HISTORY Congenital Disorders?

Other heredofamilial disorders?

I. Identifying info:
VII. Birth Hx
Name:
Age: Antenatal:
Gender: Prenatal care
Residence: Diet
Infections
II. Source of Hx: Other illnesses
Other complaints
III. Chief Complaint: Medications
X-ray procedures
IV. Hx of Present Illness: Amniocentesis

Date of Onset: Natal:

Initial Symptom: Pregnancy duration
Other Complaints: Type of delivery
Appetite: Sedation/anesthesia
Activity: Birth weight:
Medications Taken? Resuscitation required:
Onset of respiration:
V. Past Hx First cry:
Special procedures?
Hospitalized? If yes, give date and
reason? Neonatal:
Infections? If yes, give date and
Apgar score:
severity? Color:
Contagious diseases? If yes, give date Cry (kind)
and severity? Paralysis
Other serious non-infectious diseases? Convulsions
Fever
VI. Family Hx Congenital abnormalities
Birth injuries
Diabetes? Length of hospital stay
Cancer?
Epilepsy?
VIII. Nutrition
HPN?
Allergy? Feeding (breast of formula)
Blood Dyscrasias? Duration
Mental/Nervous Diseases? Supplements
CVD? Solid foods
 Food like/dislikes Type (age during shots, # of shots, rxn)
Idiosyncrasies
Allergies XII. Environmental Hx
General attitude to eating

IX. Developmental Milestones

Raised head
Rolled over
Sat alone
Pulled up
Walked with help
Walked alone
Word
Sentence
Comparison of devt with sibling

X. Personal-social Hx

Mother
Age:
Occupation:
State of physical and emotional health:
Living or dead? If dead, give cause and
nature?

Father:
Age:
Occupation:
State of physical and emotional health:
Living or dead? If dead, give cause and
nature?

Grannies, sibling
Age:
Occupation:
State of physical and emotional health:
Living or dead? If dead, give cause and
nature?

XI. Immunization and tests

PHYSICAL EXAMINATION  IS THE OCCIPITOPARIETAL REGION
SWOLLEN?
General Survey:
 PRESENCE OF ANTERIOR AND
POSTERIOR FONTANELLES?
Growth pattern:
 FACIAL PROFILE? IS IT FLAT
Recent behavioral changes:
Development:
Eye
Nutrition:
 COLOR OF IRIS?
Sensorium:
 COLOR OF SCLERA?
Distress:
 ARE SCLERA NONECTERIC?
Gait:
 COLOR OF CONJUCTIVA?
Posture:
Orientation:  CORNEA?
Type of cry/voice:  SHAPE OR DIRECTION OF PALPEBRAL
Muscle tone: FISSURE?
 PRESENCE OF BRUSHFIELD SPOTS IN
IRIS?
Vital Signs:
Ear
BP:
 POSITION? ARE THEY LOW SET?
HR:
 ARE PINA WELL DEVELOPED
RR:
 DISCHARGES?
Temp:
 PRESENCE OF APPENDAGES/PITS?
L/H:
W:
Nose
HdC:
Infant
AbdC:
 PRESENCE OF NASAL FLARING?
ChC:
 NASAL BRIDGE?
Skin  DISCHARGES?
 COLOR  IS NASAL SEPTUM IN THE MIDLINE?
 PATCHES?  NASAL BRIDGE?

HEENT Mouth and Throat

Head  PRESENCE OF CLEFT LIP AND PALATE?
 SHAPE-NORMAL CEPHALIC? Infant
 COLOR OF HAIR?  PRESENCE OF WHITISH PINPOINT DOTS
IN MIDLINE OF PALATE?
Infant-3YO  PRESENCE OF THRUSH (YEAST
 CIRCUMFERENCE-IF NOT GIVEN INFECTION) IN TONGUE?
 THE PRESENCE OF CAPUT  PRESENCE OF TEETH?
SUCCEDANEUM?  IS MANDIBLE SMALL?
Neck P: IS LIVER EDGE FELT?
 LENGTH? MASSES?
 PRESENCE OF LOOSE SKIN? P: TYMPANITIC SOUND?
 HAIRLINE? A: ARE BOWEL SOUNDS HEARD?
 PRESENCE OF LYMPHADENOPATHIES
OR MUMPS? Spine and Back

*USE IPPA IN CHEST AND LUNGS, HEART AND Genitalia

ABDOMEN Female:
Chest and Lungs  PRESENCE OF NORMAL FEMALE
INSPECTION: -SYMMETRY OF CHEST? GENITALIA?
-EQUAL EXPANSION OF LUNGS?  DEVELOPMENT OF VAGINA FROM
-PRESENCE OF 2 NIPPLES? INFANTILE?
-ARE THE NIPPLES WIDELY  PRESENCE OF PUBIC HAIR
SPACED?  PRESENCE OF VAGINAL BLOODY
-RETRACTIONS? DISCHARGE?
-PARADOXICAL MOVEMENT?  SWOLLEN?
Male:
PALPATION: -ARE TACTILE FREMITUS  HAVE BOTH TESTES DESCENDED?
EQUALLY FELT?  DISCHARGE?
-EQUAL EXPANSION?
Extremities
PERCUSSION: -IS RESONANT NOTE HEARD ON  LENGTH?
BOTH LUNG FIELDS?  SWELLINGS?
 DEFORMITIES IN ARMS OR LEGS?
AUSC: -ASK FOR BREATH SOUNDS?  ABNORMAL DIGITS?
 SINGULAR CREASES?
Breast-female  FLAT FOOTED?
 DEVELOPMENT OF BREAST?
 TENDERNESS? Joints

CVS Motor: Muscle bulk:_____ Muscle Tone:______

I: -POINT OF MAXIMAL IMPULSE? Strength (1-5); DTR’s (0,1,2,3)
P: -THRILLS?
P: -CARDIAC DULLNESS (DIAKOSURE) R L
A: -IS RHYTHM NORMAL? Biceps
-MURMURS? Triceps
Brachioradialis
Knee jerk
Abdomen Ankle jerk
I: SHAPE?
Sensory: Light touch____ Pain____ Temp_____
Meningeal Signs: ( ) neck rigidity ( ) Kernig’s
(Brudzinki’s)
Autonomic function:
Urinary incontinence_____
Bowel incontinence______

Neonatal Reflex:
Palmar grasp B-3-4m

Plantar grasp B-6-8m

Moro/startle B-4-6m

Asymmetric Tonic B-2m

Positive support B-2-6m

Rooting B-3-4m

Trunk B-2m
incurvation/Galant’s

Placing and B-variable

stepping
Landau B-6m

Parachute 4-6m-none

Nutritional Assessment: Gomez Classification

(Weight-for-Age)