temperature - 98F
 Pulse - 74 beats/min
 Respiration - 22 breaths/min
 Blood pressure - 110/70 mm-Hg
Anthropometric measurement
 Body weight - 48 kg
 Height – 159 cm
 Mid upper arm circumference - 16 cm
 BMI - 19 kg/ m2
Head
 Shape and size is normal. Head is bilaterally symmetric
 Anterior fontanelle - closed
 Posterior fontanelle - closed
 Sutures - normal
 Abnormalities - no abnormality is present
Face
 Face is bilateral symmetric
 Shape is normal
 There is swelling of face present
 Paralysis or abnormal movements of face are not present
Eyes
 Shape - normal
 Symmetry - bilaterally symmetrical
 Colour of sclera - normal
 Discharge - absent
 Relation with ear level - normal
 Abnormality - nothing significant
 Subconjunctival hemorrhage, congenital cataract, strabismus are not present
Nose
 Shape - normal
 Symmetry - bilaterally equal
 Nasal Bridge - normal
 Nasal discharge - nil
 Nasal flaring - nil
Ears
 Shape and size- normal
 Symmetry- literally equal
 Position- normal, evidence of low set ears
 Discharge - nil
 Others - no preauricular sinus and no other abnormality is present
 Pinna is firm with definite cartilage and instant recoil
Mouth
 Lips - pinkish in colour
 Texture - moist and no sign of cleft lip
 Gum - healthy
 Teeth - no natal teeth is present
 Tongue - normal, healthy, voice and moves freely
 Uvula - normal
 Oral cavity - normal and healthy. Sign of ulcer, mucositis or oral thrush. No sign
of cleft lip and cleft palate.

Neck
 Neck is normal in size. There is no thyroglossal cyst, cystic hyngroma, webbing of
neck excessive folds.

Integumentary system
Skin
 Colour- pink
 Texture - normal
 Turgor - good
 Hydration - maintained
 Integrity - intact. No rash, abrasion, laceration present

Hair
 Distribution - equal
 Colour- black
 Texture- rough and very dirty
 Nail
 Shape - normal
 Capillary refill - < 3 sec

Respiratory system
 Shape and size of chest - normal
 Symmetry - normal
 Air entry - bilaterally equal
 Movement of chest - bilaterally equal
 Abnormal lung sounds - no abnormal lung sound is present

Cardiovascular system
 Heart rhythm - normal
 Heart sound - s1, s2 present
 All pulses are palpable
 Cyanosis - nil

Nervous system
 The child is alert and active without any adverse neurological sign.
 Neurological reflexes are present

Gastrointestinal system
 Normal shape and size of abdomen
 Peristalsis sound is present
 No abnormal mass present in palpation
 Liver and spleen is not palpable
 Passed stool regularly

Hematologic and lymphatic system

 Lymph Gland is not palpable
 No pallor is present

Musculoskeletal system
 Spine- normal and intact
 Upper extremity - no abnormality present
 Lower extremity- no abnormality present
 Joints- joints are movable
 Muscles - tone is adequate
 Genitourinary system
 External genitalia - normal
 Pubic hair present and spread over entire pubis
 Anus - opening present
 Patency of anus- patent
 The child passes urine normally
 Urethral opening is in normal position

Impression
The boy has attained normal growth and development according to age. General
health condition is good. He is having an aggressive behaviour with poor attention and
concentration span. That’s why he is attending counselling sessions at adolescent clinic.