History Taking and Examination

VS  Dani; RS  Agrawal

History Taking and Examination1

• Informant

Person(s) from whom history is obtained.

Patient's Name________________ Age _____________

Sex ________________

Education ________________ Religion _______________

Caste ____________________

Address _______________________________________

Rural/Urban/Slum ________________________________

Date of Admission ________________________________
Chief complaints in chronological order ____________________________________________________________

• History of Presenting Illness

• Past History

H/o similar complaints in past
H/o any major illness in past

• Treatment History

H/o treatment received
H/o previous hospitalization

2

• Family History

Age of everybody

Number of siblings
H/o similar illness
H/o herido-familial disease
H/o infectious disease

• Socioeconomic History

Kuppuswami classification—(Modified)

(a) Upper 26 to 29
(b) Upper-middle16 to 25
(c) Lower-middle 11 to 15
(d) Lower-upper 5 to 10
(e) Lower < 5
Types of families

Nuclear
—
Mother + Father + Child
Expanded
—
Mother + Father + Child +Grandparents
Combined
—
All above + Uncle and Auntie
Overcrowding

1 Room
—
2 Persons
2 Rooms
—
3 Persons
3 Rooms
—
5 Persons
4 Rooms
—
7. 5 Persons (Child from 1-10 years is counted as half)
5 Rooms
—
10 Persons (Additional 2 for each further room).
Housing condition
Water supply

• Personal History (Bowel-bladder Habits)

• Birth History

Prenatal History

Booked/Unbooked case

G (Gravida) — P (Para) — A (Abortion) — L (Live) —

First Trimester

H/o abortifacient methods (Allopathic drugs, other pathys, manual manipulation)
H/o rubella (TORCH infections)
Hyperemesis gravidarum
H/o radiation

Second Trimester Onwards

Syphilis (Genital ulcers)

Toxaemia (High blood pressure)

Diabetes mellitus

Bleeding per vagina

H/o X-ray exposure

Natal History

Full-term / Pre-term/ Post-term

Place of delivery	—	Hospital/Home
Presentation	—	Vertex/Breech/Other
Type of delivery	—	Normal /Forceps Vacuum extraction/LSCS did baby cry immediately after birth?
H/o	—	Cyanosis/Jaundice/Convulsions at birth

Postnatal History

Birth weight

Resuscitation needed	–	Suction, tactile stimulation, bag and mask ventilation, chest compression, intubation, drug.
H/o	–	Cyanosis/Jaundice/Convulsions.

• Developmental History

Gross motor, fine motor and adaptive, language and social milestones

• Immunization

• Nutrition History

Exclusive breastfeed / Top-fed / Mixed.

Age of initiation of breastfeeding.

Duration of breastfeeding

Age of weaning

Present diet Expected diet Deficit in proteins and calories

Anthropometry

Respiratory System (General Examination)

Mental status/Alertness
Position
Built and nutrition
Pulse
Temperature
Respiratory rate, depth and type of respiration
Lower chest indrawing
Trail sign
Flaring of alae nasi
Grunting/Wheezing/Stridor
Cyanosis
Clubbing

5
E/o tuberculosis: Phlyctenular conjunctivitis, long eyelashes, sinuses in neck or bone, erythema nodosum, scrofuloderma of skin
BP
Puffiness of face/Edema feet
JVP
Pallor/Polycythemia/Icterus
Lymphadenopathy—Group, number, size, consistency, tenderness, fixed to deeper tissue.
BCG scar
Rash
S/o PEM
Spine deformity

Respiratory System (Systemic Examination)

Upper respiratory tract

Nasal cavity
Sinus points tenderness
Throat
Ear discharge/Mastoid swelling and tenderness / Otoscopy
Posterior nasal drib

Lower respiratory tract — Inspection

Shape of chest
Symmetry
Scar
Sinus
Deformity—Pectus excavatum/Carinatum
Harrison's sulcus
Intercostal spaces—Redness, fullness, retraction, flattening

6
Movement of chest with respiration
Intercostal drain – Position and movement of column

Palpation

Local temperature
Tenderness
Position of — Mediastinum/Trachea/Cardiac impulse
Confirm whether respiratory movements are equal
Tactile vocal fremitus
Friction fremitus
Chest expansion — Right and left hemithorax

Percussion

•	Percuss identical areas on both sides
•	Percussion note — Impaired/Dull/Stony dull/Hyper-resonant/Tympanic
•	Anteriorly —	Right	Left
		Kronig's isthmus	Kronig's isthmus
		Clavicular (Direct)	Clavicular (Direct)
		Intercostal	Intercostal
		UBLD	Cardiac dullness
		Tidal percussion	Traube's area
		Shifting dullness	Shifting dullness
•	Axilla	— Upper/Mid/Lower
•	Posteriorly	— Suprascapular/Interscapular/ Infrascapular

Auscultation

• Breath sounds
Intensity	—	Normal/Diminished.
Quality	—	Vesicular/Bronchial/Purile
Vocal resonance	—	Bronchophony/Whispering pectoriloquy/Aegophony (identical areas on both sides)
Adventitious sounds	—	Pleural Rub/Crepts (fine, coarse)/Rhonci.7
Other tests	—	Hydropneumothorax: coin test, succussion splash
	—	Cavity: post-tussive succussion, post-tussive crepitations

Cardiovascular System (General Examination)

•	Position of patient
•	Temperature
•	Respiration	—	Rate / Depth / Signs of respiratory distress
•	Pulse	—	Rate
		—	Rhythm
		—	Volume
		—	Character
		—	Radial femoral synchronization
•	Peripheral pulsations	—	Dorsalis pedis / Posterior tibial/Popliteal / Femoral / Brachials/ Carotid
•	Pulse deficit
•	Built and nutrition
•	Blood pressure	—	In all 4 limbs
•	Pulse pressure (S-D)
•	Anthropometry	—	Weight/Height/Arm span/US/LS ratio/Head circumference
•	SMR
•	Markers of congenital heart disease	—	Facial dysmorphism, Skeletal deformity
•	Edema
•	Jugular venous pressure/ Hepatojugular reflux
•	Pallor
•	Icterus
•	Dental caries8
•	Clubbing	—	Grade 1 (Softening of nail beds) Grade 2 (Obliteration of angle of nail beds) Grade 3 congenital (Drum-stick appearance)
•	Cyanosis	—	Central, peripheral, differential
•	Polycythemia
•	Rash
•	Joints swelling
•	Subcutaneous nodules
•	Throat examination
•	Significant cervical lymphadenopathy
•	Examination of spine
•	Fundus examination for Roth's spot

• Systemic Examination

Inspection

•	Chest	—	Symmetry/Deformity/Scar
	Precordium	—	a) Bulging/Flat b) Quite/Hyperkinetic
•	Apical pulsation
•	Other pulsation	—	Suprasternal notch	Neck	Pulmonary area
			Left parasternal	Epigastric	Right side of chest
•	Dilated veins over chest wall

Palpation

•	Apex beat	—	Position Character — Heaving; Tapping; Forceful
•	Left parasternal lift
•	Diastolic shock
•	Thrill — Site; Timing: Systolic/Diastolic

Percussion

Left border
Right border
Second left intercostal space
Second right intercostal space

Auscultation

•	Heart sounds	—	Intensity; Splitting
•	Added sounds		S3 Gallop/Opening Snap/Ejection Click
•	Murmur	—	Systolic/Diastolic/Continuous Site of maximum intensity Pitch Character Grading Radiation/Conduction Relation to position Relation to respiration Better heard with Bell/Diaphragm Maneuvers (Exercise/Valsalva
•	Pericardial rub

Abdomen (General Examination)

•	Mental status
•	Position
•	Temperature
•	Pulse rate
•	Respiration - Rate/ Depth
•	Blood pressure
•	Weight
•	Height
•	Surface area
•	Head circumference
•	SMR10
•	Facies
•	Edema
•	Eyes pallor/ Icterus/ Xerophthalmia/ Cataract/ Xanthelasma/ K F ring/ Phlycten/ Subconjunctival Hemorrhage/Proptosis/Fundus examination for Chorioretinitis
•	Mouth and oral cavity	Breath
		Gums
		Dentition
		Tongue
		Oral ulcers
•	Lymphadenopathy
•	BCG scar
•	Rosary and wide wrists
•	Xanthoma
•	Nails	Clubbing/ Leukonychia/ white bands
•	Hydration
•	Rash	Scratch marks/ Palmar erythema/ Spider nevi/ Diffuse hyperpigmentation/ Purpura/ Ecchymosis/ Erythema nodosum/ Leg ulcers
•	Joint swelling
•	Asterixis
•	Bony tenderness (Sternum/ Spine)
•	Stool/Urine–color

Systemic Examination

Inspection

Shape—Scaphoid/Distended/Normal
Umbilicus
Movement of abdominal wall with respiration
Visible pulsations
Visible peristalsis
Scar–Position/Color/Linear or stretched

11
Dialated anterior abdominal wall veins–upper abdomen/ Umbilical/ Lateral abdomen
Hernial orifices
Genitalia

Auscultation

•	Bowel sounds
•	Murmur	Right hypochondrium/ Epigastric region
•	Bruit	Right hypochondrium/ Epigastric/ Umbilical region
•	Rub-hepatic, splenic

Palpation

•	Anti-clockwise	—	Start from left iliac region
•	Superficial	—	Tense/ Guarding, rigidity/ Doughy/Tenderness
•	Deep	—	Rebound tenderness Edema of abdominal wall Left Kidney, Spleen (Size, consistency, surface, lower border, notch, tenderness) Right Kidney, Liver (Size, shape, edge, consistency, surface, pulsation, tenderness) Urinary bladder, Aorta, para-aortic glands and femoral vessels

Examine for—	Any other lump palpable
	Renal angle tenderness
	External genitalia
	Abdominal girth
	Direction of flow of blood

Free fluid thrill

12

Percussion

•	For free fluid in abdomen
	Grade 1	—	Puddle sign (percuss periumbilical area in knee-elbow position)
	Grade 2	—	Shifting dullness
	Grade 3	—	Flank dullness
•	Liver span
•	Spleen, bladder, other lump
•	Per-rectal examination prolapse/ Polyp/ Hemorrhoids

NERVOUS SYSTEM

General Examination

•	Level of consciousness
•	Position of patient
•	Rectal temperature
•	Pulse rate, peripheral pulsation, radio-femoral delay
•	Respiratory rate and type (Cheyne-Stokes, Hyperventilation, Apneustic, Biot's, Ataxic, paradoxical respiration)
•	Blood pressure in all 4 limbs
•	Weight
•	Length/ Height
•	Facies
•	Pallor
•	Icterus
•	Significant lymphadenopathy
•	Rash
•	Neurocutaneous markers —	Café-au-lait spots, Neurofibromas, Hyperpigmented lesions, Shagreen patches, Adenoma sebaceum
•	BCG scar and tubercular stigma
•	Ear discharge/ Mastoid swelling including otoscopy
•	Hydration13
•	Nerve thickening
•	Meningeal signs —	Neck stiffness, Kernig's sign, Brudzinski's sign

Examination of Head

Inspection	:	Microcephaly/ Large head, dilated veins, shunt, shiny skin, frontal prominence, small occiput
Palpation	:	Absent fontanel pulsation, bulging fontanel, sutural separation, shunt potency, heavy head
Percussion	:	Massewan sign (Crack-pot sign)
Auscultation	:	Bruit

Examination of Spine

Deformity, swelling, LP mark, sinus, tenderness

Examination of Back: Bedsores

Developmental Assessment

Motor
Social
Fine motor and adaptive
Language
Developmental age
Developmental quotient
Mental retardation

Systemic Examination

Higher Functions

Consciousness	—	Alert/Response to verbal stimuli/ Response to painful stimuli/ Unconsciousness14
Glasgow Coma Scale—
Speech	—	Aphasia (Motor/Sensory/Global) Dysarthria.
Orientation Handedness	—	For time, place, person
Handedness

Cranial Nerves

1. Olfactory	—	Sense of smell (Asses individual nostril separately)
2. Optic (a) Acuity of vision (b) Field of vision (c) Color vision (d) Fundus examination disc (Colour, Contour, Cribrosa, Cup, Circulation)	—
3. Oculomotor
4. Trochlear
5. Abducent
Inspection	—	Ptosis, squint
On Examination	—	Ocular movements: (a) Conjugate, (b) Individual
	—	Pupil-size and symmetry
Reflexes	—	Light —Direct/Indirect (consensual)
	—	Accommodation
	—	Cilio-spinal
6. Trigeminal	—	Right and left side
Motor	—	Pterygoid, Temporalis, Masseters
Sensory	—	Ophthalmic, Maxillary, Mandibular divisions
Reflexes	—	Superficial-Corneal, Conjunctival
Deep	—	Jaw-jerk15
7. Facial	—
Motor	•	Inspection
	•	Facial asymmetry
	•	Wide palpebral fissure
	•	Bell's sign
	•	Epiphora
	•	Exposure conjunctivitis and keratitis
	•	Dribbling of saliva through angle of mouth
	•	Absence of nasolabial fold
	•	No involuntary blinking
	•	Drooping of angle of mouth to healthy side
Motor Examination
Orbicularis oris	—	Inability to whistle, asymmetry of nasolabial groove in an attempt to show teeth.
Orbicularis oculi	—	Inability to close eye properly. Bell's phenomenon
Occipito-frontalis (frontal belly)	—	No wrinkling of forehead
Nasociliary	—	No frowning of forehead
Buccinator	—	Cheeks puff out with expiration
Muscles of facial	—	Flattening of nasolabial fold, drooping of angle of mouth expression
Sensory	—	Lacrimation (Schirmer's test), taste sensation over anterior 2/3 of examination tongue, salivary secretion test
8. Auditory	—	Acuity of hearing (Watch test); Rinne's test, Weber's test, caloric test
9. Glassopharyngeal and
10. Vagus	—	Soft palate and pharynx — Nasal speech, Nasal regurgitation, Difficulty in swallowing, Ah test (note palatal movements),16
		Gag reflex
	—	Larynx — Hoarseness/ Stridor/ Aphonia Laryngoscopy
	—	Taste sensation — Posterior third of tongue for 9th nerve
11. Accessory	—	Trapezius
	—	Sternomastoid
12. Hypoglossal	—	Tongue movements, wasting and fasciculation

Motor System

Nutrition	—	Hypertrophy/Wasting
Tone	—	Normal tone, hypotonia, hypertonia (Spasticity/Rigidity)
Tested by	—	Passive Tone- Resting posture, Scarf sign, Adductor angle, Popliteal angle, Dorsiflexion angle, resistance to extension and passive recoil

Active Tone	—	Head support, Pull to sit, Pull to stand
Power	—	Grade 0	—	Complete paralysis
	—	Grade 1	—	Flicker of contraction
	—	Grade 2	—	Movement possible if gravity is eliminated
	—	Grade 3	—	Against gravity movements possible but not against resistance
	—	Grade 4	—	Movements possible against some resistance
	—	Grade 5	—	Normal movement against resistance possible

Power should be tested on both sides —

Shoulder joint	—	Elevation, abduction, adduction, rotation
Elbow joint	—	Flexion, extension
Wrist joint	—	Flexion, extension
Finger joints	—	Flexion, extension, abduction, adduction
Thumb	—	Abduction, opposition,
Trunk	—	Abdominal muscles, back muscles
Neck	—	Trapezius, Sternomastoid
Hip joint	—	Flexion, extension, abduction, adduction, rotation
Knee joint	—	Flexion, extension
Ankle joint	—	Dorsiflexion, plantar flexion, eversion, inversion

• Co-ordination

Upper limb	—	Finger-nose test, buttoning, hand writing Rapid alternating movements of wrist (Disdiadochokinesia)
Lower limb	—	Heel-knee test, straight walking test, Romberg's test
Abnormal movements	—	Tremors, chorea, athetosis, dystonia, hemiballismus, fasciculation, fibrillation

Reflexes

Superficial reflexes Plantar reflex (L5-S1) — Flexor/Extensor

(a) Oppenheim method (b) Babinski's method

—

Cremastric (L1,2)

—

Anal (S3,4)

—

Abdominal (T7 to T12)—should be seen in all 4 quadrants

Deep reflexes

—

Triceps (C6,7)

—

Biceps (C5,6)

—

Supinator (C5,6)18

—

Knee (L3,4)

—

Ankle (S1,S2)

Grading of reflexes

—

Absent	—
Depressed	+
Normal	++
Brisk	+++
Brisk with clonus	++++

Sensory System

	—	Touch: Light, pressure
	—	Pain: Superficial, deep
	—	Temperature: Hot and cold
Posterior column sensation	—	Joint position without looking at the joint, vibration sense
Cortical sensations	—	Two point discrimination, Astereognosis, Sensory inattention
Gait	—	Normal, Circumducted, Scissor, High stepping, Stamping, Dancing, Ataxic, Waddling.

Cerebellar signs

•	Nystagmus	•	Hypotonia
•	Intention tremor	•	Dysmetria
•	Dysarthria	•	Inco-ordination
•	Ataxic gait	•	Pendular knee jerk
•	Disdidochokinesia	•	Rebound phenomenon

Autonomic Nervous System Examination

•	Cardiovascular reflexes	—	Heart rate, blood pressure
•	Skin response	—	Color, temperature, sweating
•	Salivary glands	—	Increased or decreased salivary secretion19
•	Eyeball	—	Pupils dilatation and constriction
•	Urinary bladder	—	Contraction of bladder with relaxation of urethral sphincter or relaxation of bladder with contraction of urethral sphincter
•	Rectum	—	Contraction of rectum with relaxation of anal sphincter or relaxation of rectum with contraction of anal sphincter

Release of primitive reflexes/ Persistence of primitive reflexes.

ANNEXURES

1. KUPPUSWAMI SCALE (MODIFIED)

•	Upper class	—	26 to 29
•	Upper middle	—	16 to 25
•	Lower middle	—	10 to 15
•	Upper lower	—	5 to 10
•	Lower	—	Below 5

	Education of head of family	Score	Occupation of head of family	Score	Income per capita/month in Rs.	Score
•	Illiterate	1	Unemployed	1	<40	1
•	Primary	2	Unskilled	2	40-119	2
•	Middle school	3	Semiskilled	3	120-199	3
•	High school	4	Skilled	4	200-299	4
•	Post high school	5	Clerical/Shop/Farm	5
•	Graduate	6	Semiprofessional	6	300-399	6
•	PG or professional degree	7	Profession	10	400-799 >800	10 12

2. ANTENATAL MEDICATIONS AND EFFECT ON NEONATE

Teratogenic Agents

Antibiotics—

Tetracycline	:	IUGR, permanent brownish staining of teeth, enamel hypoplasia, congenital cataract
Sulfa, Nitrofurantoin	:	Hemolytic anemia in G6PD deficient babies
Gentamicin, Streptomycin	:	Eight nerve involvement (deafness)

Anticonvulsants—

Dilantin, Diazepam, Valproic acid
:
Cleft palate, Congenital heart defects, Microcephaly
Phenobarb
:
Hemorrhagic disease due to deficiency of Vitamin K dependent factors

•	Warfarin, Dicumarol, Haloperidol	:	Phacomelia, Skeletal hypoplasia
•	High doses of Vitamin A; Antihistaminics	:	Congenital malformations
•	High doses of Vitamin D	:	Supravalvular aortic stenosis, Williams’ syndrome
•	High doses of Vitamin K	:	Neonatal jaundice
•	Quinine, Antifolates	:	Fetal death
•	Vitamin B₆	:	Inhibits lactation by interfering with secretion of Prolactin Pyridoxin dependent convulsions

Maternal addiction to—

Alcohol, LSD, Amphetamine, Opium, Tobacco	:	Congenital malformations, IUGR, Microcephaly
Salicylates	:	Neonatal bleeding due to deficiency of Vitamin K dependent factors
Morphine, Pethidine	:	Respiratory depression
Progestrogens	:	Masculinization of female fetus
Oxytocin induced labor	:	Early and intense neonatal jaundice

Diuretics—

Thiazide
:
Neonatal bleeding due to thrombocytopenia

•

Iodide from cough mixture,

Lithium carbonate,
Antithyroid drugs

Fetal goiter

3. NUTRITIONAL VALUE OF FOOD ARTICLES

No.	Items	Quantity	Calories	Proteins (In gm)
1.	Rice (cooked)	30 gm (1 katori)	100	2
2.	Chapati	30 gm (1 fulka)	100	3.5
3.	Bread (medium size)	25 gm (1 slice)	50	2
4.	Poha	30 gm (1 katori)	100	1.5
5.	Upma	100 gm (1 cup)	250	6
6.	Idli	1	50	2
7.	Puri	40 gm (1)	200	3
8.	Dhal (cooked)	30 gm (1 katori)	100	6
9.	Soyabean (uncooked)	100 gm	430	43
10.	Wheat dalia	30 gm (1 katori)	100	2
11.	Breast milk	100 ml (1 cup)	65	1.1
12.	Cow's milk	100 ml (1 cup)	67	3.3
13.	Buffalow's milk	100 ml (1 cup)	115	4.4
14.	Paneer	25 gm (1 piece)	64	4
15.	Curd	150 gm	100	5
16.	Orange	1	50	1
17.	Banana	1	100	1
18.	Papaya	100 gm	30	1
19.	Apple	1	50	0
20.	Mango	100 gm	70	1
21.	Potato	1/4 cup	50	1
22.	Leafy vegetables	1/4 cup	25	2
23.	Seasonal vegetables	1/4 cup	15	1
24.	Egg (hen)	1	65	6
25.	Tea without sugar	100 ml (1 cup)	0	0.5
26.	Sugar	5 gm (1 tsf)	20	0
27.	Coconut oil	1 ml	8	0
28.	Ghee	10 gm	90	0
29.	Butter	10 gm	70	0
30.	Glucose biscuit	5 gm (1)	25	0.523
31.	Groundnut	100 gm	570	25
32.	Laddu (Bengal gram flour, Wheat flour, Jaggery, Ghee 1 part each)	100 gm(1)	500	10
33.	Shakti Aahar (Rosted wheat 40 gm, Rosted gram 20 gm, Rosted peanut 10 gm, Jaggery 30 gm)	100 gm	390	11
34.	Hyderabad mixture (Whole wheat 40 gm, Bengal gram 16 gm, Groundnut 10 gm jaggery 20 gm)	86 gm	330	11

4. DAILY REQUIREMENT

Age	Calories/kg	Proteins in gm/kg
Infant (< 1 year)	110	2
Pre-school (1-5 years)	90	1.5
School (5 to 10 years)	80	1.3
Adolesence	70	1.0

Average Indian diet is predominantly vegetarian.

Average Indian diet has NPU 65 related to egg.

5. NATIONAL IMMUNIZATION SCHEDULE

Age	Vaccine	No. of doses	Route
First week	BCG	1	ID (intradermal)
	OPV	1	Oral
6, 10, 14 weeks	DPT	3	IM
	OPV	3	Oral
9-12 months	Measles		SC
16 to 24 months	DPT	1 Booster	IM
	Polio	1 Booster	Oral
5 to 6 years	DT	1	IM
10 and 16 years	TT	1	IM

Interval between 2 doses of vaccine should be Not less than 1 month or Not more than 6 months, for proper immunity.
Minor cough, cold, fever are not contraindications to vaccination.

24

6. IMPORTANT MILESTONES

Gross Motor

1	month	Chin slightly off couch in prone position. Total head lag in supine position
2	months	Chin off the couch in prone position. Head lag on pull to sitting from supine position
3	months	Neck control present but head sways while turning. Chin and shoulder off the couch in prone position
4	months	Complete neck control
6	months	Rolls from supine to prone position
7	months	Sits with hands forwards for support
8	months	Sits without support
9	months	Stands with support
10	months	Crawls
1	year	Walks with support
15	months	Walks alone. Creeps upstairs. Cannot come down the stairs
18	months	Walks upstairs with helping hands/ holding the railing Runs carefully
2	years	Runs. Walks up and down stairs holding on to rail, with 2 feet per step, kicks ball
2	years 6 months	Jumps. Goes upstairs with alternating feet still holding railing
3	years	Rides tricycle.Walks alone up stairs alternating feet
4	years	Walks up and down stairs with feet alternating, rides bicycle
5	years	Skips on alternate foot, walks on a line, hops forward in each foot
6	years	Jumps with feet together.

Fine Motor and Adaptive Milestones

1	month	Watches the objects if brought in midline. Doll's eye movement present
2	months	Fixation develops. Can converge
3	months	Hand regard. Follows moving object from side-to-side 180 degrees.
4	months	Tries to reach for the object, with both the hands with ulnar side with over-shooting (Bidextrous ulnar grasp)
5	months	Hand-to-mouth co-ordination present
6	months	Foot-to-mouth co-ordination present. Eyes move in unison any squint now abnormal
7	months	Transfers the object from one hand to other
9	months	Looks around the corner for object, 360 degrees
10	months	Pincer grasp present
1	year	Able to release the grasp. Enjoys casting objects on to floor.
15	months	Can feed himself with spoon. Scribbles
18	months	Draws vertical line. Feeds him with cup. Turn pages in a book in bunches.
2	years	Can draw horizontal line. Can turn pages of book one by one, Hand preference
3	years	Can draw circle. Dresses and undress fully. Matches 2 or 3 colors
4	years	Draws plus sign, cross. Draws a man with 2 to 4 parts. Buttons the clothes fully, Matches and names four colors
5	years	Draws triangle, square. Counts fingers. Can tie shoe-laces
6	years	Draws diamond
7	years	Writes

LANGUAGE AND HEARING

1	month	Quiets when bell rings
2	months	Vocalization begins. Cooing.
3	months	Turns head to the sound. Says aah, ngah
4	months	Laughs aloud
5	months	Razing, Ah-goo
7	months	Turns head in curving arc towards sound. Monosyllables ba, ma, da
8	months	Turns head diagonally and directly towards the sound
9	months	Polysyllables mama, dada, baba
1	year	2-3 words with meaning. Understands more
15	months	Jargon (Fluently speaks meaningless words)
18	months	6-20 words
21	months	Uses noun
24	months	Uses pronoun
2	years 6 months	Normal speech
3	years	Full control on modulation of voice. Can sing. Vocabulary of 250 words, Stuttering
4	years	Counts upto 20 or more, Grammatically correct speech
5	years	Fluent speech, knows date of birth
6	years	Knows Address, Telephone number

Social Development

1	month	Watches mother's face intently
2	months	Social smile
3	months	Recognizes mother
4	months	Invites strangers and laugh aloud27
5	months	Watches mirror image
6	months	Holds arms out to be picked up. Prefers mother
7	months	Plays hide and seek
8	months	Develops stranger anxiety
9	months	Learns to cover his face to avoid strangers
10	months	Waves bye-bye
1	year	Enjoys mimicry
2	years	Handedness is beginning
2	years 6 months	Knows full name. Learns concept of sharing. Can make friends
3	years	Develops abstract thinking, logic. Handedness established. Knows his or her sex.
4	years	Enjoys imagination, fantasy
5	years	Recognises 7 names 4 colours
6	years	Can discriminate in right and left

Toilet Control

Bladder				Bowel
•	1 year	—	Indicates wet pant	•	1 year	—	Indicates spoiled nappy
•	2 years	—	Dry by day	•	1 year 6 months	—	Can be conditioned for defecation
•	3 years	—	Dry by night	•	2 years	—	Can be trained for toilet use
•	4 years	—	Stops and starts urine flow	•	3 years	—	Can postpone passage of stools voluntarily

7. ANTHROPOMETRY

Weight

Birth Weight	—	3 kg
1. Weight gain in	—	0 to 3 months	—	800 to 900 gm/ month (30 gm/day)
		4 months to 1 year	—	400 gm/month

2. Birth weight (approximate)

Doubles	—	6 months	—	6 kg
3 times	—	1 year	—	9 kg
4 times	—	2 years	—	12 kg
5 times	—	3 years	—	15 kg
6 times	—	5 years	—	18 kg
10 times	—	10 years	—	30 kg

3. At birth 3 kg

3 to 12 months	— (Age in months + 9)/2
1 to 6 years	— 2 (Age in years) + 8
7 to 12 years	— 3 (Age in years)

Length/ Height

	Double: 4 years	Triple: 12 years
1.	At birth	—	50 cm
	3 months	—	60 cm
	6 months	—	65 cm
	9 months	—	70 cm
	1 year	—	75 cm
	2 years	—	90 cm
	3-6 years	—	6 cm every year
	Then	—	5 cm every year till puberty
2.	6 (Age in years) + 77 = length in cm (for age 2-12 years)

Normal upper segment/Lower segment ratios

Age	Ratio
Birth	1:7
3 years	1:3
8 to 10 years	1:0
18 years	0:9

Head Circumference

1.	At birth	—	(Length in cm/2) + 7.5 + −2.5 cm
	0-3 months	:	Increases by 0.5 cm/week
	3-6 months	:	Increases by 0.25 cm/week
	6 months-1 year	:	Increases by 0.125 cm/week
2.	At birth	—	35 cm
	3 months	—	40 cm
	6 months	—	43 cm
	1 year	—	45 cm
	2 years	—	48 cm
	3 years	—	49 cm
	5 years	—	50 cm
	7 years	—	51 cm
	12 years	—	52 cm

Chest Circumference

At birth	—	Chest circumference < Head circumference
At 1 year	—	Chest circumference = Head circumference
After 1 year	—	Chest circumference > Head circumference

Mid Upper Arm Circumference

Shakir's tape	—	Red zone < 12.5 cm	—	Malnourished
	—	Yellow zone 12.5 to 13.5 cm	—	Borderline
	—	Green zone > 13.5 cm	—	Normal

MUAC at birth is 10 cm. It becomes 16 cm at 1 year and it increases .25 cm/year and becomes constant (17 cm) at 5 years.

8. SEXUAL MATURITY RATING: STAGES I - V

Girls: Breast Development and Pubic Hair

Stage	Breast	Pubic hair
1	Preadolescent	Preadolescent
2	Breast and papilla elevated as small mound	Sparse, hypopigmented, straight
3	Breast and areola enlarged No contour separation	Darken. Increase in amount. Begin to curl
4	Areola and papilla form secondary mound	Coarse, curly, amount less than adult
5	Nipple projects	Spread to medial surface of thigh
Mean age of Menarche - 12.6 years.

Boys: Genital Examination and Pubic Hair

Stage	Pubic hair	Penis	Testes
1	None	Preadolescent	Preadolescent
2	Scanty. Hypopigmented	Slight enlargement	Some enlargement, texture altered
3	Darken. Begin to curl	Longer	Larger
4	Coarse, curly less than adult	Breadth and length Increase in size. Glans develops	Scrotum darken larger
5	Spread to medial side of thigh	Adult size	Adult size
Mean age of spermarche - 14.5 years

9. MODIFIED GLASGOW COMA SCALE FOR INFANTS AND CHILDREN

		Child	Infant	Score
Eye opening (E)	—	Spontaneous	Spontaneous	4
	—	To verbal command	To verbal command	3
	—	In response to pain	In response to pain	2
	—	No response	No response	1
Best motor response	—	Obeys command	Moves purposefully	6
	—	Localizes painful stimulus	Withdraws to touch	5
	—	Withdraws to painful stimulus	Withdraws to painful stimulus	4
	—	Flexion in response to pain (Decorticate posture)	Flexion in response to pain	331
	—	Extension in response to pain pain (Decerebrate posture)	Extension in response to	2
	—	No response	No response	1
Verbal response	—	Oriented, appropriate	Coos and babbles	5
	—	Confused conversation	Irritable cries	4
	—	Inappropriate words	Cries to pain	3
	—	Incomprehensible sounds	Moans to pain	2
	—	No response	No response	1

Maximum GCS score at	< 6	months is	9
	1	year is	11
	2	years is	12
	5	years is	13
	>5	years is	14

Minimum GCS score at any time is 3. Even a dead child will have GCS 3.

NEWBORN CASE HISTORY

Baby of __________ Sex _______ Day of life _________ Order of birth __________

History of Siblings

•	Order of birth	Age	Sex	Place and type of delivery	Birth event	Present health status
	1.	____	___	____________	_______	______
	2.	____	___	____________	_______	______

Prenatal History

Age of mother ______ Blood group _____ Height _______ Weight _______
•	Maternal diseases	—
	Before pregnancy	—	Anemia, Diabetes, Hypertension, Chronic renal disease, Cardiovascular diseases, Bleeding disorder

During pregnancy	—	STORCH infection (Exanthe-matous fever, Lymphadenopathy, Genital ulcers, mid trimester abortion)
		PIH, Diabetes mellitus, Severe anemia, Bleeding per vaginum, Jaundice, STD, Tuberculosis, HIV positive.
		History of chorioamnionitis (Peripartum fever, foul smelling liquor, suprapubic tenderness)

•	Drugs in antenatal period	—
•	Irradiation	—
•	Antenatal check-up	—	Booked/Unbooked/Treatment received
	LMP ____________		EDD ____________

Birth History

•	Duration of labor	—
•	Rupture of membrane before delivery	—	No/if yes, how many hours before delivery
•	Type of delivery	—	Vaginal / LSCS/Instrumental
•	Presentation	—	Vx / Breech/Others
•	Indication of interventation	—
•	Time interval of first cry and birth of baby
•	History of resuscitation measures	—
•	History of fetal distress	—
•	Liquor	—	Meconium stained/Foul smelling/Oligo or polyhydramnios
•	Passed meconium	—	Hours after birth
•	Passed urine	—	Hours after birth.

EXAMINATION OF NEWBORN

Temperature
Heart rate
Respiration rate	Respiratory distress (Retraction/ Grunt/ Flaring)
Color	Pink/Peripheral cyanosis/Central cyanosis/Pale/Mottling
Capillary refilling time
Weight
Length
Head circumference
Ponderal index

Gestational age Assessment	SGA/ AGA/ LGA
Physical	Neuromuscular
Skin	Posture
Lanugo	Arm recoil
Ear	Scarf sign
Breast nodule	Square window
Genitalia	Popliteal angle
Plantar surface	Heel to ear

General Examination

E/o birth trauma, congenital malformation
Scalp	Cephalhematoma/Caput/Moulding
Eye	Subconjunctival hemorrhage/ Epicanthic folds/ Cataract/ Sticky
Ear	Low-set/Hairy Pinna
Nose	Choanal atresia
Oral cavity	Cleft lip/palate/thrush
Icterus	Face/Chest/Lower abdomen and thigh/ Arm and lower legs/ Palm and sole
Edema
Rash
Umbilical stump (Periumbilical redness, discharge)
Hydration	—
Extremities	—	Congenital dislocation of hip, Talepes equinovarus.

Cardiovascular System
Femoral pulse	—
Heart sounds	—
Presence of murmur	—

	Abdomen
Liver	—
Spleen	—35
Any mass in abdomen	—
Genitalia	—
Bowel sounds	—

	Respiratory System
Breath sounds	—
Adventitious sounds	—

	Central Nervous System
Skull	Anterior fontanelle — Flat/Boughy/Full/Tense,Size, Sutural separations
Spine	Neural tube effects
Heigher functions	Cry, State of awake
Cranial nerves	Light reflex, Doll's eye, Corneal reflex, Facial asymmetry, Startle reflex, Sucking and Swallowing
Motor	Activity, Tone
Sensory
DTR
Neonatal reflexes

ANNEXURES

NEONATAL REFLEXES

The neonate has no voluntary control on his muscles at birth because myelination of cortico-spinal motor pathways is not present at birth. Myelination of subcortical motor pathways originating in brainstem is present in full-term neonate at birth (It starts at 28 weeks of gestation and is complete at 40 weeks of gestation. So reflexes originating from brainstem are weaker in pre-term babies). Myelination of corticospinal motor pathways occurs in cephalocaudal direction after birth. Thus, the muscle control gradually develops from cephalocaudal direction.

The neonatal reflexes are those involuntary reflex actions, which are helping or protecting the baby before the development of voluntary control. Since there is no voluntary control, baby is unable to do these actions.

These reflexes must disappear at appropriate age when baby develops voluntary control of those muscles. Thus, different reflexes are present at different age groups to enable the baby to achieve the next milestone.

Rooting or Search Reflex

When baby's cheeks come in contact with mother's breast, baby seeks the nipple. When upper lip, lower lip or cheeks are stimulated the baby will turn to that side to find the source of milk.

Appearance	—	present in normal full-term babies.
Disappearance	—	3 months (Awake), 6 months (Sleeping)

At birth there is no neck control. So baby cannot voluntarily turn to source of milk. Thus, this reflex action will help the baby for finding the breast. This reflex will disappear when baby develops neck control and can voluntarily turn and find the breast.

Sucking and Swallowing Reflex (Cortical)

Sucking reflex can be elicited by introducing baby's own finger into the mouth. Baby starts sucking vigorously.

Appearance	—	28 weeks of gestation. Sucking is stronger and well synchronized with swallowing at 34 weeks
Disappearance	—	3 months (Awake), 6 months (Sleeping)
Importance	—	Absence in full term babies suggest developmental defect

ATNR — Asymmetrical tonic neck reflex (Brainstem)

How to test	—	Passive rotation of head to one side in supine position for 15 seconds leads to, extension of upper limbs on facial side and flexion on opposite side
Appearance	—	At birth
Disappearance	—	3 months
Increased intensity	—	Spastic cerebral palsy
Persistence beyond 6 months	—	Spastic cerebral palsy

Importance:

Prevents baby from rolling. So it must disappear when baby learns to turn prone voluntarily
Reflex extension of upper limb will prevent voluntary arm movements, and will prevent the baby from turning to prone position. So it must disappear when active voluntary movements of arm develop and control over trunk muscles start developing, thus enabling the baby to turn prone.

38

STNR (Symmetrical Tonic Neck Reflex)

How to test	—	Passive extension of head in prone position leads to, extension of both upper limbs and flexion of lower limbs. If head flex passively, arm flex, hip extended and child falls
Appearance	—	3 months
Disappearance	—	6 months
Persistence	—	Cerebral palsy

Importance: When baby learns to turn to prone position, choking over bed may asphyxiate him. So if baby lifts the chin by extension of neck, automatically both upper limbs are extended and choking is avoided.

However, this reflex must disappear if baby has to crawl, as that will require voluntary flexion and extension of upper and lower limbs. So it disappears by 6 months.

Righting reflexes: Act in the background. Help in overall posture of the baby.

Neck righting reflex (Mid brain):

How to test	—	If neck is turned sideways, body as a whole follows
Appearance	—	Present at birth. Strong at 3 months
Disappearance	_—	6 months

Importance: Before the development of neck control, (age < 3 months) passive movement of neck sideways can cause twisting of neck. This is avoided if body automatically turns to the same side.

At 3 months neck control is achieved but there is no control on trunk. When neck is turned voluntarily, again twisting could occur. This is avoided by neck righting reflex.39

At 6 months, control over trunk muscles develops as baby starts turning prone. Thus, body can voluntarily follow neck movement in sideways, so the reflex disappears.

Body Righting Reflex

How to test	—	Change of posture of body in vertical direction leads to neck movement follows in the same direction. Thus, head moves along the trunk in vertical direction
Appearance	—	Starts at 6 months (as neck righting reflex wanes). Gradually becomes stronger. Strong at 9 months
Disappearance	—	12 months.

Importance: At the age of 6 months control over trunk is present, but yet there is no control over lower limbs, which gradually develops after 6 months. Next milestone to be achieved is crawling, sitting, and standing. So now body movements are in vertical plane. When body moves, the neck flexion or extension will automatically follow the body. Thus “spatial” head position is well maintained.

When child starts standing alone, and walking with little support, (good control over trunk and lower limbs), the need for this reflex is over and it disappears by the age of 12 months.

Palmer Grasp Reflex (Cortical)

Appearance	—	34 weeks of gestation
Disappearance	—	3 months
Persistence beyond 6 months	—	Spastic cerebral palsy
Increased in	—	Spastic cerebral palsy, Kernicterus
Asymmetrical	—	Hemiplegia, Cerebral damage
Absent	—	Klumpke's paralysis

How to Test

Pre-requisite	—	Head should be in midline.
Phase 1	—	Grasp reflex	—	Touch the ulnar side of palm of baby by your index finger to initiate grasp reflex.
Phase 2	—	Response to traction	—	As you lift your index finger, flexor muscles of forearm of baby become tight, and baby supports his whole weight. Baby can be lifted off the couch due to tight grasp reflex.
			—	Phase 2 is present only in term babies.

Landau Reflex (Position Reflex)

How to test	(a)	Passive extension of neck in ventral suspension leads to extension of spine, lower and upper limbs
	(b)	Passive flexion of neck leads to flexion of spine, lower limbs and upper limbs.
Appearance	—	6 months
Disappearance	—	1 year
Importance	—	Absent in cerebral palsy.

Parachute Reflex (Position Reflex)

How to test	—	In ventral suspension, head low position, baby is brought down towards ground from height, as if baby is falling. This leads to extension of both upper limbs in attempt to avoid injury to face41
Appearance	—	9 months
Disappearance	—	Never disappears. Persists all through life
Importance	—	Absent in cerebral palsy.

Righting reflexes: Act in the background. Help in overall posture of the baby.

Moro's Reflex

Vestibular Reflex

Appearance	—	28 weeks of gestation. Reflex is complete after 32 weeks of gestation
Disappearance	—	3 months
Persistence	—	Seen in pathological conditions like cerebral palsy
Diminished reflex	—	Seen in hypertonia, Severe hypotonia, Cerebral damage
Absent in	—	Crying baby, Hypertonia, Hypotonia, Shock, Sleep, Sedated baby
Asymmetrical in	—	Erb's palsy, Spastic hemiplegia, Fracture of humerus or clavicle, Closed hand.

How to test:

Pre-requisite	—	Head should be in midline and hands should be open.
Method	—	Place baby in supine position. Support back of head on palm of hand. Flex the neck by 15 degrees. Release the head to initiate the reflex.

Components of reflex:

Phase 1	—	Abduction of arms at shoulder and extension of arms at elbows with hands open.
Phase 2	—	Adduction of arms and flexion of forearms. In preterm babies phase 2 is absent because of weakness of antigravity muscles.

(a) Upper 26 to 29	(b) Upper-middle16 to 25
(c) Lower-middle 11 to 15	(d) Lower-upper 5 to 10
(e) Lower < 5

Nuclear	—	Mother + Father + Child
Expanded	—	Mother + Father + Child +Grandparents
Combined	—	All above + Uncle and Auntie

1 Room	—	2 Persons
2 Rooms	—	3 Persons
3 Rooms	—	5 Persons
4 Rooms	—	7. 5 Persons (Child from 1-10 years is counted as half)
5 Rooms	—	10 Persons (Additional 2 for each further room).

Dilantin, Diazepam, Valproic acid	:	Cleft palate, Congenital heart defects, Microcephaly
Phenobarb	:	Hemorrhagic disease due to deficiency of Vitamin K dependent factors

Chapter Notes

History Taking and Examination1