PEDIATRIC ASSESSMENT

 Demographic data:
Name of patient:
Name of Father/Mother/Attendant:
Chronological age:
Gestational age:
Expected Date of Delivery (EDD):
Gender:
Religion:
Occupation:
Address:
Dominant handedness:
Head circumference:
Weight (kgs):
Height / Length (cm. /Mts.):
Body Mass Index (BMI) (Kg/m2):
IP/OPD No. :
Date of Admission (DOA):
Date of Examination (DOE):
 Chief complaints: -
 Other complaints:-
 History of presenting illness(HOPI):
 Pre-Natal /Maternal history
 Pedigree chart
 G(Gravida) P(Parity) L(Live births) A(Abortion) D(Death)
 Age of mother at the time of conception
 H/o of consanguinous marriage
 H/o pre-eclampsia, gestational diabetes, anemia, fever, infections, etc.
 H/o of alcohol intake / drug intake, medications not prescribed by the doctor
 H/o regular ultrasonography scans during 1st ,2nd& 3rd trimester
  Perinatal history-
 Place of birth- Hospital/Home
 Type of birth- FTND(Spontaneous/ Vacuum delivery/ Forceps delivery) or C-
Section
 Birth weight-
 Birth cry- Immediately / Delayed
 APGAR Score

 Post-Natal history
 H/o Prematurity/ hospital stay in NICU/ PICU/ Paediatric ward for____ day due
to __________
 Any other known history
 Family history
 Vaccination /Immunization history (follow WHO guidelines)
 Feeding history-
 H/o breast-feeding for _____months
 H/o weaning since ______
 At present, solid/ semi-solid/ liquid/ semi-liquid food intake.
 Developmental history-
 Gross motor skills
 Head control
 Rolling
 Prone on elbows
 Prone on hands
 Creeping
 Sitting supported & unsupported
 Crawling
 Pull to stand
 Standing supported & unsupported
 Walking
 Running
 Climbing stairs
 Fine motor skills
 Grasp – Maturity
Quality &/ or efficiency
 Coordination
 Finger dexterity
 Hand preference
 Isolated finger movts.
 Threading
 Writing

 Social skills& speech

 Social smile
 Recognition of mother
  Recognition of strangers
 Cooing
 Mono-syllabus
 Bi-syllabus
 Speaking in sentences
 Visual skills
 Visual Fixation
 Visual tracking
 Visual scanning
PHYSICAL EXAMINATION
 On observation(O/O)
 Active posture &Movements -
 Transitions from one position to another (supine lying / prone lying / sitting,
standing etc.)
 Ambulation
 Visual fixation/ tracking/ scanning
 Auditory response to noise / name/
 Passive posture & movements – When put in supine lying / prone lying / sitting,
standing etc.
 Posture
 Gait
 On Examination (O/E)
 Vitals :- HR-
RR-
Temperature-
BP-
 Higher mental functions:
 Consciousness
 Mood / regulation level-
 Vision –
 Hearing-
 Speech-
 Intelligence-
 Memory-
 Attention-
 Behaviour-
 Orientation-
 Cranial nerve examination
 Joint ROM
 Passive ROM- Right & Left UE & LE
 Active ROM- Right & Left UE & LE
 End feel
 Contractures / Tightness
 Joint deformity
 Muscle tone
Right Left
 Upper limb (Hypertonic/hypotonic/ Absent)
 Lower limb
 Trunk
If spastic, take Modified Ashworth Scale (MAS) Grades

 Girth measurement
 MMT
 Limb length discrepancy
 Reflexes
 Neonatal / Primitive reflexes –
o brainstem level
o Mid-brain level
o Cortical reactions
o Automatic reactions
Right Left
 Superficial reflexes
(Areflexia / Diminished/ Normal/ Exaggerated/ Brisk)
 Deep tendon reflexes
 Clonus
 Tremor – Type , amplitude
 Involuntary movts
 Associated reactions

 Sensory examination
 Superficial sensations
 Deep sensations
 Cortical sensations

 Posture & Balance

 Postural stability during activities (right & left side)
- Gross motor
- Fine motor
Eg. Lying, sitting, standing
 Weight shifts- Upper (lateral/ diagonal)
Lower
 Head righting – forward
Vertical- backwards
-Side
Horizontal – prone,
-Supine
-Side lying
 Protective reactions
 Equilibrium – sitting , standing
 Posture & balance relative to position
 Coordination (Equilibrium & Non equilibrium tests)
 Gait- Type, phases of gait , determinants of gait- absent, short / lengthened time
periods
 Functional evaluation
 Feeding /eating
 Bed mobility
 Toileting
 Dressing
 Ambulation
 Communication
 Cardio-respiratory examination
 Aids / Orthosis
 Diagnosis
 ICF
 Problem list
 Treatment goals (SMART GOALS) – Short term (within 3 months) & long term
(> 3 months)
 Treatment plan
 Referrals, if required
 Follow-up/ review
 Treatment progression/ change