GOALS
Ever since the time of Hippocrates, history-taking and clinical examination of the child occupy pride of place as a remarkable art that builds up gradually on a good foundation through repeated exposures, application of knowledge and guided practical experience spread over years and years. Major goals of history-taking and clinical examination are:
- Data collection, both from history and physical examination
- Arriving at clinical diagnostic probablities
- Planning investigations to confirm the clinical diagnosis
- Treatment plan.
THE ART OF HISTORY TAKING
The best person to give the history (“informant”) is the mother of the child or someone else responsible for his care. If the child is old enough to communicate information, he should also be interviewed. History obtained from father, uncles, aunts or grandparents, who have not been deeply involved in child's care, is less reliable.
As far as possible, history should be taken in a room with minimum of noise and disturbance and an environment that is child-friendly.
The approach to the child as also the informant should be friendly. Let the informant tell the story as she sees it. You may later put leading questions to fill in the gaps and for detailed elaboration. Avoid putting trying and embarrassing questions. Creating a feeling of guilt or shame in the informant's mind will only make your job difficult. Yet, important information has got to be obtained and. This may require extra-tact in handling the situation. At times, it may be more workable to obtain some such information rather later in the interview, during the clinical check-up or even at a subsequent interview.
The case-sheet must have a record of clear and precise information about the history in chronologic order. Besides the entries regarding name, age and sex, parents' name and address, etc. the recording should be in the following order with marginal modifications as and when indicated.
- Basic information
- Presenting complaints
- History of present illness
- History of past illness
- Bith history
- Antenatal
- Natal
- Perinatal, and
- Postnatal
- Developmental history (Milestones)
- Dietary history
- Immunization history
- Personal history
- Family history
- Socioeconomic history
Basic Information
It should include child's name, sex, parentage and address along with the name of the informant.
Presenting Complaints
The first question to be asked is: “Well, what is the main complaint? This leads the informant to state the problem. Mind you, here reply is to be written down in her own words rather than in medical jargons. 4It is wrong to convert “has not passed urine since yesterday” to “anuria-1 day.”So, presenting complaints must be in informant's own account and must include the duration also.
Furthermore, the complaints need to be recorded in chronologic order, i.e. in order of occurrence.
You must obtain detailed information about the various complaints such as cough, fever, breathlessness (Box 1.1), vomiting, diarrhea, abdominal pain, hematemesis, bleeding per rectum, appetite, micturition, failure to thrive, swelling (edema), rash, jaundice, cyanosis, pallor, etc. depending on the merits of the case.
History of Present Illness
After the chief complaints, you should record the details of the present illness. When was the child quite well? How and when did the present problem start? How was its further progression? Was it stationary, improving or worsening? What were the new symptoms? Any aggravating/alleviating factors? Pertinent negative data that may have bearing on the diagnoses that are crossing your mind? Any treatment given?
History of Past Illnesses
How was child's previous health? Make a note of duration, dates and types of various illnesses. Also, state if any treatment was given. History of recurrent diarrhea and recurrent sinopulmonary infection with failure to thrive despite good dietary intake is very suggestive of cystic fibrosis. Umbilical sepsis in neonatal period may well be a precursor of portal hypertension later in life. Likewise, in a child who present with acute wheeze, a history of similar episodes in the past may well strongly point to the diagnosis of bronchial asthma.
Birth History
You should elucidate the factors that may have bearing on child's health before, during and after birth.
Antenatal It is important to know about mother's health during pregnancy. How was her diet? Any history of illnesses such as rubella, syphilis, toxemia, diabetes, hypertension, heart disease, tuberculosis, exposure to radiation, or drug intake? Maternal intake of such antiepileptic drugs (AEDs) as phenytoin, valproate and trimethadione may have teratogenic effect on the fetus. Do ask about blood group incompatibility between the parents.
Natal Was it a hospital or home delivery? Who conducted it—a qualified doctor or midwife, or simply an untrained dail. Was the delivery normal or not? What was baby's birth weight? Did he look healthy or sick? Any cyanosis? Any respiratory distress? Cry? Was any resuscitation needed?
Postnatal Apgar score? Any jaundice, cyanosis, convulsions, congenital anomalies, or birth injury noticed during the neonatal period. Any resuscitation measures employed after delivery? How was the umbilical cord cut? Any pus oozing out of it? Any suckling difficulty? What was the birth weight ? Excessive weight loss? When was the meconium passed? Absence of meconium passage may point to intestinal obstruction; a passage after 24 hours may suggest cystic fibrosis. When was the urine passed? Voiding of urine after 48 hours indicates renal agenesis or an obstruction in the system.
Developmental Milestones
You must find out when the child gave first social smile and learned head-holding, sitting with and without support, crawling, standing and walking with and without help and talking meaningful words and sentences. Any dental eruption and the timing?
Also ask about control over bowel and bladder, both during day and night.
Any regression in milestones? Any period of growth failure or unusual growth should also be
elicited.
It is important to know about school grade and quality of work.
Immunization Status
You must ask about the various vaccinations (including the new vaccines, optional vaccines, and pulse polio) received by the child with dates, if available. If certain vaccination has been omitted, find out why. Also, ascertain if any vaccination caused some complication(s).
Dietetic History
Was the child breast or bottle fed? If on formula, how was it prepared? Find out about sterilization of the feeding equipment and whether the dilution of the formula was as recommended or much too much. Any feeding difficulties?
When were the semisolids and solids introduced? Find out more details about the weaning foods and how they were given and in what quantity.
When were vitamin and mineral supplements started?
It is important to provide some details of the current dietary intake. Does child's appearance match the mother's story about his intake?
Also, you must get information about child's food “likes” and “dislikes”. How does he react to eating?
Any food allergy (cow milk, egg, soybean).
Personal History
How are child's relations with the sibs, other family members and children in the school? Is he a difficult child? Does he cling to mother's apron strings? Is he negativistie? Is he outgoing? How are his eating, sleep, bowel and bladder habits? History of pica, enuresis, breath-holding, tics and temper-tantrum should be specially elicited.
Family History
Apart from history of consanguinity (Box 1.2), the health status of the siblings, parents and grand-parents should be recorded. In case of infectious and familial diseases, history of such illness in the family members must be pointedly sought. In inherited disorders, it is advisable to make a family tree (Fig. 1.1). In disorders like Down syndrome, it is good to know the ages of the parents.
Socioeconomic Status
How much is the family income? It may be significant to know about the occupation of the parents and the housing, school and play facilities available for the child.
System Review
At the end of history recording, it is advisable to review each system in turn so that nothing vital is missed (Box 1.3).
THE ART OF PHYSICAL EXAMINATION
Before embarking on physical examination, it is important to get friendly with the child and win his confidence. This can easily be done while you are taking the history from the mother. During this period, you may also make certain observations about the child. Is he acutely sick? Does he take interest in the surroundings? Is he apprehensive, apathetic or hyperactive? Does he have any obvious malformation or deformity? Is their any thing characteristic about his appearance?
The child may be examined while he is in mother's lap or over the shoulder. The dress should be removed bit by bit to avoid resistance from a shy child and to prevent exposure in a chilly weather. Physical examination of a child is from “region to region”. The examiner must first develop a friendly rapport with him. Examination which is likely to be “irritating” should be done towards the end. You must make sure that the whole of the body from scalp hair to tips of the toes is properly inspected The sequence of examination depends upon the cooperation received from the child. As a rule, uncomfortable procedures such as examination of throat, ear or rectum should be left to the last. Else, an irritated, panicky child is going to be a difficult subject to examine. It is also wise to avoid a prolonged examination.
Furthermore, it is of distinct value to highlight the positive findings and put question marks (?) against the doubtful findings which may well be crosschecked later.
General Appearance
Does the patient look acutely sick? Is there any suggestion of a respiratory distress? Does he look mentally retarded? Is there any evident congenital defect? Is he comfortable, cooperative and interested in the surroundings? Is he wasted, obese or average?
Note his cry. A high-pitched shrill cry may suggest meningitis. A weak cry may be the result of grave illness, respiratory muscle weakness or generalized weakness. A child in agony because of pain may give a strong cry.
A child appearing comfortable in the bed or on the table but irritable in mother's lap, the so-called “paradoxical irritability”, should arouse suspicion of such conditions as poliomyelitis, scurvy, infantile cortical hyperostosis or acrodynia.
A “frog-like” posture may mean poliomyelitis or scurvy.
It is advisable to make a note of vital signs at this stage (Table 1.1).
Anthropometry
It is essential to record child's weight, height or length, head, chest, and mid-upper-arm circumferences (MAC) and, if possible, skin-fold thickness. In certain instances, it is of value to measure the upper and lower segments and arm span. For details, see Chapter 3.
Skin
Note its color for cyanosis (Box 1.4), jaundice, pallor and caroteinemia.
Look for pigmentation. Localized bluish spots, usually on the buttocks and the back, are the so-called “mongolian spots”. They are self-limited, having no clinical significance. “Cafe-au-lait spots” may be associated with phakomatosis. Reticular pigmentation may be a feature of megaloblastic anemia or infantile tremor syndrome. In Addison disease, the pigmentation usually gives the skin dirty brown color and may also be present at the gum margins and cheeks.
Skin turgor is lost in dehydration and marasmus. In order to elicit pitting edema, greater pressure requires to be applied in children than in adults.7
Presence of rashes, petechiae, ecchymoses or specific diseases should also be observed.
While examining skin, it is appropriate to look for subcutaneous nodules over bony prominences in suspected cases of rheumatic fever or rheumatoid arthritis (Box 1.5).
Lymph Nodes
Note the location, size, consistency, mobility, tenderness and warmth of lymph nodes, particularly in the suboccipital, preauricular, anterior and posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal regions.
Posterior auricular and suboccipital adenitis may be the result of otitis externa, scalp infection or lice.
Palpable nodes up to 1 cm in inguinal region and up to 3 mm in rest of the areas may well be passed as within normal limits in healthy children.
Head
It is important to measure its circumference at mid forehead anteriorly and the most prominent part of the occiput posteriorly (Table 1.2). At birth, it measures 34-35 cm. Then a gain of 2 cm/month for first 3 months (total gain 6 cm), 1 cm/month in next 3 months (total gain 3 cm) and 0.5 cm in the subsequent 6 months (total gain 3 cm) occurs. Thus, there is a total gain of 12 cm by the end of the first year. During second and third years, when it measures 47 cm increase is 2 cm and 1.5 cm, respectively. During 3-14 years, it is 2.5 cm. At 14 years, head circumference is 53 cm.
You should note its shape as well—whether scaphocephaly, oxycephaly (acrocephaly), brachycephaly or plagiocephaly. Palpation of the sutures may reveal evidence of craniosynostosis. In hydrocephalus, sutures may be separated. Craniotabes may be demonstrated in occipitoparietal region and should arouse search for other signs of rickets, prematurity, osteogenesis imperfecta or syphilis. In suspected hydrocephalus, it is desirable to do transillumination of the head in darkroom. Positive “crack-pot” or Macewen sign on percussing the skull with a finger does not always suggest hydrocephalus. It may well be positive normally as long as the fontanels are open. Since posterior and lateral fontanels close very early in infancy, it is the anterior fontanel that has clinical value. It usually closes between the ages of 9 to 18 months. Early-closure suggests craniosynostosis and late closure rickets, congenital hypothyroidism, malnutrition, hydrocephalus, syphilis, etc. A truly bulging anterior fontanel suggests raised intracranial tension or pseudotumor cerebri. A depressed fontanel is a sign of significant dehydration. An intracranial bruit on auscultation, particularly in temporal region, may well be a normal finding or evidence of an aneurysm, or facial hemangioma.
While examining the head, you should inspect hair for color, texture, sparseness and easy pluckability. Light-colored, sparse, silky or coarse, easily pluckable hair is usually seen in kwashiorkor or infantile tremor syndrome. Localized alopecia without any sign of infection is seen in trichotillomania. With presence of infection and pruritic lesions, it should suggest ringworm.
Face
It should be examined for expression, asymmetry, paralysis, bridge of nose, hypertelorism/pseudohypertelorism, distribution of hair, size of the maxilla and mandible and tenderness over sinuses. Dull and expressionless facies are commonly seen in mental retardation. So characteristic are the facies in such disorders as Down syndrome, cretinism (congenital hypothyroidism), adenoids and gargoylism (Hurler/ Hunter syndrome) that a well conversant observer is often in a position to make the diagnosis from a distance.
Eyes
You should examine the eyes for photophobia, visual acuity, mongoloid or antimongoloid slant, epicanthal fold, Brushfield spots, exophthalmos or enophthalmos, pupils, cataract, corneal opacities, squint, nystagmus, xerophthalmia, or Kayser-Fleisher ring around the iris.
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Ophthalmoscopy is important in selected cases.
Nose
It should be examined for patency, discharge, bleeding, deviated septum, flaring of nostrils, foreign body, polyp and depressed bridge.
Mouth and Throat
Note any unusual shape, cleft lip, nevi, lesions at the corners, ulcers on buccal mucosa, tongue or pharynx, spongy gums, dental caries or malocclusion, opening of the Stensen duct at the level of second upper molar, Koplik spots, hard and soft palate, tonsils and postnasal discharge.
If a baby can move his tongue over the alveolar margin (which is invariably the case), the so-called “tongue-tie” is out. Fissuring of the tongue occurs in many cases of Down syndrome. Tremors may suggest Werdnig-Hoffmann disease. Frenular ulcer is a feature of pertussis. Macroglossia may be encountered in cretinism, and gargoylism. Glossoptosis occurs in association with micrognathia and cleft palate in Pierre-Robin syndrome.
Ears
You must note the shape, size and position of the ears. Deformities may well be a pointer that kidney anomalies are also present. Low-set ears may be associates of other congenital anomalies seen in certain syndromes such as Treacher-Collins syndrome, Apert 9syndrome, carpenter syndrome, or Noonan syndrome. Such an ear lies below an imaginary line joining the lateral angle of the eye to the external occipital protuberance.
It is useful to examine the ear drum. Mastoid bone should be percussed for tenderness. Hearing should also be tested. A valuable bedside test consists in observing an infant's response to sound. In normal hearing, he will turn his head to the direction of the sound.
Neck
Neck is examined for head-holding, swelling, torticollis, JVP (Fig. 1.2), sinuses or fistulas. Any webbing, bull neck or position of trachea should also be noted.
Chest
The size, shape and symmetry are carefully examined. A special note should be made about presence of any retraction (suprasternal, intercostal), rachitic rosary, pigeon chest deformity, funnel chest, gynecomastia, etc.
In examination of lungs, it is important to note the type of breathing, dyspnea, chest expansion, cough, vocal dullness, percussion note, breath sounds, crepitations, wheeze, etc. Remember that in young children, breathing is mainly abdominal.
Table 1.2 gives significance of certain observations in examination of respiratory system.
You should examine the heart for location of apex beat, its intensity, precordial bulging, thrills, size, shape, sounds, murmurs, friction rub, etc.
Remember that heart should be examined while the child is erect, recumbent and turned to left. Also that extrasystoles may he heard in many normal children. Likewise, sinus arrhythmia may be a normal finding in childhood. Cardiac examination must in particular be very careful, noting the presence of a precordial bulge, substernal thrust, apical heave or a hyperdynamic precordium, thrills (both systolic and diastolic), aortic bruits, etc.
Auscultation of the precordium requires patience, first concentrating on the characteristics of the individual heart sounds and then on the murmurs. An accentuated or loud first heart sound over the mitral area suggests tachycardia, hyperkinetic heart syndrome, hyperthyroidism or mitral stenosis. In mitral regurgitation and myocarditis, the first heart sound over the mitral area is particularly faint. In tricuspid atresia, the first heart sound over the tricuspid area is accentuated or loud. The second sound is split little beyond the peak of inspiration; it closes with expiration. A wide splitting is encountered in pulmonary stenosis, tetralogy of Fallot, atrial septal defect, total anomalous venous return and Ebstein anomaly. A narrow splitting points to pulmonary hypertension. The third sound is best heard with the bell at the apex in middiastole, especially if the child assumes a left lateral position. It is of significance in the presence of signs of congestive cardiac failure and tachycardia in which situation it may merge with the fourth sound. The latter, coinciding with atrial contraction, may be heard a little before the first sound in late diastole. The phenomenon of poor compliance of the ventricle with an exaggeration of the normal third sound associated with ventricular filling is termed “gallop rhythm”.
After the heart sounds, attention should be focussed on clicks. Aortic systolic clicks, best heard at the left lower sternal border occur, in aortic dilatation as in aortic stenosis, tetralogy of Fallot, or truncus arteriosus. Pulmonary ejection clicks, best heard at the left midsternal border, occur in pulmonary stenosis. In prolapse of the mitral valve, a mid-systolic click precedes a late systolic murmur at the apex.
Murmurs need to be described as to their timing, intensity, pitch, area of highest intensity and transmission.
Whether a particular murmur is just functional (innocent with no significance) or has a pathological 10origin (congenital heart disease) must be decided. Murmurs are audible sounds arising from the flow of blood through blood vessels, valves or heart chambers evincing turbulence. In children, because of closeness of the heart to the thin chest wall, murmurs are relatively more easily heard. As a rule, narrower the blood vessel or opening, or higher the turbulence of flow, louder is the murmur. Murmurs are usually classified as systolic, diastolic, and continuous.
Systolic murmurs may be ejection, pansystolic or late systolic. An ejection systolic murmur rises to a crescendo in midsystole. It is, as a rule, coarse. Examples of such murmur are aortic stenosis, aortic coarctation, pulmonary stenosis and atrial septal defect. A pansystolic murmur occurs all through systole. It is caused by flow of blood through a septal defect (ventricular septal defect) or an incompetent mitral or tricuspid valve (mitral incompetence), tricuspid incompetence, or a patent ductus arteriosus. A late systolic murmur is heard well beyond the first sound and stretches to the end of systolic phase (mitral valve prolapse). According to intensity, systolic murmurs are categorized into six grades (Table 1.3).
Diastolic Murmurs may be
- High-pitched blowing along the left sternal border, indicating aortic insufficiency or pulmonary valve insufficiency.
- Early short, lower-pitched protodiastolic along the left mid and upper sternal border, indicating pulmonary valve insufficiency or after repair of pulmonary outflow tract in such conditions as tetralogy of Fallot.
- Early diastolic at the left mid and lower sternal border, indicating atrial septal defect or atrial valvular stenosis.
Table 1.3 Six grades of systolic murmurs (Keek's classification) GradeCharacteristics1.Faintest, requiring very careful auscultation in noise-free environments (consultant's murmur); innocent2.Soft though slightly louder; usually innocent3.Moderately loud without a thrill; may be innocent or organic.4.Loud, accompanied by a thrill; always organic5.Very loud, accompanied by a thrill; still needs stethoscope in contact with chest; always organic6.Loudest possible, accompanied by a thrill heard with stethoscope not necessarily in contact with the chest; always organic. - Rumbling middiastolic at the apex after the third heart sound, indicating large right to left shunt or mitral insufficiency.
- Long diastolic rumbling murmur at the apex with accentuation at the end of diastole (presystolic), indicating anatomical mitral stenosis.
A continuous murmur (machinery murmur) is a systolic murmur, best heard over the second and third left parasternal spaces, that extends into diastole. It indicates a patent ductus arteriosus. It must be differentiated from a pericardial friction rub, as also from a venous hum.
Remember, over 30% children may have a murmur without significant hemodynamic abnormalities. Typically, the so-called “innocent murmur” is heard in the age group 3 to 7 years, occurs during ejection, is musical and brief, is attenuated in the sitting position, and is intensified by pyrexia, excitement and exercise. As the child grows, such a murmur shows a tendency to be less well heard and may regress fully.
It is of help to apply the time-honored Nada's criteria for presence of heart disease in suspected cases (Chapter 18).
Abdomen
It is helpful to bear in mind the anatomic topography (Fig. 1.3) and to examine the abdomen when it is relaxed, i.e. when the infant is taking his feed or sucking at the “sugar tip”, the mother's lap or shoulder (when the child is struggling and abdomen can be examined from the back) is the best place for abdominal examination.
Fig. 1.3: Anatomical topography of the abdomen: Region 1 represents right hypochondrium; 2 epigastrium; 3 left hypochondrium; 4 right lumbar; 5 umbilical: 6 left lumbar; 7 right iliac: 8 hypogastrium: 9 left iliac
An important tip is to do palpation only when the child breathes and abdomen is relaxed (ballotment method). Note its size and contour, distention, movement with respiration, visible peristalsis, umbilicus, hernias, local or rebound tenderness, palpable organ or lump, hyperresonance, shifting dullness, alteration in bowel sounds, etc. Gentle palpation is of greater value than deep, particularly in the case of spleen. Secondary umbilical hernia is common during first 2 years of life and usually regresses spontaneously.
Palpability of liver should be determined in both the midline and the right nipple line. As a rule, liver is normally palpable up to 2 cm below the costal margin until age 4 years. Therefore, rather than just palpability of liver, it is more reliable to measure the liver span (distance between upper margin of liver dullness and lower edge of liver in the midclavicular line). Normal liver span is 4.5-5.0 cm at 1 week. By 12 years, it goes up to 6.0-6.5 cm in girls and 7.0-8.0 cm in boys.
The tip of spleen is palpable far more laterally in infants and young children than in older children (Fig. 1.4). In infants until the age of 2-3 months, spleen may be normally palpable.
Genitalia
In case of male genitalia, look for circumcision, urethral (meatal) opening, hypospadias, phimosis, paraphimosis, hydrocele, hernia, and undescended testes. Make sure you have warmed your hands before you begin to examine the testes.
Fig. 1.4: Direction of splenic enlargement. Just palpable spleen is a normal finding in 35% term infants, 10% infants at 1 year and in an occasional child thereafter
In case of female genitalia, examine the urethral opening, vagina, hypertrophy of clitoris, and labia minora and majora. Avoid digital or speculum examination.
Rectal Examination
Note any anal fissure, polyp, prolapse, or perianal erythema. Rectal examination should be done with a little finger that is gloved and lubricated with petroleum jelly. Once the finger is in, you may assess the anal muscle tone. Note if the rectum is empty or full. The glove should be examined for feces, mucus and blood after the finger is withdrawn.
Limbs and Feet
These should be examined for any deformity, asymmetry, hemihypertrophy, bow legs, knock-knees, edema (Fig. 1.6), any swelling or limitation of movements of the joints, etc. Do count the digits and the number of fingers and toes. Also, look for incurving of the little finger, syndactyly, simian crease, platenychia or koilonychia, clubbing (Box 1.7, Fig. 1.7), and presence, absence or diminution of arterial pulses. It is absolutely within normal limits for many infants to have flat feet and bow legs.
Spine and Back
Look for scoliosis, kyphosis, lordosis, dimples, sinuses, spina bifida, tufts of hair, stiffness of neck and back, any swelling, mongolian spots or tenderness. It is helpful to watch child's gait. Remember that lumbar lordosis together with potbelly may well be a normal observation in the second year of life.
Neurologic Examination
CNS examination of an infant or a young child frequently poses difficulties. This is particularly true in case of sensory examination. Table 1.4 summarizes the special features of CNS examination of infants and children.
Evaluation of cerebral function, cranial nerves (Table 1.5) and their integrity, cerebellar function, motor system meningeal signs (Fig. 1.8) and involuntary movements should be done as and when indicated. In the case of a newborn, it is important to assess the primitive reflexes (Chapter 33). An estimate about the developmental and mental age should be made (Chapters 3 and 19).
Fig. 1.6: Pitting edema: For its demonstration in a child, the examiner needs to put more pressure with the index finger than in adults, especially in doubtful cases
Fig. 1.7: Clubbing: Note the normal “window” (left) disappearing in case of clubbing because of the increased amount of soft tissue under the base of the nails (right). The so-called “diamond sign” or “Schromroth sign” is quite sensitive for even slight clubbing. Clubbing can also be elicited by rocking the nail on its bed between your finger and thumb. It seems to float
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Fig. 1.8: Kernig sign. The hip and knee are flexed to a right angle. Then, the leg is gradually extended. Tightness of the hamstring and pain limitation of movements indicate a positive sign. Reciprocal flexion of the contralateral knee during this maneuver indicates a positive Brudzinski sign
A SAMPLE (MODEL) PEDIATRIC CASE SHEET
Child's Name, Age and Sex, Reg. No., Father's Name and Occupation
Full Address
Date of Admission | Date of Discharge |
Provisional Clinical Impression
Final Diagnosis
Suggested Follow-up
Any Other Remarks
Informant and His/Her reliability
CHIEF COMPLAINTS (in chronologic order)
HISTORY OF PRESENT ILLNESS
HISTORY OF PAST ILLNESSES BIRTH HISTORY
Antenatal
Natal
Postnatal
SALIENT DEVELOPMENTAL MILESTONES
Social smile | Sitting | Standing | Teething |
Head-holding | Crawling | Walking | Speech |
IMMUNIZATION STATUS
PERSONAL HISTORY
FAMILY HISTORY
SOCIOECONOMIC STATUS
PHYSICAL EXAMINATION*
General Remarks (appearance, etc.)
Weight (—%) Height/Length | (—%) Head cirf. |
Midarm cirf. | (—%) Chest cirf. |
Muscle status | skinfold |
Anterior fontanel | Dermatosis |
Pallor | Cyanosis jaundice |
Whether feverish
Pulse/heart rate | Respiratory rate |
Clubbing | Lymphadenopathy |
Koilonychia/platenychia | Any other finding |
Edema/puffiness
Any vitamin deficiency signs
SYSTEMIC EXAMINATION
Respiratory system
Cardiovascular system
Abdomen
CNS
Musculoskeletal system
ENT
Eyes
SUMMARY OF THE CASE
Provisional clinical diagnosis.
DISCUSSION
(Please give important points in support of your clinical impression. Also comment on the differential diagnosis).
INVESTIGATIONS (You would like to do) PROGRESS NOTES
(Brief record of investigations done, treatment given from time to time and patient's progress in the hospital)
FURTHER READING
- Gupte S. Differential Diagnosis in Pediatrics, 5th edn Jaypee Nw Delhi: 2008.
- Gill D, O' Brien N. Pediatric Clinical Examination. Churchill Livingstone, London: 1988.
- Stones. Pediatric Check-up, 4th edn. Smith and Smith London: 2006.