ASSESSMENT GUIDE FOR NORMAL PEDIATRICS

(for Infant, Toddlers, Pre-schoolers, Schoolers and Adolescents)

I.VITAL INFORMATION

Name of Child: D. E. T. Date and Time of Interview: 09/30/24 9:25 AM

Sex: Male Name of Informant: J. P.
Date of Birth: March 13, 2024 Relationship with the child: Mother
Age: 6 months
Address: Magsaysay Village, La Paz, Iloilo City
Name of Mother: J. P. Age: 29 years old
Educational Attainment: 3rd Year College
Occupation: N/A
Name of Father: D. T. Jr. Age: 39 years old
Educational Attainment: College Graduate
Occupation: Tricycle driver
Approximate income of the Family: 600-800 pesos per day

II. PERSONAL HISTORY:

A. PRENATAL

Mother’s general health:

J. P verbalized that her pregnancy was sensitive, in terms of pain and discomfort she felt throughout her
pregnancy. At 9 weeks, J.P. said that she experienced bleeding, and was immediately rushed to WVMC. No complications
were found at consultation and was only told to be cautious with her daily activities. J.P. also stated that throughout her
pregnancy, she experienced muscle pain and fatigue, expressing difficulty in rising from bed.

B. OBSTETRIC

OB Score: GTPAL: G3 T3 P0 A0 L3 LMP: June 21, 2023 EDD/EDC: March 28, 2024 AOG: ___N/A_____

Type of Delivery: 🗹 NSVD ⃞ CESAREAN SECTION

Place of Delivery: Home__________ Hospital: WVMC Health Center_________

Birthing Center_________

Analgesia used: Client cannot recall

Consultation during pregnancy: Private Physician ________ Municipal health Officer ___✔___

Others: ____________

Complications during delivery: Preeclampsia

C. BIRTH

APGAR Score________

Birth weight: 2.1 kg Head circumference ___N/A___

Feeble Vigorous (cry/movements) 🗹

Resuscitated Cyanosis
Pallor Dyspnea

III. FAMILIAL HISTORY

 Birth order of the child ____3rd______ Total number of siblings 2
Number of living siblings ____2____ Type of housing (description)
Serious diseases among siblings Owned ✓
________________N/A_____________ Rented
Death of siblings_________N/A______ Cause of death___N/A_________
Heredo-familial disease
Maternal Asthma, Hypertension
Paternal Diabetes

IV.PAST MEDICAL HISTORY

Number of past hospitalizations___N/A___

Date of last confinement _____N/A______
When _______________N/A________
Where ___________N/A___________
Number of days of hospitalization________N/A_______

Reason for hospitalization (Brief history: include treatments, medications, x-rays,

etc.)____________________________________N/A___________________________________
___________________________________________________________________________

V. NUTRITIONAL HISTORY

Type of Check and Age started Type of milk Dilution Total intake
feeding Specify for 24- hours
Bottlefeeding x N/A N/A N/A N/A
Breastfeeding ✓ Birth Breast milk Pure J.P. does not
measure as it
is directly
from her.
Mixed feeding x N/A N/A N/A N/A
Total

Age of weaning ____6 months____

Supplementary feeding (specify) “Sabaw”
Vitamins (Type and Amount) Cherifer Drops and ascorbic acid (PedCee Drops). The initial dosage for each of them was
2.5 ml. After that, they continued to give 0.3 mL once a day of each vitamin.

VI. EATING PATTERNS (for older children)

Meals Usual Foods Taken Amount Time of day

Breakfast N/A N/A N/A
Lunch N/A N/A N/A
Supper N/A N/A N/A
Snacks N/A N/A N/A

Food likes _____________________________N/A_______________________________________________

Food dislikes _______________________________N/A___________________________________________
Beliefs and Falacies _________________________N/A____________________________________________

VII. REST AND SLEEP

Usual Bedtime and Waking Hours Bedtime: 11:00pm-6:00am

Waking Hours: 6:00am-8:30am, 10:00am-2:00pm,
6:00pm-11:pm
Naps 8:30am-10:00am, 2:00pm-6:00pm
Bedtime rituals Breastfeeding until asleep
Problems with sleep and usual remedy Not really a problem, but if the infant wakes up in
the middle of the night, J. P. breastfeeds until he
sleeps again.
Total number of sleeping hours 12 ½ hours to 14 hours

VIII. ELIMINATION PATTERN

A. Bowel Elimination
Frequency twice a day
Problems and usual remedy N/A

B. Urinary Elimination
Frequency 4-5 times a day
Problems and usual remedy N/A

C. Toilet Training
Age started
Bowel N/A
Urine N/A

IX. IMMUNIZATION STATUS

Type of Immunization First dose Second dose Third dose

1. BCG Age: Birth Date: Age Date Age Date

3/13/2024

2. Hepa B Age Birth Date: Age Date Age Date

3/13/2024

3. Pentavalent Age 1 ½ months Age 2 ½ months Age 3 ½ Date:

Vaccine Date: 4/24/2024 Date: 6/05/2024 7/03/2024

4. Oral Polio Age 1 ½ months Age 2 ½ months Age 3 ½ Date:

Vaccine Date: 4/24/2024 Date: 6/05/2024 7/03/2024

5. Inactivated Polio Age 3 ½ Date: Age Date Age Date

Vaccine 7/03/2024

6. PCV Age 1 ½ months Age 2 ½ months Age 3 ½ Date:

Date 4/24/2024 Date 6/05/2024 7/03/2024

7. MMR Age 1 ½ months Age Date Age Date

Date: 4/24/2024

X. CEPHALOCAUDAL ASSESSMENT

Temperature 36.8°C Pulse 154 Respiratory rate 31

BP N/A Height/Length 65 cm Weight 6.2kg

General Appearance : Alert and responsive to the environment, good muscle tone, symmetrical blinking and
movement, light brown skin color, no signs of distress, lesion found on the right cheek.

Head: Midline; Thin black hair; Anterior fontanelle: firm, slightly curved inward, soft, flat; Head circumference: 42 cm.

Eyes: Eyelashes: equally distributed, curled slightly outward; Pupils: black, equal in size; Symmetrical blinking and
movement; No discharge or lesions.
Ears: Pinna: symmetrical, no lumps or lesions; Cerumen present: off-white to yellowish color.

Nose: Midline and symmetrical; Uniform in color; No discharge, flaring, lumps, or lesions.

Mouth: Lips: pink, slightly moist, symmetrical; No teeth observed; Gums, Buccal Mucosa, Tongue: uniformly pink and
moist.

Neck: Not assessed.

Chest: Equal chest movement.

Back: Not assessed.

Abdomen: Umbilicus: No swelling, tenderness, or discharge.

Upper Extremities: Symmetrical in size and movement; No tenderness, swelling, or lesions.

Lower Extremities: Symmetrical in size and movement; No tenderness, swelling, or lesions.

Genito-anal: Not assessed.

Skin: Uniform in color: light brown; Lesion (birthmark) found on the right cheek; No bruises or lacerations.

XI. DEVELOPMENTAL ASSESSMENT

Found in Textbook Actual Observation Significance

A.GROSS MOTOR Begins to show ability to sit When D.E.T. was placed Gross motor skills
DEVELOPMENT by 6 months on his mother’s lap, it was involve movements
observed that he could sit that use large
upright with only support muscle groups,
from the back. Baby was such as sitting,
also seen bending standing, walking,
forwards and backwards and running. baby
is progressing
normally in their
gross motor
development

B. FINE MOTOR Starts to transfer objects When given an object, like Fine motor skills
DEVELOPMENT hand to hand a towel or a small toy, involve movements
D.E.T. is seen holding and that use small
transferring it to the other muscle groups,
hand. such as those in the
hands and fingers.
This milestone is
normal for infants
in this age. This
demonstrates their
increasing hand-eye
coordination skill
and their improving
dexterity
C. SENSORY Vision: 6 month old infants Vision: D.E.T.is observed The ability to
DEVELOPMENT are capable of organized to be able to focus on perceive depth is
depth perception objects and people at crucial for tasks like
Hearing: 6 month old infants different distances. reaching for
are able to locate sounds Hearing: D.E.T is able to objects, navigating
made above them move his vision to look at their environment,
sources of loud sounds or and developing
speech. When clapping spatial awareness.
above the D.E.T., he looks Also, the ability to
up at the direction of the focus on objects at
sound. different distances
indicates that the
baby's eyes are
developing the
necessary
accommodation
skills.

The ability to locate

sounds is essential
for understanding
their environment,
attending to
important stimuli,
and developing
language skills.
Also, the ability to
move their vision to
look at loud sounds
demonstrates the
integration of
auditory and visual
information.

C. REFLEXES Moro and tonic neck reflex, These reflexes are not Reflexes are
palmar grasp starts to fade apparent when observed. involuntary
movements that are
present at birth and
gradually disappear
over time as the
child’s nervous
system matures.
The fading of these
reflexes indicate
that the infant’s
brain allows for
more voluntary
control over their
movements.
D. PSYCHOSOCIAL May start to show fear of D.E.T. did not frown or cry This is a common
DEVELOPMENT strangers at 7 months at the sight of strangers. developmental
AND stage, often
SOCIALIZATION referred to as
"stranger anxiety,"
that typically begins
around 7 months
old. The absence of
stranger anxiety at
this stage doesn't
mean that the
infant won't
develop it later on.
 Some infants may
show stranger
anxiety at a later
age. However, the
lack of fear at this
stage is generally
considered a
positive sign of
healthy social
development.
I. LANGUAGE / Starts saying vowel sounds, J.P. verbalized that D.E.T. The infant’s ability
SPEECH (oh-oh) says vowel sounds like to produce vowel
DEVELOPMENT “oh-oh” or ‘ah-ah” during sounds
play and waking hours. demonstrates that
their vocalization
skills are
developing.w

Vowel sounds are

the most basic
fundamentals of
language.
Mastering these
sounds is essential
for speech
development,
including the
production of
consonants and
words.

XII. AREAS IDENTIFIED NEEDING HEALTH TEACHINGS

CUES HEALTH TEACHINGS

No health teachings needed

because J.P. continues
breastfeeding which is the
complete source of nutrition for
NUTRITION infants.

No health teachings needed

because D.E.T. demonstrates the
usual activities that are normal
for 6-month old infants.
ACTIVITIES

No health teachings needed

because J. P. is on track for the
immunizations of baby D. E. T.

IMMUNIZATION
 ● Pathway to house is ➢ Ensure to always look at
slippery where you walk, have it
● Trash and debris in the cleared for better view
surroundings and if possible, have a
● Mosquitoes present as stable support like a cane
SAFETY verbalized by J. P. (can be an umbrella or a
strong piece of wood)
➢ Clean and clear the
surroundings of the trash
and debris to lessen risk
of accidents
➢ Use mild mosquito
repellants and mosquito
net

OTHERS

Reflexes How elicited Actual Significance

Observation

Shine a bright light or When we snapped our The blink reflex is a

clap hand near the eyes fingers near D. E. T., he protective and
Blinking Reflex of the infant. This will immediately blinked. involuntary response
cause the blinking. that helps protect the
eyes from potential
harm, such as bright
light, foreign objects, or
sudden movements near
the face.
When you touch a D. E. T. still breastfeeds The sucking reflex is
newborn’s mouth or and we observed that essential for feeding. It
Sucking Reflex place the nipple into he is thumb sucking at allows the infant to latch
their mouth to begin times. onto the breast and
breastfeeding or, they extract milk efficiently.
will start sucking. Even at 6 months,
infants may continue to
suck on fingers,
pacifiers, or other
objects for comfort.
Loud noises or sudden When J. P. picked up Moro reflex has a
movements such as a D.E.T. from the protective role. It occurs
Moro Reflex quick change in position “abuy-abuy”, D.E.T. in response to a sudden
can stimulate this reflex. immediately reached for change in the infant's
With the startle or Moro his mother’s embrace. environment, such as a
reflex, your baby should loud noise, a sudden
throw his or her arms movement, or a
and legs outward, cry sensation of falling. By
this time though, it
 loudly, and then draw should start to diminish
them back in. or fade.
Put your finger into the When I put my finger The fading of the palmar
palm of the infant's into the palm of D.E.T., grasp reflex is essential
Palmar Grasp Reflex hand and the infant will he grabbed my finger for the infant to gain
tightly grab the finger. but it was a little loose. control over their hands
and fingers. This allows
babies to develop fine
motor skills.
Firmly stroke the infant’s As I stroked my finger The presence of the
foot from its heel to the from D.E.T’s heel to toe, Babinski reflex is
Babinski Reflex toe. Their big toe moves his toes fanned out. expected and normal. It
upward or toward the is a normal sign of the
top surface of the foot, developing nervous
while the rest of the system and reflects
toes open up and healthy, age-appropriate
separate. neurological function for
the infant.