PEDIATRICS CASE

Demographic Data :-
Name :

Age :

Gender :

Address :

Informer : Mother/Father/Gaurdian

Date of Birth :

Date of Examination :

Chief Complaints :-

HOPI :-
1] Pre-natal History :-
1) Mother LMP :
2) Mother EDD :
3) H/O TORCH infection :
4) H/O hypertension (HNT) :
5) H/O diabetes mellitus (DM) during pregnancy :
6) H/O convulsions :
7) H/O trauma or accident :
8) H/O drug therapy :
9) H/O oligohydramnios ( level of amniotic fluid) :

2] Natal History :-
1) Delivery : Fullterm/Pre-term
2) Mode of delivery : Normal/LSCS
3) Cried Immediately After Birth (CIAB) : Yes/No
4) Respiratory distress or hypoxia :
5) APGAR score : a) Activity –
b) Pluse –
 c) Grimace –
d) Appearance –
e) Respiration –

6) Meconium aspiration :

7) H/O congenital infection :

8) H/O trauma during birth :

3] Post- natal History :-

1) H/O infection : Pneumonia/Meningitis
2) H/O epilepsy/Seizures :
3) H/O fever :
4) H/O accident or trauma :
5) H/O metabolic diseases :
6) H/O vascular diseases :
7) H/O IUGR (Intra-uterine Growth Restriction) :
8) H/O NICU care : Yes/No If yes how many days? -
9) H/O cardiac condition :

Medical History :-
1) Any drug history :
2) H/O any surgery : Spina bifida/Hydrocephalus

Immunisation History :-
Family History :-
1) Consanguinity degree :
2) H/O siblings & age:
3) Same problem in family :

Personal History :-
1) Feeding (How many times?) :
2) Sleeping Pattern : Irritable/Not sleepy/Continuous
3) Stool :
4) Urine :
5) Type of food baby take : Solid/Semisolid/Liquid

Socioeconomic Status :- { Kuppuswamy Scale }

Father Mother

Education of Parents :

Occupation of Parents :

Family Income :

Area where they stay? :

Developmental History :-
1] Gross Motor Development :-

Sr.No. Age Milestones Achievement Delay

1 3 Months Neck holding
2 5 Months Rolls over
3 6 Months Sits with tripod
fashion (sitting
with own support
4 8 Months Sitting without
support
5 9 Months Stands holding on
(with support)
6 12 Months Creeps well; walks
but falls; stands
without support
7 15 Months Walks alone;
creeps upstairs
8 18 Months Runs; explore
drawers
9 2 Years Walks up &
downstairs (2
feet/step); jumps
10 3 Years Rides tricycle;
alternate feet
going upstairs
11 4 Years Hops on one foot;
alternate feet
going downstairs

Interpretation -

2] Fine Motor Development :-

Sr.No. Age Milestones Achievement Delay

1 4 Months
2 6 Months
3 9 Months
4 12 Months
5 15 Months
6 18 Months
7 2 Years
Bidextrous reach
(reaching out for
objects with both
hands)
Unidextrous
reach(reaching out
for objects with
one hand);
transfers objects
Immature pincer
grasp; probes with
forefinger
Pincer grasp
Imitates scribbling;
tower of 2 blocks
Scribbles; tower of
3 blocks
Tower of 6 blocks;
 vertical & circular
stroke
8 3 Years Tower of 9 blocks;
copies circle
9 4 Years Copies cross;
bridge with blocks
10 5 Years Copies triangle;
gate with blocks

Interpretation -

3] Social/Communication & Language :-

Sr Age Milestones Achievem Delay Mileston Achievem Delay

.N (Personal & ent es ent
o. Social) (Languag
e)
1 1 Month Starts to smile Alerts to
sound
2 2 Social smile Cooing
Months
3 3 Recognizes Says Aah
Months mother;
anticipates
feeds
4 4-6 Recognizes Laughs
Months strangers, loud;
stranger Monosylla
anxiety bles (ba,
da, pa), ah-
goo sounds
5 9 Waves “bye- Bisyllables
Months bye” (mama,
baba,,
dada)
6 12 Comes when 1-2 words
Months called; Plays with
simple ball meaning
game
7 15 Jargon Follows
Months simple
commands
9 18 Copies parents 8-10
Months in task words
vocabulary
10 2 Years Asks for food, 2-3 words
drink, toilet; sentences,
pulls people to uses
shoe toys pronouns
“I”, “me”,
“you”
11 3 Years Shares toys; Asks
knows full questions;
name and knows full
gender name &
gender
13 4 Years Plays Says song
cooperatively or poem;
in group; goes tells stories
to toilet alone
14 5 Years Helps in Asks
household meaning of
tasks, dresses words
& undresses
by self

Interpretation -

Anthropometric Measurement :-
 Head circumference -
 Length of baby -
 Weight of baby -

Motor Examination :-
1] Tone :-

 On palpation -
 On passive movement -

2] Voluntary movements :- Reciprocal kicking

 Mass kicking

3] ROM :-

4] MMT/Power :-

Sensory Examination :-
Vision -

Auditory -

Touch -

Pressure -

Pain -

Temperature -

Reflex Assessment :-
1] Primitive reflexes :-

2] Superficial reflexes :-

3] Deep tendon reflexes :-

Posture Assessment :-
Supine

Sitting

Standing

Balance assessment

Functional assessment :- “Wee FIM scale”

Gait assessment
Type of gait

Phases of gait