PRESENTATION OF PAEDIATRIC CASE.A PROTOCOL -Dr.C.NAGARAJAN , Prof.of.Paediatrics 1 Name ,Age, Sex---Name-( ,Cong. anomalies). Sex—sex linked disorders-eg.- Haemophilia A,B, DMD, Vit. D resistant Rickets.( Age—completed years only) 2. Address—Epidemiology of diseases ( eg. Malaria, Kala azar, Filariasis ete.) 3. Informant—Mother, Father, Grandmother, Others whose reliabity is Good! Fair/ Poor 4. Complaints—i. Presenting complaint in patient’s/informant’s own words 1,2.3,4 ete. in ascending order Main complaint should be stressed. 5 History of presenting illness—Every complaint should be briefly elaborated in medical terms, Nature, time of occurrence, progress/ course,precipitating, aggrevating & relieving factors, possible aetiological factors, severity, frequency, diurnal& postural variations, improvement with trt. etc. to be elaborated. Positive history first, Negative history next 6. Past history — whether the patient has suffered from same type of illness in the past, admitted, investigated & treated, nature of trt.. H/O. any related illness -eg. Portal Hypertension—umbilical catheterization umb. sepsis to be elicited 7. Family History—Total no. of children in the family, Birth order of this child, Consanguinous/ non- consanguinous parents, degree of consanguinity, other children suffer from such illness.any congenital/ genetic disorders in the family. Pedigree chart to be put(Autosomal Recessive inheritance common in consanguinity) 8.Antenatal history—Age of the mother at conception, AN visits, immunization details,H/O ingestion of Abortifaecients,H/O X-ray exposure, H/O TORCH infection, H/O systemic maternal illness -Diab,, HT, PIT, H/O Antithyroid, antiepileptic, antidiabetic, anticancerous drugs, alcohol etc. 9. Natal—Delivery--FTND/ Preterm- Instrumental/ assisted/ LSCS delivery, cried well after birth, resuscitation procedures,Breast feeding started -----hours after birth, 10. Postnatal—H/O breathing difficulty, feeding difficulty, cyanosis, scizures, jaundice... umbilical sepsis,umb. vein catheterization, biood transfusion etc. 11.Developmental history—Developmental milestones- Gross motor, Fine motor, Social& Adaptive, Speech -normal/ delayed. If delay +, nature of delay—expected milestones, present status, devpt.al age to be elaborated—Refer Devpt.al milestones . Delay is global or confined to one area- to be mentioned.12.Diet( Nutrition) history—How long BF continued, weaning started when, diet menu, calorie’ protein required/consumed, calorie gap/ protein gap, measures of bridging the gap ete. In PEM case, history should be elaborate& complete. 13.Immunisation history--immunized as per age, Immunisation at various ages , last/ recent immunization, (UIP knowledge ~a must) 14. Socio-economic history—total members! total caring members, total monthly income, per capita income, status—LIG, MIG, HIG.( Upper/ Upper middle/ Lower! Lower middle/ High- Kuppusamy's scale-2007) Living in pucca house/ katcha-low thatched roof, ventilation facilities, too many members in the family-overcrowding, drinking water supply, sewage disposal etc., pet animals 15. Environmental history—Living in slum, sanitation& water supply, cattles ind around, sewage disposal 16. Contact history—contact with TB, Leprosy, Exanthem or any other communicable disease either in the family or in the neighbourhood—(to be mentioned in relevant cases only.) GENERAL EXAMINATION Conscious, Alert, Active, Cooperative,Posture _ Febrile’ Afebrile, comfortable/ Dyspnocic/ Tachypnoeic/ Toxic. a) PICCLE—Pallor,leterus, Cyanosis, Clubbing, Lymphadenopathy, oEdema ~b) Anthropometry 1.Weight-—-----kgs 2.Height----- cms 3. Mid-arm circumference---—-cms(I-S years) st circumference----cms (New-borns) circumference----cms ( Micro/ Macrocephaly) R un, Volume, Tension, Condition of the vessel wall, all elt, any Radio-Radial /Radio- Femoral delay(.Rate per one min.) UL lying/ sitting posture mminal/ abdomino-thoracic, regular’ irregular n necessary) ook for the following. Ifeverything is normal, say noLH ¢ad—Micro/Macrocephaly, AF/ PF, Flat occiput, Frontal bossing 2.Hair-Sparse, Alopacia —areata/ totalis, Hypopigmentation “3 Ears----Low- set earsASOM/CSOM, Pre-auricular sinus, skin tags. 4, Eyes—Upward/ downward slant, Hypertelorism, Epicanthie folds, Cataract, Proptosis, Nystagmus, Vit. A def signs. Ptosis,Periorbital oedema, sunken eyes, KF ring. S.Face—Mangoloid , Haemolytic, Coarse facies of Cretin, MPS, Cushingoid, 6. Nose—Depressed bridge , Upturned nostrils 7.Mouth—Microstomia, Large tongue, Ariboflavinosis, Aphthous ulcer, Dental caries, Malocclusion,, Protruding teeth, Cleft Lip/ Palate, Facial palsy, High-arched palate, ‘Micro/ Macro / Retro gnathia 8, Neck—Webbing, Torticollis, Short neck , Low hairline 9. Chest—Widely placed nipples’ supernumery nipples, Gynaecomastia, Pectus Excavatum/ Carinatum, Ricketty rosary/ Scorbutic. rosary 10. Abd—Umb. Hernia, Ing. Hernia 11. Genitalia—Hydrocele, Micropenis, Hypospadias, Chordae, Cryptorchidism, Ambiguous Genitalia 12. Skeletal—Upper limb— Proximal shortening, Simian crease, Cleinodactyly. Polydactyly, Syndactyly. Lower limb—Genu valgus, varus,, CTEV, Club foot. Kyphosis, Scoliosis, Kyphoscoliosis, Gibbus ‘Skin—Macule, Papule, Vesicle,, Pustule, Wheal, Petechiae, ra,Eechymosis,Hypo/ Hyperpimentation, Scabies, Mangolian blue giomas, Telengiectasia, Spider Naevus, Salmon patch, Portwine stain, marginatuny nodosum, Café-au-lait spots eous Markers (CNS cases only ) ait spots-->Smm &>6 no. in prepubertal /.> 15mm8&>6 in no. in post- freckling, mented patches -2mm diameter, 2 or more nodules- Hamartomas in iris, ‘more neurofibromas’ | plexiform (Neurofibroma): hagreen patches, macule,Sub- ungual fibroma, Adenoma sebaceum (Tuberous sclerosis);,9. Pilo-nidal sinus,/ dimp occulta); 10. ,Capillary haemangioma (Sturge-weber);, 11. Telengiectasia( Ataxia Telengiectasia) le, Tuft of hair in sacral area ( Spina bifida’ Spina bifida AE RCC Re I AC a A