PAEDIATRIC EXAMINATION

Subjective Assessment: (from the parents or the case file)

Name:
Age: – Chronological: Corrected:
Gender:
Address:
Date of Birth: Expected Due Date:
Weight- At Birth: Present:
Head Circumference – At Birth: Present:
Length – At Birth: Present:
Profession- Father: Mother:
Date of Evaluation:
Dominance:
Phone No:
Referred By:

Chief Complaints: (in the words of the parents or caretakers)

History:
Prenatal:
Spontaneous/Planned:
Pregnancy detection:
1st trimester (Antenatal care, Supplements):
2nd trimester (Immunization):
3rd trimester (Weight gain):
Mother’s habits (alcoholism, smoking):
Medications taken:
Psychological state of the mother:
Any infections in the mother (Rubella, Cytomegalovirus):
Any trauma during the pregnancy:
Development of diabetes mellitus:
Hyper-emesis:
Bleed:
P-V Leak
Eclampsia:
Pregnancy induced hypertension:
Others:
Natal:
Type of delivery (Normal/ Caesarean section):
Assistive Devices used:
Term of pregnancy (full term, premature):
Episiotomy:
Labor Pain: Onset; Induced/Non-Induced:
Duration of labor:
Labor Complications:
Presence of doctor or midwife:
Mother’s participation during normal delivery:
Complications developed during the delivery:
Whether a paediatrician was present during the delivery or not:
Presentation of the baby:
Birth Cry: Type; Duration; Onset
APGAR:
NICU/HRI:

Postnatal: (details of events from birth till date)

Birth Weight:
Head circumference:
Feeding: Onset; Type; Success
NICU Management till discharge:
Post discharge status:
Seizures:
Any apparent deformity:
Assistive devices:
Other hospital admissions:
Color of the skin:
Level of activity:
Presence of convulsions:
Blood glucose level:
Immediate medical history:
Medications given and supportive measures:
Previous Physiotherapy/ Alternate Medicine taken: Sessions; Prognosis;
Treatment:
Reason for referral:
Past Medical History:
Any treatment taken for the present dysfunction:
Duration:
Effect:
Reasons for discontinuing the past treatment:

Surgical History:

Family:
Age of the parents during the birth of the child:
Type of marriage:
Presence of similar complaints in siblings or other family members:
Presence of any other medical complaints in the family:
Health of mother and siblings:
Pedigree Chart:

Obstetric History:
GPLAD:

Gynecological History:
Menarche:
Menstrual Cycle Details:

Socio-economic
Occupation of the parents:
Annual income:
Literacy level of the parents:

Personal
Sleep pattern:
Bowel and Bladder habits:
Appetite:

Present Medication History:

Immunization History:
As per age:
Feeding:
Teething:
Chewing:
Swallowing:
Dietary details:

Developmental History:

Gross Motor Development:

a) Head Holding – Prone: Supine:

b) Rolling – Prone-Supine: Supine – Prone:
c) Sitting: Supported: Unsupported: Upright:
d) Crawling:
e) Pull to Stand:
f) Standing – Supported: Unsupported:
g) Walking – Supported: Unsupported:
h) Climbing Stairs – Both feet: One at a time:
i) Skips on one foot:

Fine Motor Development:

a) Hand Regard:
b) Hand Opening:
c) B/L/ Reach:
d) U/L Reach:
e) Objects to midline:
f) Transfer:
g) Pincer Grasp:
h) Holds out objects but does not release:
i) Releases objects:
j) Building blocks:
k) Turning pages:
l) Dressing and undressing:
m) Draws a person:
Personal, Social Development:

a) Gaze contact:
b) Smile:
c) Social smile:
d) Recognizes mother:
e) Laughs aloud:
f) Smiles at mirror image:
g) Indicates desire by pointing:
h) Shakes head to no:
i) Waves Bye-Bye:
j) Comes when called:
k) Self-feeding:
l) Simple pretend play:
m) Tells name:
n) Complex pretend play:
o) Mutual Play with other children:
p) Tells stories:
q) Dry by day:
r) Dry by night:
s) Imaginary comparison:
t) Emerging time concepts:

Language Development:

a) Babbling:
b) Responds to own name:
c) Monosyllables:
d) Bi-Syllables:
e) One word with meaning:
f) Five words with meaning:
g) Simple command:
h) Identifies parts of the body:
i) Speech intelligible to strangers:

Oromotor Development:

a) Swallowing
b) Chewing
c) Biting
General Health History:

Allergies:
Nutrition and Energy expenditure:
Fluid intake and bladder function:

Educational and Social History:

Early Intervention:
Preschool:
School – Participation, Socialization, Schedule, Time spent. Therapy, Leisure
activity, Play

Differential Diagnosis (based on history)

On Observation

Developmental Milestones
 Gross Motor: Head holding, Rolling, Sitting, Crawling, Standing, Walking
 Fine Motor: Grasp, Reaching out and transfer of objects
 Personal/ Social : social smile, turns head, Anxiety towards strangers,
 Language : Cooing, Babbling, Monosyllables, Words, Formation of
sentences

Skin Colour
Nails
Head and neck
Behavior (Fatigue levels, Communication modes)
Position (preferable, ability to maintain)
Presence of involuntary movements
Symmetry
Postural alignment
Gait
On Examination

A) Higher Mental Functions

Hearing
Vision
Speech
Alertness
Awareness
Orientation
Intelligence
Perception
Memory

B) Reflexes
 Neonatal : sucking, rooting, Moro’s, palmar grasp, plantar grasp
 Automatic : Gallant’s trunk incurvatum, Parachute reaction, Landau’s
reaction
 Spinal : Flexor withdrawal, Extensor withdrawal
 Brainstem : ATNR, STNR, TLR (supine and prone), positive
supporting reaction, negative supporting reaction
 Righting : Neck righting, optical and vestibular
 Equilibrium : supine, prone, quadruped, sitting, standing, walking
 Deep tendon reflexes
 Superficial reflexes

C) Sensory
Superficial (touch, pain, temperature)
Deep (position, movement, vibration, pressure)
Cortical (tactile localization, two point discrimination, stereognosis…)
Special (auditory, vision)

D) Musculoskeletal
Joint range of motion
Tone
Muscle bulk
Muscle power
Contracture/ tightness
Deformities
 Muscle imbalance
Limb length discrepancy
Hand function
Voluntary control
Growth parameters (height, weight)
Spine (Range, deformities)
Gait
Co-ordination
Balance
Self-care and daily activities
Oro motor function

E) Functional assessment

F) Scales

Differential Diagnosis

Investigations
Diagnosis

ICF

Goals
A) Parent goals

B) Long term goals

C) Short term goals

D) Session goals

Treatment Plan