1.

Patient details
Name, age, sex, address :
Informant (reliable/not) :
Date of admission :
2. Presenting complaint
(In chronological order, in patient’s own words)
3. History of presenting complaint
Onset (sudden, gradual, insidious)
Progression (increasing, decreasing, static)
Quality
Relieving, aggravating factors, radiation
Severity
Timing
Associated symptoms
Diurnal variations
Present status
Negative status
Note: In a CP Child Past History and Birth History can be combined
4. Past medical history
H/o similar illness (if yes, describe)
H/o previous hospitalization
H/o any significant illness (asthma, TB, epilepsy, jaundice, diarrhea, heart disease)
H/o vaccine preventable diseases (TB, mumps, measles, hepatitis, whooping cough)
H/o any surgeries
H/o any drug intake
5. Birth history
(A) Antenatal history
Age of mother at conception
Age of father at conception
Birth order
Consanguineous / non-consanguineous marriage
H/o any abortions

T1 - Pregnancy confirmed by UPT

Regular antenatal checkup
2 doses of TT taken /not
Iron folic acid tablets taken/not
H/o UTI, abdominal pain
H/o bleeding, leaking PV, fever with rash
H/o drug intake (Na valproate, phenytoin, steroids)
Anomaly scan done?
T2 - Quickening felt at _______ months.
Iron, folic acid, calcium, vitamin tablets taken.
H/o DM, HTN
H/o UTI, abdominal pain
 H/o edema
H/o bleeding /leaking PV
USG done?
T3 - Nature of fetal movement (increased/decreased)
H/o DM, HTN
H/o UTI, abdominal pain
H/o edema
H/o bleeding /leaking PV
(B) Natal history
Full trim/ preterm/ past term/ small for gestational age
Normal vaginal /caesarian /instrumental delivery (if CS mention indication)
Birth weight (lbw/not)
Delivered at home /hospital
Any h/o malpresentation, malposition?
Any complication?
(C) Postnatal history
Baby cried immediately after birth/not
Any h/o resuscitation?
Breast fed immediately/ in how many hours?
Any feeding difficulty, repeated vomiting, respiratory distress, cyanosis, umbilical
sepsis, seizures, jaundice, bleeding manifestations?
When meconium passed (normal within 24 hours)
When urine passed? (normal within 48 hours)
6. Developmental history

Developmental milestones attained upto age / not?

a) Gross motor development :
 Neck holding/ head control 3 months
 Rolls over (P to S / S to P)  5-6 months
 Sits in tripod fashion (sits in own support) 6 months
 Stands with support 9 months
 Stand w/o support, walks but falls, creeps well 12 months
 Walks alone, creeps upstairs 15 months
 Run, explore drawers 18 months
 2 feet per step upstairs and downstairs, jumps 2 years
 Alternate feet upstairs, rides tricycle 3 years
 Alternate feet downstairs, hops on one foot 4 years
 Skips 5 years

b) Fine motor development :

 Grasp reflex stops at 3 months
 Hand regard (observing own hands intently) 3 months; stops at 5
 Bidextrous reach 4 months
 Unidextrous reach; ulnar palmar grasp; transfer of objects 6 months
 Mouthing 6 months (stops at 1 year)
  Radial palmar grasp; immature pincer grasp; probes with forefinger
9 months
 Mature pincer grasp; drinks from cup but stills; pull off caps, socks
12 months
 Tower of 2 blocks ;scribbling ;drinks from cup w/o spilling turn 2-3 pages at a
time  15 months
 Tower of 3 blocks; feeds self with spoon; draws vertical strokes, unzip dress but
can’t unbutton 18 months
 tower of 6 blocks/train ;horizontal and circular stroke; put socks, shoes, undress
completely 2 years
 Train with chimney  21/2 years
 Train of 9 blocks; bridge, draws circle, dress and undress fully (if helped with
button)  3 years
 Make gate with blocks; draws cross  4 years
 Draws square 4 1/2 years
 Draws triangle; ties shoelace  5 years
 Square with diagonal and median  6 years
 Draws diamond  7 years
 Draws cylinder  9 years
 Draws cube  11 years

c) Personal & social development :

 Regards faces  1 month
 Social smile 1 1/2 - 2 months
 Smile of recognition, recognizes mother  3 months
 Mirror smile  6 months
 Stranger anxiety 6-7 months
 Waves bye-bye 9 months
 Understand simple questions like “where is papa?” ; plays simple ball games
 1 year
 Points to object he is interested in 15 months
 Domestic mimicry; follow simple order 18 months
 Asks for food, drinks, toilet; pulls people to show toys, name 2-3 objects; name
3-4 body parts 2 years
 Share toys, knows full name & gender; begins to count, sing simple rhymes,
identify 1-2 colors 3 years

d) Language milestone :
 Turn head to sound 1 month
 Cooing (vowels) 3 months
 Laugh out loud 4 months
 Monosyllables (ba,da,pa) 6 months
 Bisyllables (mama,papa) 9 months
 2-3 words with meaning 12 months
 Vocabulary of 10-15 words 18 months
 Vocabulary of 100 words, 2-3 word sentence 2 years
  Asks questions, knows full name and gender 3 years
 Coherent account of events, experiences, simple stories 4 years
 Asks meaning of words 5 years

e) Vision :
 Follow upto 45 0  at the birth
 Visual fixation; follow upto 90 0  1 month
 Follow upto 180 0  3 months
 Adjusts position to follow objects of interest  6 months
 Fixation on rapidly moving objects  1 year

f) Hearing :
 Respond to sound by ery, blink, etc….  at birth
 Turns head toward source of sound  3-4 months
 Directly looks at the source of sound 10 months

g) Bowel & bladder control :

 Bladder control (dry by day  1 1/2years ; dry by night  3 years)
 Bowel control 3 years

7) Dietetic history
 When put to breast?
 Exclusive breast feeding upto _______ months, and breast feeding continued upto
_____ months / year.
 When Complementary feeding was started? With what?
 When was solid food started?
 When started sharing family diet?
 The child is getting ______ kCal and _____ g protein respectively against the ICMR 2010
recommendations of _______ & _______ for age.
Hence, calorie gap = _______, protein gap = ______.
 Diet rich in fruits, green leafy vegetables, non- veg diets, vitamins & minerals.
 Any dietary modifications due to illness?
 Dietary modifications you have advised.

INDEX

Item Qty. K cal Protein (g) Item Qty. K cal Protein (g)

Cooked rice 1 cup 175 4 Dosa 1 70 2

Uncooked rice 1 tsp 100 2 Idly 1 50 2

Cow’s milk 1 glass 130 6.6 Chappathi 1 70 2

(200 ml)
 Egg 1 80 6 Puri 1 35 1

Fish 1 oz 80 6 Uppuma 1 cup 250 6

Sardine 1 30 3 Bread 1 slice 10 2

Human Milk 100 67 1.1

Groundnut 10 20 1 Beef

Banana 1 100 1 Upperi 1 cup 10 2.5

Pappad 1 20 0 Sambhar 100 g 50 2.5

Fruits 100 g 60 0.5

Puttu 50 2 Coconut 1 tsp 444 45

Vada 1 50 1 Sugar 1 tsp 20 0

Cooked dal 1 tsp 8 0.5 Lactogen 100 g 100 2

(6 tsp)
Ragi 100 g 100 2 Amritham 100 g 100 6.8
(6 tsp) (6 tsp)

RDA for Energy * Protein (ICMR 2010)

Age Net Energy (Kcal/kg) Protein (g/kg)

0-6 mon 92 KCal/kg/day 1.16 g/kg/day

6-12 mon 80 KCal/kg/day 1.69 g/kg/day

1-3 years 1060 KCal/kg/day 16.7 g/kg/day

4-6 years 1350 KCal/kg/day 20.1 g/kg/day

7-9 years 1690 KCal/kg/day 29.5 g/kg/day

10-12 years 2190 KCal/kg/day 39.9 g/kg/day

2010 KCal/kg/day 40.4 g/kg/day

13-15 years 2750 KCal/kg/day 54.5 g/kg/day

2330 KCal/kg/day 51.9 g/kg/day

16-17 years 3010 KCal/kg/day 61.5 g/kg/day

 2440 KCal/kg/day 55.5 g/kg/day

Adult male 2830 KCal/kg/day 60 g/kg/day

Adult female 2230 KCal/kg/day 55 g/kg/day

8) Immunization history
 Whether immunization is adequate for age? If not, reason?
 Bcq scar present
 Last vaccine taken on?
 Any optional vaccine taken? If so, mention details?
 Booster doses of the vaccine taken?
 Advice given to the parent, if any?

INDEX : NATIONAL IMMUNIZATION SCHEDULE

at birth BCG, OPV -0

6 weeks ( 11/2months ) OPV -1, PV -1

10 weeks ( 2 1/2 months) OPV -2, PV – 2

14 weeks ( 3 1/2 months ) OPV – 3, PV -3

9 months Measles, Vit-A

18 months ( 1 1/2 year ) DPT 1stbooster, OPV 1st booster, MMR, Measles-2 ( if MMR
not given ), Vit-A (Vit-A doses given every 6 months from
then till 5 years - total 9 doses)

5 years DPT 2nd booster

**PV = DPT + Hi b

9) Family history
 Draw Pedigree (3 gen)
 Mother - age, healthy/not
 Father - age, healthy/not
 Consanguineous/non consanguineous marriage? If yes, then degree?
 Siblings - age, health/not
 Order of birth
 Any significant illnesses in the family? (TB, asthma, epilepsy, jaundice, heart disease,
DM, HTN)
 Any congenital anomalies, abortion, still birth?
10) Socioeconomic history
  APL / BPL family
 Joint / Nuclear family
 Education ,Occupation of parents
 Family income
o Housing ;
o Roof  thatched/tiled/terrace (RC)
o Floor
o Ventilation
o No. of rooms
o Any overcrowding?
 Sanitation
 Water supply? Distance from toilet?
 Drinking boiled /cooled water or not?
 Environment and surroundings?
 Any risk of passive smoking in the family?
 Any financial supports? (RSBY, JSY, old age pension, pension for disabled)

General examination
 During examination, the child is
Conscious /cooperative (mental attitude)
Active /playful/comfortable /restless/bedridden (physical attitude
 Vitals (given below)
 Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
 Skin, hair, nails?
 Other findings if any (mantoux, IV line, nasogastric tube, catheter etc…)

Vitals:
(1) Pulse rate, rhythm, volume, character, RF delay, vessel wall thickening, all peripheral
pulsation.

Pulse rate in : NB-140/-, upto 1 year -120/-, upto 5 year-100/-, upto 10 year -90/-, >10 year – 80/-
Tachycardia : >200 in NB, >150 in infants, >120 in older children.

(2) Blood pressure  -------- mm of Hg at RUL in supine/sitting position.

 Cuff 2/3 rd size of arm, length; 80 % of arm circumferences, breadth; 40 % of arm circumference.
 Doppler method is more accurate.
 Flush method is infants (tie cuff-raise limb-massage to branch-fully inflate cuff-gradually deflate-
point of sudden flushing of distal limb
= (mean arterial pressure) ( mean BP =diastolic BP + 1/3 PP )
 LL BP > UL BP (app. 10 mm of hg).
 Normal BP is defined as SBP & DBP < 90 th percentile for that age & sex
 HTN is average SBP or DBP> 95 th percentile for that age & sex or at least 3 occasions.
 NB-60/40 mm Hg; upto 2 years-70/50 mm Hg; upto 5 years-90/50 mm of hg.

(3) Respiratory rate  ( /min, regular/irregular, abdominothoracic/thoracic/abdominal

depth (shallow/deep/normal)
Abdomino –thoracic  upto 6 years in both male and female
Thoraco – abdominal  females > 6 years

New Born : 40 / min Tachypnea

Upto 1 year : 30 /min < 2 months : 60 /min
Upto 5 year : 20 /min 2 months - 1 year : 50 /min
Upto 10 year : 18 /min 1 year - 5 year : 40 /min
10 years : 18 /min 5 year - 12 year : 30 /min

(4) Temperature  febrile/afebrile; temp?

 Infants /young children < 5 years axillary/rectal; > 5 years oral temperature
(Oral temperature = Rectal-0.5 0C / Axillary+0.5 0C)
 Normal temperature varies from 36.5 o – 37.5 0 C (> 41 0C - hyperpyrexia)
(< 35 oC - hypothermia)
 NB: 36 - 37 0C ; upto one year 36.5 – 37.5 0C ; greater than 1 year  37±0.2 0C

Head to foot examination

 Head : size; anterior fontanelle (size,closed/not,bulging/depressed) (measured by
the lines joining the midpoint of opposite sides)
 Hair: depigmentation, alopecia, flag sign, low hairline?
 Face: any dysmorphism
 Eyes: pallor, icterus, signs of vitamin a deficiency, cataract, hypertonic eyes?
 Any anomaly? Low set ears?

Low set ears in: trisomy 13,18,21 (patau, edward’s, turner ), down’s syndrome, cri du chat syndrome,
noonan syndrome, digeorge syndrome, apert’s syndrome, potter’s syndrome.
Method to identify: make the patient stand straight and an imaginary line is drawn from outer
canthus of eye straight back to occiput, thus parallel to the floor (normally 1/3 rd of the eye comes
above this line. When <20 % comes above this line, it is a low set ear).
 Nose: DNS , polyp ?
 Oral cavity: hygiene, dentition, palate, tonsils, lips. Any caries, glosittis,stomatitis.
 Neck: LNs, short neck, low neckline, (below C5 spine, as in turner’s)
(normal neck:height = 1:13)
 Chest: shape, wide nipples, other findings of rickets?
 Limbs: UL pallor, clubbing; LL edema
 Abdomen: distension, dilated veins?
 External genitalia :
 Spine: any deformities?
 Skin: rashes, pyoderma, neurocutaneous markers, finding of PEM, others?
  Nails: normal/not? Not; koilonychia, discolouration?

Anthropometry
1. Weight actual -----, expected ------, inference?

Birth 7-10 Days 3 mon

Loses 10 % of 30 g/day
B.W due to loss Regains B.W
of ECF 20 g/day

12 mon 9 mon 6 mon

12 g/day 15 g/day

Age Wt WEECH’s formula to calculate weight

At birth x
6 months 2x
 3-12 months – (x in months)
1 years 3x
 1-6 years - (x in years)
2 years 4x
3 years 5x  7-12 years - (x in years)

5 years 6x
1 S.D = 12.5 % of value
7 years 7x
10 years 10x

IAP classification of PEM IAP classification of PEM Welcome trust classification of PEM

PEM Wt for age Wt. For age Nutritional status

Normal > 80 % 60-80 % + no E Under nutrition
Grade -1 71 – 80 % 60- 80 % + E Kwashiorkor
Grade -2 61 – 70 % < 60 % + no E Marasmus
Grade -3 51 – 60 % <60 % + E Marasmic-Kwashiorkor
Grade -4 < 50 %

2. Length/Height: Actual………., Expected………., Inference?

 Age Normal length Age Rate of increase
Birth 50 cm birth –3 months 3.5 cm /mon
3 months 60 cm 3 mon – 6 mon 2 cm/ mon
9 months 70 cm 6 mon – 9 mon 1.5 cm /mon
1 year 75 cm 9 mon – 1 year 1.3 cm/mon
2 year 87.5 cm 1 year – 2 year 1 cm /mon
3 year 94 cm 2 year – 5 year 6-8 cm /year
41/2 year 100 cm 5 year – 12 year 5 cm /year
WEECH’s formula to calculate expected height from 2 to 12 years;
Expected height (2- 12 years) = 6x +77
Target height ( helps to assess the child’s growth potential ),
Boys (cm) = father’s height + mother’s height + 6.5
2
Girls ( cm) = father’s height + mother’s height - 6.5
2
 The correct acceptable range of height for a child is within 2 S.D of the target height
percentile. [1 S.D =4 % of value]

 Short stature = reduction in height by more than 2 S.D

 Indicators of PEM:
1. Weight for age (W/A): most sensitive indicator of malnutrition. If the child has low
W/A, it is said to be under weight. Low W/A is seen in both a/c & c/c malnutrition.
2. Height for age (H/A): if the child has low H/A, it is said to be stunted. It is seen in c/c
malnutrition.
H/A = height of the child x 100
height of the (n) child of same age
3. Weight for height (W/H): if the child has low W/H, it is said to have wasting. Low
W/H implies a/c malnutrition.
W/H = weight of the child x 100
weight of (n) child of same height
WATERLOW’s grading of wasting based WATERLOW’s grading of stunting based on
on weight for height (W/H) height for age (H/A)

> 90 % No wasting > 95 % Normal

80 – 90 % Mild wasting 90 – 95 % Grade 1 stunting
70 – 80 % Moderate wasting 85 – 90 % Grade 2 stunting
< 70 % Severe wasting < 85 % Grade 3 stunting

3. Head Circumference: actual ………, expected………, inference?

Maximum circumference of head from the occipital protuberance to the supra orbital ridges
on the forehead is recorded by cross taping.
DINE’s Formula for H.C in 1st year of life
H.C = l/2 + 9.5 ± 2.5 cm (l = length of child in cm)
Age Normal H.C (cm) Age Rate of increase of H.C
At Birth 34-35 Birth – 3 mon 2 cm/ mon
2 mon 38
3 mon 40 3 – 6 mon 1 cm/ mon
4mon 41
6 mon 43 7 – 12 mon 0.5 cm/ mon
1 year 45
2 year 47 1 - 3 years 2 cm/ mon
3 year 49
4year 50 3 – 5 years 1 cm/ mon
5 year 51 1 S.D = 2.5 % of value
12 year 52 (1.25 cm approx.)
 Microcephaly  reduction in h.c by > 3 S.D from normal (or) less than 5 th percentile for
the age and sex.
(Down’s syndrome, Edward’s syndrome, IU infections –toxoplasmosis, rubella, fetal alcohol
syndrome, fetal hydantoin syndrome)
 Macrocephaly  increase in H.C by > 2 S.D from normal (or) H.C more than 95th
percentile for age.
(Hydrocephaly, rickets, achondroplasia, Noonan syndrome, hydrencephaly)

4. Chest circumference: C.C = _________, inference?

 Measure at the level if nipple, midway between expiration and inspiration.

 At birth , C.C = H.C - 3 (approx. 31 cm ) & in malnourishment, H.C > C.C even 9 months – 1
year H.C = C.C
 5. Mid upper arm circumference MUAC = ________ inference?
 Age independent criteria between 1- 5 years
 While the child hangs the LEFT upper limb by the side, mark the midpoint
between acromion & olecranon process. Measure by cross taping.

Average normal values Arnold’s classification of PEM

 13.5 – 16 cm : normal ,no PEM

 At birth : 11-12 cm
 12.5 – 13.5 cm : mild to moderate PEM
 1- 5 years : 15- 16 years  < 12.5 cm : severe PEM

Other methods;
 Shakir’s tape: plastic tape with coloured zone -->green, yellow, red
(green >13.5 cm, yellow - 12.5 to 13.5 cm, red < 12.5 cm.
 Bangle test: if the bangle of inner diameter $ cm crosses the elbow, the child is
malnourished.
 Quack-stick method: it consists of two set of marking - one indicating (Ht) and other
MUAC for the corresponding height. MUAC is measured and the stick is placed
behind the standing child. If the height is more than the expected height for
measured MUAC, the child is malnourished.

6. Upper segment – Lower segment ratio = ……………… inference?

 To be taken if the patient is too short or too small. at birth 1.7 : 1

 U.s =from vertex to public symphysis; L.S =from pubic
symphysis to sole 6 months 1.6 : 1
 First measure L.S .then calculate U.S =height – L.S
1 year 1.5 : 1
 Proportionate dwarfism  U.S : L.S ratio normal for age
2 years 1.4 : 1
Disproportionate dwarfism   U.S : L.S ratio not normal
for age 3 years 1.3 : 1
 U.S > L.S Hypothyroidism, Achondroplasia, Turner’s
Synd, Rickets, Osteogenesis imperfecta, cretinism, 4 years 1.2 : 1
Hypochondroplasia, chondrodysplasia
 L.S > U.S Mucopolysaccharidosis, Hypogonadism, 7 years 1:1
Mucolipidosos, Spondylocpiphyscal dysplasia, Carics
spine. > 7 years 0.9 : 1
 7. Arm span: A.S = _____ Inference?

 The distance between the tips of middle finger of both < 5 years A.S 2 cm lesser
arms when the arms are spread apart right angle to the than height
body.
5- 10 years A.S 1 cm lesser
 The child is to be positioned to the wall as to measure
than height
the height.
 A.S > height  marsan’s syndrome, klinfelter’s 10 years A.S = height
syndrome, homocystinuria.
 A.S < height achondroplasia , cretinism.
>10 years A.S 2 cm more
than the
height