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
8 3 Years
9 4 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
Tower of 9 blocks;
copies circle
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 -

Sr. UPPER LIMB MUSCLES RIGHT LEFT

No. JOINTS
1. Shoulder Flexors
Extensors
Abductors
Adductors
 Medial Rotators
Lateral Rotators
2. Elbow Flexors
Extensors
3. Wrist Flexors
Extensors
Radial Deviators
Ulnar Deviators

Sr. LOWER LIMB MUSCLES RIGHT LEFT

No. JOINTS
1. Hip Flexors
Extensors
Adductors
Abductors
Medial Rotators
Lateral Rotators
2. Knee Flexors
Extensors
3. Ankle Dorsiflexors
Plantarflexors

2] Voluntary movements :- Reciprocal kicking

Mass kicking

Sr. UPPER LIMB MUSCLES RIGHT LEFT

No. JOINTS
1. Shoulder Flexors
Extensors
Abductors
Adductors
Medial Rotators
Lateral Rotators
2. Elbow Flexors
Extensors
3. Wrist Flexors
Extensors
Radial Deviators
Ulnar Deviators

Sr. LOWER LIMB MUSCLES RIGHT LEFT

No. JOINTS
1. Hip Flexors
Extensors
Adductors
Abductors
Medial Rotators
Lateral Rotators
2. Knee Flexors
Extensors
3. Ankle Dorsiflexors
Plantarflexors

3] ROM :-

Sr. UPPER LIMB ACTIONS RIGHT LEFT END FEEL

No. JOINTS

1. Shoulder Flexion
Extension
Adduction
Abduction
Medial Rotation
Lateral Rotation
2. Elow Flexion
Extension
3. Wrist Flexion
Extension
 Radial Deviation
Ulnar Deviation

Sr. LOWER LIMB ACTION RIGHT LEFT END FEEL

No. JOINTS

1. Hip Flexion
Extension
Adduction
Abduction
Medial Rotation
Lateral Rotation
2. Knee Flexion
Extension
3. Ankle Dorsiflexion
Plantarflexion

4] MMT/Power :-

Sr. UPPER LIMB MUSCLES RIGHT LEFT

No. JOINTS
1. Shoulder Flexors
Extensors
Abductors
Adductors
Medial Rotators
Lateral Rotators
2. Elbow Flexors
Extensors
3. Wrist Flexors
Extensors
Radial Deviators
Ulnar Deviators
Sr. LOWER LIMB MUSCLES RIGHT LEFT
No. JOINTS
1. Hip Flexors
Extensors
Adductors
Abductors
Medial Rotators
Lateral Rotators
2. Knee Flexors
Extensors
3. Ankle Dorsiflexors
Plantarflexors

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