PAEDIATRIC ASSESSMENT FORM

I). ANTHROPOMETRIC DETAILS Name: Age: Gender: Date of birth: Expected date of delivery: Corrected Age Birth weight: Birth Head circumference: Birth Height: II). CHIEF COMPLAINT: III). HISTORY: Antenatal history: Ask the mother if sheWent for regular antenatal checkups? Took iron, calcium and folic acid supplementation? Felt fetal movements at which month? Did they increase progressively? Had any history of fever, rash, infection? (TORCH infections) Had history of gestational diabetes, hypertension Any other complications during pregnancy Natal history: Ask the mother about the duration of labor, was it induced? Ask the mother if the baby Was born full term, pre term or post term? Normal delivery or caesarian section? Presentation- cephalic or breech? Any other complications during delivery- cord around the neck, prolapsed cord etc. Did the baby cry immediately after birth ?if not, after how long? Was the baby kept in NICU for any reason? When was the baby first breast fed? Was he able to suck properly? Any history of fever, jaundice, seizures? Any history of congenital deformities? Any other complications? Post Natal History Is similar to history of present illnessIt traces the course of illness from when the problem first occurred till the date of assessment. It includes, but is not limited to the following pointsWhen did the parents first notice the problem, Any history of seizures, meningitis, fever, trauma? Did the parents consult a doctor? Was physiotherapy advised? Was it done regularly? How is the condition progressing? Is the child better or deteriorating?

Family history Includes fathers and mothers age, No. of children their age /any history of abortions, deaths History of similar complaints in the family Consanguinity Draw a family chart as show in the example

Development history Gross motor Head control (4 months) Rolling supine to sidelying (4-5 months) Rolling supine to prone (5- 6 months) Rolling prone to supine (5- 6 months) Sitting with support (6- 7 months) Sitting without support ( 7- 8 months) Pull self to stand ( 11 months) Standing with support ( 10- 11months) Standing without support (11- 12 months) Walking with support (11-12 months) Walking without support (12- 13 months) Climb stairs ( 2 -3 years) Fine motor- voluntary grasp (5 months) Reach (4-5 months) Pincer grasp (1 year) Personal social Social smile ( 2 months) Recognizes mother ( 2-3 months) Stranger anxiety ( 5-6 months) Communication Cooing Monosyllables Bisyllables IV). ON OBSERVATION: General Is the child alert, playful, drowsy, irritable, crying Built Facial appearance OBSERVE THE CHILD IN EACH OF THE POSTURES HE IS ABLE TO ATTAIN And HOW HE ACHIEVES THOSE POSTURES( Transitions) appropriate for the childs age. For example Supine Head in midline or not, turning to both sides Visual tracking Position of upper limbs able to bring to midline or not

Position of hands, manipulation skills Position of lower limbs- movement of lower limbs Breathing pattern /rate, any flaring of ribs. Prone- Able to turn head to side in prone? ( for neonate) Able to lift head in prone? Able to sustain posture (for child 5 months or above) Able to achieve prone on forearms? Able to reach for toys with one hand? Sitting Sitting on floor describe the position in terms independent or dependent, Sitting on stool if independent- centre of mass and base of suppport Standing Analyse the position, independent/ dependent Center of mass Base of support Transitions Supine to sidelying Sidelying to prone Supine to sitting Sit to stand Ambulation Crawling / walking Analyze how the child moves from one position to other

V) ON EXAMINATION
1.Higher cortical functionsAlertness Recognize family members Gives response to play activities Follow commands Is able to tell needs Is aware of surroundings Well oriented 2.Cranial Nerve examinationChild older than 5 years, tested as in adults Less than 5 yearsII- Blink reflex III, IV, VI Eyes follow movement V- Rooting ,sucking reflex Clenching of teeth VII Facial symmetry while laughing or crying, nasolabial fold, wrinkling forehead VIII Loud nosies yields MOROS reflex until 4 months Eyes follow direction of sound Startle response IX, X Gag reflex, swallowing, coordinates sucking, swallowing XII- Symmetry and tone of tongue 3.Sensory examinationChild older than 5 years, tested as in adults Less than 5 yearsCheck for awareness or response (eye ball movement/ turns head toward side of touch etc)- when touched Check pain, if absolutely essential Check for any signs suggesting hyper response or aversive response to touch 4.Neuromuscular examination Tone ( Modified ashworth scale) Superficial reflexes- Abdominal, Corneal, Plantar Deep tendon reflexes If more than 2-3 years old use reflex hammer Less than 2 yr old, tap using finger

Developmental reflexes- To be done based on the childs developmental age Primitive- Rooting, sucking, plamar grasp, plantar grasp, Moros, placing, Landaus, Spinal Flexor withdrawal, crossed extension withdrawal 5.Musculoskeletal examination Range of movement- active and passive of all joints Muscle strength If child more than 5 years- MMT If less than 5 years- Document if movement against gravity is present or absent in limbs. Tightness Deformity/ contracture Limb length if Limb girth applicable 6. Cardio respiratory assessment Breathing pattern Breathing Rate Chest expansion Chest symmetry Flaring of ribs On auscultation 7. Oromotor assessment Tone of oral musculature Palate- high arched/ normal Tongue- shape, tone, position Mouth closure Drooling of saliva Chewing of food in older children Swallowing Also assess, if any sensory seeking behavior is present 8) Any other assessment as appropriate, for eg, assessment of balance, coordination, gait

VI) SCALES
INFANIB GMFM Posture and fine motor assessment of children Functional evaluation weeFIM/ FIM

VII) INVESTIGATIONS
X ray Ct scan Electrodiagnostic tests

VIII) DIAGNOSIS IX) PROBLEM LIST X) GOALS

XI) MANAGEMENT