PEDIATRICS

GENERAL HISTORY TAKING

 DATE OF HISTORY TAKING

 PERSONAL AND DEMOGRAPHIC DETAILS

1. NAME
2. AGE (DATE OF BIRTH)
3. GENDER
4. INFORMANT AND HIS RELIABILTY
5. RESIDENTIAL ADDRESS
6. DATE OF ADMISSION

 CHIEF COMPLAINTS
1. PRESENTING COMPLAINTS WITH DURATION
2. IN CHRONOLOGICAL ORDER
3. IF TIME SAME, THEN IN ORDER OF SEVERITY

 HISTORY OF PRESENTING COMPLAINT

1. WHEN
2. ACUTE/CHRONIC
3. DURATION
4. SEVERITY
5. PROGRESSION (WORSENING, IMPROVING, FLUCTUATING)
6. TEMPORAL (INTERMITTENT, CONTINUOUS, DIURNAL VARIATIONS)
7. PRECIPITATING FACTORS AND AGGRAVATING FACTORS
8. RELIEVING FACTORS
9. ASSOCIATED SYMPTOMS
10. PREVOIUS EPISODES

Review of Systems:
A. Weight - recent changes, weight at birth
B. Skin and Lymph - rashes, adenopathy, lumps, bruising and bleeding, pigmentation
changes
C. HEENT - headaches, concussions, unusual head shape, strabismus, conjunctivitis, visual
problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, mouth
breathing, snoring, apnea, oral thrush, epistaxis, caries
D. Cardiac - cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain,
palpitations
E. Respiratory - pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis, TB
F. GI - stool color and character, diarrhea, constipation, vomiting, hematemesis, jaundice,
abdominal pain, colic, appetite
G. GU - frequency, dysuria, hematuria, discharge, abdominal pains, quality of urinary
stream, polyuria, previous infections, facial edema
H. Musculoskeletal - joint pains or swelling, fevers, scoliosis, myalgia or weakness, injuries,
gait changes
I. Pubertal - secondary sexual characteristics, menses and menstrual problems, pregnancies,
sexual activity
J. Allergy - urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

 TREATMENT HISTORY

 PAST MEDICAL HISTORY:

1. Has the child had:
a. Blood: anemia (iron deficiency, Sickle Cell, Thalessemia)
b. Blood transfusions
c. Chicken pox (Varicella)
d. Contusions
e. Convulsions
f. Fractures
g. German Measles (Rubella)
h. Hospitalizations
i. Measles (Rubeola)
j. Meningitis
k. Mumps
l. Operations
If yes, what illness?
m. Poison ingestion
n. Other serious medical illnesses
If yes, what kind?
o. Is your child currently taking any medications, vitamins or herbs?
Medication Strength/Dose How Often?
p. Reaction to medication or food (allergy)
If yes, please explain:
q. Any chronic or recurring pain?
If yes, please explain:
2. Eyes:
a. Any visual problems?
b. Do eyes look crossed?
c. Does the child wear eyeglasses?
3. Ears:
a. Any hearing problems?
b. Three or more ear infections?
4. Nose:
a. Does the child have frequent attacks of sneezing or rubbing his/her nose?
b. Has the child had frequent nose bleeds?
5. Throat:
a. Does your child have three or more strep throat infections per year?
6. Heart:
Have you ever been told your child has
a. A heart murmur?
b. Heart defect?
c. High blood pressure?
7. Lungs:
Has your child ever had
a. Asthma/wheezing?
b. Bronchitis or pneumonia?
c. Chronic cough?
8. Does your child tire easily?
9. Abdomen
Has your child ever had
a. Blood in bowel movement?
b. Difficulty with appetite or eating?
c. Frequent abdominal pain?
d. Frequent vomiting or diarrhea?
e. Jaundice?
f. Marked weight loss?
If yes, please explain:
10. Kidney:
a. Does your child ever complain of burning or frequency of urination?
b. Does your child wet the bed?
c. Has there ever been blood in the urine?
d. Has your child ever had a urinary tract infection?
11. Skin:
a. Acne?
b. Any sensitivity or allergy?
c. Eczema or atopic dermatitis?
12. Extremities:
Has your child
a. Had weakness or paralysis of arms or legs?
b. A persistent limp?
c. Every worn corrective shoes or braces?
13. Neurological:
Has your child ever had
a. Breath holding?
b. Convulsions or seizures?
c. Dizziness?
d. Fainting?
e. Frequent headaches?
f. Temper tantrums?
14. Is your child:
a. Impulsive?
b. Lacking in self-control?
c. Overactive?
d. Does your child have problems with:
i. Attending school?
ii. Attention span?
iii. Learning?
iv. Mood?
v. Parents?
vi. Peers?
vii. Siblings?
viii. Sleep?
e. Are there concerns about physical, sexual or emotional abuse?
15. Has your child begun puberty?
16. Any other concerns you would like to discuss?

 DRUG HISTORY

 PRENATAL HISTORY
1. While pregnant, did mother have:
a. Bleeding or spotting
b. German measles (Rubella)
c. Gestational diabetes
d. High blood pressure
e. Illness other than cold/flu
f. Kidney disease
g. Premature labor
h. Threatened miscarriage
i. Toxemia
2. Were medications or herbs taken during pregnancy?
If yes, what kind:
3. Was a fertility treatment used for this pregnancy
If yes, what kind:
Ask if all three sonography reports were normal or not
  BIRTH HISTORY
1. Where was child born:
2. Was labor induced?
3. Was labor helped by medication?
4. Duration of labor:
5. Was child born early (less than 38 weeks)?
6. Was child born late (after 42 weeks)?
7. What was the method of delivery:
_ Breech
_ Caesarean (Please state reason):
_ Forceps
_ Spontaneous vaginal
8. Child’s birth weight:
9. Apgar Score (if known):
10. During the hospital stay, did child have any of the following:
a. Antibiotic treatment
b. Blue spells
c. Convulsions
d. Jaundice
e. Skin rash
f. Did child remain in hospital longer than mother?
11. How was/is baby fed?
_ Bottle
_ Breast
FIRST CRY-

 DEVELOPMENTAL MILESTONES
 FAMILY HISTORY
 PEDIGREE CHART
 ASK FOR SIMILAR PROBLEMS IN FAMILY
 CHECK FOR CONSANGUINITY
 ANY CULTURAL OR RELIGIOUS PRACTICES THAT MIGHT AFFECT
CHILD’S HEALTH CARE

 SOCIO-ECONOMIC STATUS
 MODIFIED KUPPUSWAMY SCALE
  PERSONAL HISTORY
Feeding – volume of intake / frequency of feeding
Bowel and Bladder habits
Behaviour – irritability / less responsive
Weight gain or loss – check baby book if the parent has it with them
Sleeping pattern

 DIET HISTORY
 24 HOUR CALORIE AND PROTEIN INTAKE
  IMMUNIZATION HISTORY
National Immunization Schedule in India; 2017
For pregnant women
Early in pregnancy
TT-1* 0.5 mL Intramuscular Upper arm
4 weeks after TT-1
TT-2 0.5 mL Intramuscular Upper arm
*If the pregnant woman has received two TT doses in a pregnancy within last 3 years, only
one TT-booster is required during the present pregnancy
For infants
At birth
BCG, 0.1 mL (0.05 mL for <1 month age), Intradermal, Left upper arm
0-dose OPV, 2 drops, Oral This dose is not counted
Hep-B (birth dose), 0.5 mL, Intramuscular, Anterolateral side of mid-thigh – LEFT (k/a Birth
dose)
6 weeks
Pentavalent-1, 0.5 mL, Intramuscular, Anterolateral side of mid-thigh – LEFT
OPV-1, 2 drops, Oral
*Rotavirus Vaccine, 5 drops, Oral, * In select States
#IPV, fractional dose (0.1ml), INTRADERMAL #in select States
PCV - 1
10 weeks
Pentavalent -2, 0.5 mL, Intramuscular, Anterolateral side of mid-thigh – LEFT
OPV-2, 2 drops, Oral
*Rotavirus Vaccine, 5 drops, Oral, * In select States
14 weeks
Pentavalent -3, 0.5 mL, Intramuscular, Anterolateral side of mid-thigh – LEFT
OPV-3, 2 drops, Oral
IPV, 0.5 ml, INTRAMUSCULAR, Anterolateral side of mid-thigh – RIGHT
*Rotavirus Vaccine, 5 drops, Oral * In select States
PCV - 2
9–12 months
Measles / MR, 0.5 mL, Subcutaneous, Right upper arm
#Japanese Encephalitis (1st Dose), 0.5 mL, Subcutaneous, Left upper arm, # In select
endemic districts
Vitamin A first dose, 1 mL (100,000 IU), Oral
PCV - B
For children
16–24 months
DPT booster-1, 0.5 mL, Intramuscular, Anterolateral side of mid-thigh – LEFT
OPV booster, 2 drops, Oral
#Japanese encephalitis (second dose), 0.5 mL, Subcutaneous, Left upper arm, # In select
endemic districts
Measles (second dose)/ MR/ MMR* 0.5 mL Subcutaneous Right upper arm
Vitamin A-second dose, 2 mL (200,000 IU), Oral
#J.E. vaccine Given only in select states, district, and cities that are endemic for the disease
*MMR Presently given in Delhi, Goa, Sikkim, and Puducherry
Every 6 months till 5 years of age
Three to ninth dose of Vitamin A, 2 mL (200,000 IU), Oral
The 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during
biannual rounds, in collaboration with ICDS.
5–6 years
DPT Booster-2, 0.5 mL, Intramuscular, Upper arm
10 years
TT, 0.5 mL, Intramuscular, Upper arm
16 years
TT, 0.5 mL, Intramuscular, Upper arm
 General Physical Examination:
Vital signs-
1. Temperature: Axillary temperature should be recorded by placing the bulb of the
thermometer in the apex of axilla parallel to the body for 3 minutes
2. Pulse rate: Apical pulse or femoral pulse in infant and antecubital or radial pulse
3. Respiratory rate Observe for a minute. Infants normally have periodic breathing.
observing for only 15 seconds will result in a skewed number
4. Blood pressure: It is important to use appropriate size cuff- 2/3 width of upper

Anthropometry-
1. Weight
Taken on a digital weighing scale
Height/length Measured by Stadiometer/Infantometer
3. Head Circumference (Occipital Frontal Circumference)
4. Mid Upper Arm Circumference (MUAC] for children 6months to 5 years of age
The anthropometric measurements should be taken carefully using standardised equipment
to avoid errors.

Skin and Lymphatics-

1. Birthmarks- haemangiomas, Mongolian spots etc.
2. Pallor, jaundice, oedema, hair colour and texture
3. Lymph node enlargement, location, mobility, consistency
4. Scars or injuries, especially in patterns suggestive of abuse.

Head-
Use finger tips to palpate each suture line. Look for overriding or widely open sutures
the anterior and Posterior fontanelles. The fontanelle should feel flat.
Eyes-
Placement & symmetry: Wide set: hypertelorism- Down syndrome. Close set
Epicanthal folds or upward slants-ethnicity, Down's Syndrome
Eyelids: Ptosis, lid lag, blepharitis (stye), swelling, Dacryocystitis (blocked tear duct)
"Allergic shinner" (dark circles) may indicate allergy
Periorbital oedema may indicate renal problems
Conjunctive: Inflammation, pallor
Anomalies or opacities of cornea, iris or lens
White retinal reflex indicates pathology (ie, retinoblastoma)
Visual Acuity

Ears-
Variations: Malformed pinna or low-set or obliquely-set ears may be associate
syndromes
Pus discharge
Hearing: Especially if language delay or frequent otitis media
Use Otoscope to examine the internal auditory canal and tympanic membrane

Nose-
Look for structural variations like flattened nose or
nasolabial folds that may indicate congenital anomalies

Mouth and Pharynx-

Inspect the mucous membrane for color and moisture
Teeth and gums (number, condition), Palate (intact, arch), Tonsils (size, color, exudate)
duct opening
Posterior pharyngeal wall (colour, lymph hyperplasia, bulging), Gag reflex. Inspect
symmetrical movement or bifid uvula
Neck-
Observe for Short neck, webbed neck and torticollis. Look for Thyroid, Trachea position.
Examine the child for head holding

Lungs/Thorax-
A. Inspection
Pattern of breathing: Abdominal breathing and periodic breathing are normal
Use of accessory muscles: retraction location, degree/flaring
Observe for shape, symmetry & posture. Chest deformities:
Pectus carinatum or pigeon breast, Pectus excavatum or funnel chest protrusion
Beading or rachitic may indicate vitamin D deficiency (rickets)
B. Auscultation
Look for equality of breath sounds and prolonged expiratory phase
Presence of Rales, wheezes, rhonchi
Develop a sequence for auscultating the entire chest
Broncho-vesicular breathing may be normal in young children.

Cardiovascular-
Palpate pulses both in upper and lower extremities. Femoral pulses are absent or present.
 Eyes

EXAMINATION ABNORMALITIES
 Eyebrows 1. Level, Amount Absent in Ectodermal
Dysplasia

 Eyelashes 2. Size Long in PEM and TB

Long and curly with
bushy eyebrows in
Cornelia De Lange
Syndrome

 Eyelids 3. Position Ptosis

Stye/Hardeolum in
Staphylococcal inf.
4. Movement(Blinking) No blinking in
Lagophthalmos
5. Lid Margin Entropion (inward
margin)
Extropion (outward)
 Eye ball 6. Position Exophthalmos \
Protopsis
Endophthalmos
7. Visual Axis Squint
/Strabismus(deviation)
8. Size Inc. in Buphthalmos
Dec. in congenital
microphthalmos
9. Movement

 Conjunctiva 10.Bulbar Discoloration in Anemia,

Lower palpebral Cyanosis
Upper palpebral BITOT spots in Vit A def.
  Presence of any Conjunctivitis( redness,
Follicles swelling and purulent
Concretions discharge)
Papillae Chalazion/Meibomian
Cyst
 Sclera 11. Discoloration in
Jaundice(yellow)
In Marfan’s Syndrome
(bluish)
Scleritis

 Cornea 12.Size, Shape Keratoconus

Micro\Megalocornea

13. Transparency\Opacity Glaucoma

14. Corneal sensations Lost in absolute
Glaucoma, Diabetes

 Anterior 15. Depth Shallow in Glaucoma

Chamber Inc. in Hypermetropia
Dec. in Myopia
Presence of an Artificial
Lens

 Iris 16.Colour Congenital

Heterochromia
Brushfield Spots in
Downs Syndrome

17.Irodenesis Quivering movement of

iris
Aniridia (congenital
absence of iris)
Coloboma(gap or hole in
iris)
 Pupil 18. Number Polycoria
19. Size –Miosis
-Mydriasis
20. Shape Irregular in Iridiocyclitis

21. Colour (Presence of Greyish white n

Cataract) immature cataract
Pearly white in mature
cataract
22. WHITE reflex Seen in congenital
(LEUCOCORIA) cataract, retinoblastoma
23. Exudate Seen in Iridocyclitis

 Pupillary 24. Direct Light Reflex Amaurotic Pupil

Reflexes
25.Consensual Light Reflex

 Lens 26.Position, Colour Dislocation of lens

Aphakia( absence of lens
, jet black pupil seen)
27. Shape Spherophakia
28. Colour Snow Flake opacities in
True diabetic cataract
Sunflower Cataract in
Wilsons disease

 Intraocular 29.
Pressure
 DEFICIENCY STATE SIGNS AND
SYMPTOMS
1. VITAMIN A
• Night blindness • Bitot spots on scleral conjunctiva • Xerophthalmia •
Keratomalacia • Phrynoderma- toad like skin due to follicular
hyperkeratosis • Faulty epiphyseal bone formation • Mucosal alterations
leading to frequent respiratory and GI infections • Stunting • Formation of
renal and vesical calculi
2. VITAMIN B1 (THIAMINE) • Dry Beri-Beri: Polyneuritis Ptosis Hoarseness of
voice Tenderness of calf muscles Sluggish deep tendon jerks • Wet Beri-
Beri: Palpitations Tachycardia Dyspnea Cardiomegaly Edema Low voltage,
prolonged QT interval and inversion of T waves on EKG.
3. VITAMIN B2 (RIBOFLAVIN) • Glossitis • Cheliosis • Angular stomatitis •
Scaly dermatitis at nasolabial folds • Photophobia and blurred vision due to
circumcorneal vascularization and keratitis.
4. VITAMIN B3 (NIACIN OR PP FACTOR) Pellagra characterized by: • Diarrhea •
Dermatitis (over skin parts exposed to sunlight) • Dementia (muscle
weakness, loss of memory, depression and lethargy) VITAMIN B9 (FOLIC
ACID) • Megaloblastic anemia • Glossitis • Pharyngeal ulcers • Impaired
immunity
5. VITAMIN B5 ( PANTOTHENIC ACID) • Burning sensations in hands and feet •
GI disturbances • Muscle cramps • Fatigue • Hypoglycemia
6. VITAMIN B6 (PYRIDOXINE) • Hypochromic anemia • Irritability • Seizures •
Peripheral neuritis
7. VITAMIN B12 (CYANOCOBALAMIN) • Anemia • Pigmentation of knuckles •
Thrombocytopenia • Tremors
8. VITAMIN C (ASCORBIC ACID) Scurvy characterized by: • Marked irritability
• Hemorrhages under the periosteum of long bones (pseudo paralysis with
frog-like posture), Gums, mucous membranes and skin. • Scorbutic rosary –
posterior dislocation of sternum • Increased risk of infection and poor
wound heeling
9. VITAMIN D (CHOLECALCIFEROL) Rickets characterized by: • Bossing of skull
• Craniotabes and delayed closure of anterior fontanelle • Rachitic rosary-
costochondral beading which is broad, smooth and dome-shaped • Pigeon
chest • Harrison’s sulcus- retractions at lower border of chest
corresponding to the insertion of diaphragm • Spinal deformities •
Widening and enlargement of ends of long bones • Bowing of legs • Knock
knees • Coxa Vara • Potbelly • Stunting • Tetany may occur.
10. VITAMIN E (TOCOPHEROL) • Hemolytic anemia in pre term babies •
Progressive neuromyopathy manifesting as ataxia • Paralysis of extrinsic
ocular muscles
11. VITAMIN K • Early and late -onset hemorrhagic disease of the new born
with bleeding manifestations from different sites.
 Malnutrition
The term malnutrition refers to both undernutrition as
well as overnutrition.

UNDERNUTRITION
EPIDEMIOLOGY
1. SEX – Similar prevalence
2. PLACE OF ORIGIN -- Punjab, Kerala, Jammu and Kashmir and Tamil Nadu account for
the lowest proportions (27-33%) of underweight children; while Chhattisgarh, Bihar,
Jharkhand and Madhya Pradesh report the maximum (52-60%) levels of underweight
children.
3. AGE—

4. ECONOMIC STATUS—higher prevalence in poorer communities

5. LOW BIRTHWEIGHT

Indicators for Undenutrition

 INDICATOR INTERPRETATION COMMENT

STUNTING LOW HEIGHT-FOR-AGE Indicator of chronic

malnutrition, the result of
prolonged food deprivation and/
or disease or illness

WASTING LOW WEIGHT-FOR-HEIGHT Suggests acute malnutrition, the

result of more recent food
deficit or illness

UNDERWEIGHT LOW WEIGHT-FOR-AGE Combined indicator to reflect

both acute and chronic
malnutrition

CLASSIFICATION OF UNDERNUTRITION

1. WHO CLASSIFICATION
The WHO recommends the use of Z scores or standard deviation scores (SOS) for evaluating
anthropometric data, so as to accurately classify individuals with indices below the extreme
percentiles.
SD SCORE= Observed value-median score value/Standard deviation of reference population

A score of -2 to -3 indicates moderate malnutrition and a score of +2 to +3 SOS indicates

overweight. A score of less than -3 SOS indicates severe malnutrition and a score of more
than +3 indicates obesity.
2. IAP Classification
SIGNS AND SYMPTOMS OF MALNUTRITION IN MULTIPLE ORGANS

MILD MALNUTRITION
Main features are
1. Growth failure
2. Infection.
3. Anemia.
4. Activity.
5. Skin and hair changes. These may occur rarely.

MARASMUS
It is characterized by marked wasting of fat and muscle as these tissues are consumed to make
energy. Other features

1. monkey facies
2. Baggy pants
 3. Affected children may appear to be alert
4. There is no edema

KWASHIORKOR

1. General appearance. Child may have a fat sugar baby appearance.

2. Edema. It ranges from mild to gross
3. Muscle wasting. It is always present. The child is often weak, hypotonic and unable to stand
or walk.
4. Skin changes.
i. Increased pigmentation-- flaky paint or in individual enamel spots.
Distribution is on buttocks, perineum and upper thigh
ii. Petechiae may be seen over abdomen.
iii. Ulceration of skin
iv. The lesions may sometimes resemble burns.
5. Mucous membrane lesions
6. Hair
i. Dyspigmentation
ii. loss of characteristic curls and sparseness over temple and occipital
regions.
iii. lose their lustre and are easily pluckable.
iv. A flag sign which is the alternate bands of hypopigmented and normally
pigmented hair pattern
7. Mental changes. Includes unhappiness, apathy or irritability with sad, intermittent cry
8. Neurological changes
9. Gastrointestinal system. Anorexia, sometimes with vomiting, is the rule. Abdominal
distension is characteristic.
10. Anemia. It may also be seen, as in mild PEM, but with greater severity.
11. Cardiovascular system.
i. The findings include cold, pale extremities due to circulatory insufficiency
ii. Bradycardia
iii. Decreased Cardiac output
iv. Hypotension
12. Renal function diminished

MAJOR DIFFERENCES BETWEEN KWASHIORKOR AND MARASMUS

HISTORY TAKING
The child with severe malnutrition with present with a plethora of symptoms and anomalies in its
history.History of child up to admission should be taken. Special emphasis should be given on
socioeconomic and family circumstances of the child. Special attention should e given to

1. The usual diet (before the current illness) including breastfeeding

2. Presence of diarrhoea (duration, watery /bloody)
3. Information on vomiting, loss of appetite, cough
4. Contact with tuberculosis
5. Malnutrition may be the presentation of HIV infection.

EXAMINATION TAKING
Anthropometry provides the main assessment of the severity of malnutrition. Physical
features of malnutrition as described above should be looked for. Clinical features of
prognostic significance include:
i. Signs of dehydration
ii. Shock (cold hands, slow capillary refill, weak and rapid pulse)
iii. Severe palmar pallor
iv. Eye signs of vitamin A deficiency
v. Localizing signs of infections
vi. Skin infection or pneumonia, signs of HIV infection, fever (temperature greater than
equal to 99.5 ° F)
vii. Hypothermia (rectal temperature <35.5°C or <95.9°F), mouth ulcers, skin changes of
kwashiorkor.
 ANTHROPOMETRY
 Anthropometry is the scientific study of the measurements and
proportions of the body.
 Anthropometric measures are easier and effective way to analyse and
assess growth, neuromotor development and nutritional status of
children.
 Anthropometric measures include:
 Age dependent parameters such as Weight, Height, Head
circumference and Chest circumference
 Age independent parameters such as Mid upper arm
circumference(MUAC), Weight for height, Skin fold thickness and Mid
upper arm/height ratio.
 All these anthropometric measures are analysed in an efficient way
using WHO Z scores. A Z score of +2 indicates 97.3th %ile while -2
indicates 2.7th %ile and +3 indicates 99.9 th %ile and -3 indicates 0.01 th
%ile.

WEIGHT:
 Weight measurement is simple and most reliable criteria for assessment of
nutritional assessment of children.
 Weight at birth depends upon health and nutritional status of mother
during pregnancy but after that weight is a key indicator of child’s own
nutritional status.
 Weight is measure of total body mass and is sensitive to changes in body
fat, fluid, muscle mass, skeleton and organs.
 Weight can be measured using Electronic weighing scales for infants and
children, Beam type weighing scale and Salter spring machine in field
conditions.
 Weight should be measured after ensuring minimal clothing or same
clothing each time if possible.
 WHO Z scores for ‘weight for age’ are then derived for a particular recorded
weight.
 A low weight for age below Z score of -2 indicates ‘Underweight’ child
though height and other factors also should be considered.
 Periodic recording of weight on a growth chart is essential for monitoring
the growth of under 5 children.
 Expected weight can also be measured by Weech’s formula:
 3-12 months : Expected weight(kg)= age(months)+4.5
  1-6 years : Expected weight(kg)= age(years)*2+8
 7-12 years : Expected weight(kg)= age(years)*7-2.5

HEIGHT:
 Upto 2 years of age , recumbent length is measured using Infantometer,
whereas in older children, standing height is measured using Stadiometer.
 Nutritional deprivation over a period of time(chronic), affects the linear
growth and thus the height of a child.
 The infant is placed supine over infantometer with head positioned such
that Frankfurt’s plane is perpendicular to the table and legs are extended by
pressing over the knees. The movable pedal plank of infantometer is snugly
apposed against soles and length is read from scale.
 The child is made to stand with bare feet against a rigid wall and asked to
keep his heels, buttocks, shoulder and head rested on the wall with head on
Frankfurt’s plane. With the help of a plastic ruler, the topmost point of
vertex is identified and height is measured.
 WHO Z scores for ‘height for age’ are then derived for the recorded height.
 A low height for age Z score below -2 indicates ‘Stunting’ due to chronic
suboptimal nutritional status.

 Expected height upto 12 years can be measured by Weech’s formula:

 Height(cm)= age(years)*6+77
WEIGHT FOR HEIGHT:
 Important parameter for nutritional assessment that eliminates age factor
and is thus more reliable.
 WHO Z score for weight for height below -2 indicates ‘Wasting’ due to acute
severe suboptimal nutritional status.
HEAD CIRCUMFERENCE:
 Most of the brain development takes place during fetal period(70%),
infancy(15%) and remaining during pre school years.
 Head circumference is thus routinely measured till 5 years of age.
 The head circumference is measured by placing the tape over the most
prominent parts of occiput and supraorbital frontal regions with enough
pressure to compress the hair.
 WHO Z score of less than -2 indicates ‘Microcephaly’ whereas more than +2
indicates ‘Macrocephaly’.
CHEST CIRCUMFERENCE:
 It is usually measured at the level of nipples but can be also measured at
the level xiphisternal junction because level of nipples may be variable.
 In children, chest circumference is measured on lying down position if age is
less than or equal to 5 years otherwise taken at standing position.

RELATIONSHIP BETWEEN HEAD AND CHEST CIRCUMFERENCE:

 At birth, head circumference is greater than chest circumference upto 3 cm.
 At around 9 months to 1 year of age, head circumference is equal to chest
circumference.
 After 1 year, chest grows more rapidly compared to head(brain).
 The head circumference is greater than chest circumference by more than 5
cm in cases of : Preterms, Small for date, Hydrocephalic infants.
 On malnourished children, chest circumference may be considerably lower
than head circumference because brain growth is les affected by
malnutrition. As a result, chest circumference overtakes head
circumference at a later stage of life.

MID UPPER ARM CIRCUMFERENCE(MUAC):

 MUAC remains reasonably constant between 15 cm and 17 cm upto 5 years
of age.
 It is conventionally measured at the point midway between acromion
process and olecranon process with arm bent at right angles and taken
bilaterally. The arm should be hanging loosely at the sides or the child
should be made to sit.
 MUAC is measured using fibre glass tape or steel tape.
 If MUAC is less than12.5 cm, then it is suggestive of severe malnutrition,
while MUAC between 12.5 cm and 13.5 cm is suggestive of moderate
malnutrition.
 Quick assessment of MUAC can be done by Bangle test in which a glass ring
of internal diameter 4 cm is slipped up the arm and if it passes above the
elbow, it suggests MUAC of less than 12.5 cm and thus severe malnutrition.
 Shakir tape is generally used by health workers to quickly assess MUAC as it
has red marking for severe malnutrition, yellow for moderate malnutrition
and green for normal MUAC.
 QUAC stick test is developed on the principle that acute starvation severely
affects MUAC but height is unaffected. It is a height measuring rod
 calibrated in MUAC and values of 80% MUAC are marked on stick
corresponding to heights. The malnourished child has higher than expected
height corresponding to MUAC.

SKINFOLD THICKNESS:
 It is measured with the help of Herpenden’s calliper at Triceps or
Subscapular regions.
 The skin fold with subcutaneous fat is picked with thumb and index finger
and calliper is applied beyond the pinch.
 Fat thickness:
 If greater than 10 mm, indicates healthy child upto 6 years of age.
 If less than 6 mm, indicates moderate to severe degree of malnutrition.

BODY MASS INDEX(BMI):

 BMI is considered as a better criterion for the diagnosis of overweight and
obesity .
 It is calculated as Weight(kg)/Height(m2 ).
 A BMI for age greater than 85%ile is suggestive of ‘Overweight’.
 A BMI for age greater than 95%ile or when associated with triceps or
subscapular skinfold thickness greater than 90%ile is diagnostic of ‘Obesity’
PROPORTIONAL TRUNK AND LIMB GROWTH:
 The mid point of the body in newborn is at umbilicus whereas in an adult
the mid point shifts to the symphysis pubis due to greater growth of limbs
than trunk.
 The Upper segment(vertex to upper edge of pubis symphysis) to Lower
segment(pubis symphysis to heels) ratio at birth is 1.7 to 1.0 . This gradually
becomes 1.0-1.1 in healthy adults.
 In infants, upper segment can be measured by infantometer whereas lower
segment is obtained by subtracting upper segment length from total body
length.
 Infantile upper segment to lower segment ratio is seen in Achondroplasia,
Cretinism, Bowed legs etc.
 Advanced upper segment to lower segment ratio is seen in Hypogonadism,
Turner syndrome, Klinefelter’s syndrome, Arachnodactyly etc.

ARM SPAN:
 It is the distance between the tips of middle fingers of both arms
outstretched at right angels to the body, measured across the back of the
child.
 In under 5 children, arm span is 1-2 cm smaller than body length.
 During 10-12 years of age, arm span and height are equal,
 In adults, arm span is greater than height by 2 cm.
 Abnormally large arm span is seen in patients with Marfan syndrome,
Eunuchoidism, Klinefelter’s syndrome and Coarctation of aorta.
 Abnormally small arm span is seen in patients with Cretinism and
Achondroplasia.
 RESPIRATORY SYSTEM
History :-
Major symptoms :- cough, fever, sore throat, chest pain, respiratory difficulty, coryza,
expectoration.

1.COUGH :-

Uncommon in neonates (In aspiration, chlamydial infection. )

1. Duration

2. Onset-Gradual(=Insidious)/ Sudden

3. Progress

4. Episodes

5. Expectoration

6. Seasonal variation

7. Diurnal variation

8. Postural variation

9. Relieving factors-Rest/Medicine

10. Aggravating factors

2.EXPECTORATION :-

1. Duration

2. Onset-Gradual(=Insidious)/ Sudden

3. Progress

4. Quantity-Scanty/ Copious

5. Amount____ml/day or____cups/day

6. Color

7. Consistency

8. Foul smelling

9. Blood staining

10. Seasonal variation-Present/ Absent

11. Postural variation-Present/ Absent

 12. Aggravating Factors

13. Diurnal variation-Present/ Absent

14. Relieving Factors-Rest/ Medicine

3.HEMOPTYSIS :- uncommon in children.

1. Duration

2. Onset

3. Progress

4. Episodes

5. Fresh/Altered

6. Aggravating factors and Relieving factors

 Characters of blood :- With bout of cough, bright red, usually small.

May occur due to :-

 Bacterial pneumonia
 Fibro caseous tb
 Bronchiectasis
 Lung abscess
 Pulmonary sequestration
 Pulmonary edema
 Foreign body
 Cystic fibrosis
 Pulmonary hypertension
 Bleeding disorder

4.CHEST PAIN :-

Respi + CVS disorders like pericarditis, pleurisy, pleurodynia, costochondritis,

herpes zoster, trauma, coronary insufficiency.

1. Site- localized -Retrosternal/ Lateral generalized

2. Onset-Sudden/ Gradual

3. Character- Sharp & Stabbing/ Aching/ Constipation

4. Effect of breathing & coughing-Worse/ Unrelated

5. Radiation

6. Associated symptoms

7. Time
 8. severity

5.BREATHLESSNESS (DYSPNEA)

1. Duration

2. Onset

3. Time of appearance-Early morning/ Early night

4. Progress-Stationary/ Progressive--Rapid/ Slow

5. Paroxysmal/ Exertional

6. How much exertion is needed

7. Preceding events-Cough with expectoration

8. Associated events-Cough/ Chest pain/ wheeze/ Stridor/ Shock / Fever/ Angina/

Palpitation/ Syncope/ Hypertension/Cyanosis/Weight loss

9. Grade-I/ II/ III/ IV

10. Orthopnea

11. Paroxysmal Nocturnal Dyspnea (PND)

12. Seasonal variation-Present/Absent

13. Aggravating factors

14. Relieving factors-Drugs/ Rest/ Change of smoky environment/ Squatting/ Change of

posture/ Expectoration

6.WHEEZING OR STRIDOR

1. Duration

2. Onset

3. Progress

7.FEVER

1. Duration

2. Onset

3. Type-

 Continued
  Remittent

 Intermittent-Quotidian/ Tertian/ Quartan

4. Progress

5. Paroxysm-One/ Multiple

6. Grade-High /Low

7. Chills/ Rigor

8. Diurnal Variation-How long the fever stays-

9. H/O convulsion

10. H/O drug intake

11. H/O any treatment received & its effect-

8.HEAVINESS IN THE CHEST

1. Duration

2. Onset

3. Progress

9.HOARSENESS OF VOICE

1. Duration

2. Onset

3. Progress

10.SWELLING OF FEET

1. Duration

2. Onset

3. Progress

11. Family history of :-

1. Asthma
2. Tb
3. Hay fever
4. Overcrowding
 5. Pollution
6. Smoking
General physical examination
 Comfortable
 Cooperative
 Conscious
 Oriented
 Built
 Nourishment
 Febrile/afebrile
 Vital signs
1. Pulse rate : rate, rhythm, character, pv, rf, vessel wall.
2. Bp
3. RR
•Who cut offs for fast breathing in under 5 year children :-
• Birth – 2 months = 60 or more
• 2 – 12 months = 50 or more
• 12 months to 5 years =40 or more
4. Temperature
5. Spo2
6. JVP
 Anthropometry
 Pallor
 Icterus
 Clubbing
• suppurative lung disease

• cyanotic congenital heart disease

• liver disease

• inflammatory bowel disease

• hypothyroidism, chronic pyelonephritis, toxins, Raynaud’s, Fabry’s

 Cyanosis :-Cyanosis requires at least 4-6g/dl desaturated Hb in capillary, 3g/dl in art blood
• Hb 8 SaO2 <65%

• Hb 14 SaO2 <78%

• Hb 20 SaO2 <85%

• central cyanosis

• ear lobes, retinal, mouth

• peripheral cyanosis
• increased O2 consumption or decreased blood flow

 Pedal edema
 Significant lymphadenopathy

Systemic examination
Inspection :-
Upper Airway
• Face

• micrognathia, retrognathia, depressed nasal bridge

• palate, uvula and tonsils

• nasal polyps in cystic fibrosis, allergic rhinitis

• allergic salute and rabbit twitching

• mouth breathing

Chest shape :- Cylindrical in infants.

• Asymmetry

• Hyperinflation

• Pectus excavatum

• Pectus carinatum

• Harrison’s sulci

• Chest expansion

• kyphoscoliosis

 Barrel shape
 Pigeon shape :- rickets, chondrodystrophy
 Funnel shape :- rickets, absence of pectoralis muscle, marfan syndrome, mucosa neuroma
syndrome.
 Apex beat

Symmetry :- bilateral symmetry

 Dropping of shoulder :- fibro caseous tb
 Bulge :- costal or intercostal

 Movement of chest :- Abdominal/abdominothoracic

* Abdomen may draw in when inspiration :- Diaphragm paralysis

* Little expansion of chest with abdomen :- intercostal paralysis

Respiratory cycle
• prolonged inspiration – extra thoracic obstruction

• prolonged expiration – intra thoracic obstruction

• tachypnoea with normal cycle – parenchymal disease

2.Palpation
• cervical and axillary lymph nodes
• asymmetrical chest wall expansion
• tactile fremitus - pneumothorax, consolidation
 Tender area
 Subcutaneous emphysema
 Fractured rib
 Feel abnormal vibration
 Position of trachea :-
* May slightly right.
* Sternocleidomastoid muscle head elevates
* Trachea movement towards -
Diseased side :- collapse, fibrosis, thickened pleura.
Normal side :- pleural effusion, pneumothorax, mass lesion.

3.Percussion:-
* Dull - pleural fluid, consolidation, plural thickening
* Resonant – pneumothorax

4. Auscultation :-
• vesicular
• low frequency, non-musical sound, barely audible at rest
• bronchial / tracheal breath sounds
• harsh sounds like those heard over the trachea – consolidation
• wheeze
• high pitched, musical sound in expiration – intra-thoracic airway obstruction
• flow dependent
• crackles (crepitations)
• high pitched short duration –
• movement of thin secretions, explosive opening of collapse small airways
• egophony and whispered pectoriloquy
 CVS Checklist
Introduce yourself – name / role

Confirm patient details – name / DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

History of presenting complaint

Onset – When did the symptom start? / Was the onset acute or gradual?

Duration – minutes / hours / days / weeks / months / years

Severity – e.g. if symptom is chest pain, how bad is it on a scale of 1 to 10?

Course – is the symptom worsening, improving, or continuing to fluctuate?

Intermittent or continuous? – is the symptom always present or does it come and go?

Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. GTN spray

Associated features –are there other symptoms that appear associated e.g. fever / malaise

Previous episodes – has the patient experienced this symptom previously?

Key cardiovascular symptoms:

• Chest pain – SOCRATES

• Dyspnoea – exertional / orthopnea / paroxysmal nocturnal dyspnoea

 • Palpitations – ask patient to tap out the rhythm

• Syncope / dizziness – postural / exertional / random

• Oedema – peripheral oedema (e.g. lower limbs) / sacral oedema

• Intermittent claudication – e.g. leg pain worsened on exertion / improved at rest

• Systemic symptoms – fatigue / fever / weight loss / weight gain

CARDIOVASCULAR RISK FACTORS:

• Hypertension

• Smoking

• Hyperlipidaemia

• Diabetes

• Family history of cardiac disease

Past medical history

Cardiovascular disease:

• Angina

• Myocardial infarction – bypass grafts / stents

• Atrial fibrillation

• Stroke

• Peripheral vascular disease

• Hypertension

• Hyperlipidaemia

• Rheumatic fever

Other medical conditions – e.g. hyperthyroidism

Surgical history – bypass graft / stents / valve replacements

Acute hospital admissions

Drug history

Cardiovascular medications:

• Beta blockers

• Calcium channel blockers

• ACE inhibitors

• Diuretics

• Statins

• Antiplatelets

• Anticoagulants

• Glyceryl trinitrate spray (GTN spray)

Other regular medications

Contraceptive pill – increased risk of thromboembolic disease

Over the counter drugs – NSAIDS / Aspirin

Herbal remedies – e.g. St John’s Wort – enzyme inducer (can affect Warfarin levels)

ALLERGIES – ensure to document these clearly

Family history

Cardiovascular disease at a young age –myocardial infarction / hypertension / thrombophilia

Are parents still in good health? – if deceased sensitively determine age and cause of death

Any unexplained deaths in young relatives? – long QT syndrome / channelopathies

Personal History:

Smoking – How many cigarettes a day? How many years have they smoked for?

Alcohol – How many units a week? – type / volume / strength of alcohol

Recreational drug use – e.g. Cocaine – coronary artery vasospasm

Diet – Overweight? Fatty foods? Salt intake? – cardiovascular risk factors

Exercise – baseline level of patient’s day to day activity

Living situation:
 • House/bungalow? – adaptations / stairs

• Who lives with the patient? – is the patient supported at home?

• Any carer input? – what level of care do they receive?

Activities of daily living:

• Is the patient independent and able to fully care for themselves?

• Can they manage self hygiene / housework / food shopping?

Occupation – sedentary jobs – ↑ cardiovascular risk – e.g. lorry driver

General Inspection
Evidence of distress or breathlessness

The Hands and Arms

Nails and finger tips

- Clubbing

- Peripheral stigmata of infective endocarditis

- Tar staining

Capillary refill time

Radial pulse

The Neck and Face

Carotid pulse

Assess the Jugular Venous Pressure

Inspect the eyes and conjunctivate

Inspect the mouth and cheeks

The Precordium

General inspection of

- Scars or skin changes

- Chest wall deformities

- Obvious pacemaker scar

Palpate for:

- Apex beat

- Heaves and thrills

Auscultate the heart

- Aortic valve

- Pulmonary valve

- Tricuspid valve

- Mitral valve

Accentuate the murmurs

- Listen over axilla (MR)

- Roll patient to left, listen to apex with bell (MS)

- Listen to base of the neck (AS)

Lean patient forward, listen over left sternal edge (AR)

Auscultate the carotids

Completing the Examination

Auscultate the lung bases

Assess for sacral oedema

Assess for peripheral oedema

 Model checklist for abdominal
examination
1). History: -
 Pain abdomen: - site, onset, character, radiation, timing, aggravating and
relieving factors.
 Vomiting: - Bilious or not (association with nausea or not) , timing, color,
projectile or not.
 Constipation: - Duration, associated with bleeding or not.
 Diarrhea: - Duration, frequency, association with blood and mucus, urine
output.
 Jaundice
 Abdominal distension
 Bleeding from any site:- Heamaturia, bleeding per rectum, hematemesis,
melena.
 Urinary complaints: - Dysuria, output, color.
 Alteration in appetite.
 Scrotal swelling: - Painful or not.

2). Examination:-
 Inspection: - Shape, visible lump, distension, visible veins, scars,
umbilicus, visible peristalsis.
 Palpation:-tenderness, rigidity, guarding
o Liver: size, surface, tenderness, consistency, margins.
 Spleen: Size, Consistency, notch.
o
Kidneys: Renal angle, ballotability.
o
Urinary bladder
o
Fecaliths
o
Abdominal lump: site, size, shape, consistency, margins, surface,
o
motility, signs of inflammation.
o Ascitis
 Percussion: Pudde sign, shifting dullness, fluid thrill.
 Auscultation: bowel sounds, renal bruit
 Genitalia

CNS Checklist
Name/Age/Sex/Occupation/Address

Informant and reliability :

Handedness:

Presenting Complaints:

H/o Developmental delay since early infancy/Seizures/ stiffness of limbs/ Floppiness of

limbs/weakness/deviation of angle of mouth to one side/ nasal regurgitation/ speech problems /
feeding difficulties/abnormal twisted postures or jerky movements/ headache/ vomiting

History of presenting complaints:

Explain the temporal course of each presenting complaint in chronological order

Sequence of events in patients own words which includes-

Onset, progression, nadir of the symptom, associated features, other system involvement, important
negative history pertaining to the extent of involvement (neuraxis), etiology, complications

Eg: .

1. Weakness : since – onset – acute/subacute/chronic; progression to nadir – over how many days

Upper limb

Proximal: H/o combing hair, lifting hand

Distal: H/o mixing food, buttoning shirt, writing

Lower limb
Proximal: H/o standing, climbing stairs

oDistal: H/o slippers slipping

Trunk:

H/o turning from side to side, getting upto sitting position

Neck:

H/o difficulty to lift head from bed, head drop while erect

Associated history to see the extent of weakness –

like difficulty in closing the eyes completely, expressionless fce, deviation of angle of mouth, nasal
regurgitation and feeding diff, ineffective cough and choking- s/o facial and bulbar weakness

respiratory difficulty in form of shortness of breath , paradoxical chest movements

Similarly for each complaint

Neuraxis: in the order of cognition, behaviour, speech, sleep, cranial nerves, gait, weakness,
stiffness/floppiness, sensory complaints, abnormal movements, cerebellar invt, auntonomic, bowel
bladder and meningeal signs/raised ICP signs

Etiological: fever, trauma, drug exposure, vaccination, animal bite, prodromal illness, fluctuating
illness (neurometabolic), regression of milestones (degenerative disorders), history suggestive of
systemic disorders

Complications: fixed postures(contractures), constipation,skin changes, local swelling and

tenderness, behavioural changes

Treatment history : if have received any significant treatment for the presenting complaints; course
in the hospital can be explained here

Perinatal history:

Developmental history:

Immunisation history:

Past history: anything that is relevant to the presenting complaints

Family history: Pedigree, Consanguinity, similar illness, early deaths

Socioeconomic history:

H/o sensory loss

Temperature sense: warm / cold water

Touch sense: feeling shirts, dresses

Pain sense: pinching

Others: tingling, numbness, root pain

H/o loss of consciousness:

1.Duration

2.Complete/partial

3.Aura

4.Associated with

to rule out odd's palsy

a.Bowel Bladder disturbance

5.Recovery period

6.Frequency of occurrence

History suggestive of etiology

. H/o thrombus

. H/o embolism

. H/o haemorrhage

Vomiting, diarrhoea (calf tenderness)

Chest pain, palpitation, fever with meningitis, TB

Trauma, headache, projectile vomiting, blurring of vision, convulsions, bleeding

diathesis

Level of lesion

H/o cortex

Aphasia

. Bladder involvement

. Convulsion

H/o corona radiata

H/o Internal capsule

H/o brain stem

Cranial nerves

H/o loss of sense of smell/ altered

H/o disturbance of vision

III, IV, VI : H/o diplopia, difficulty in eye movements

V:
H/o sensory loss over face, chewing disturbances

H/o loss of taste, salivation, angle deviation, drooling of saliva from mouth

VIlI: H/o hearing loss, vertigo, tinnitus

IX, H/o nasal regurgitation, nasal twang, dysphagia, hoarseness of voice

XI H/o dysarthria

ANS history:

H/o bowel:

Constipation/loss of control

H/o bladder

Difficulty in feeling the filling

Difficulty in initiating

Difficulty in complete evacuation

Dribbling

Difficulty in controlling

Impotence

Sweating

Past History:

H/o previous episodes

H/o TIA, RIND (Reversible Ischemic Neurological Deficit)

H/o DM, TB, HT, STD

H/o recurrent headache, vomiting, diarrhoea, fever

H/o cardiac disease, epilepsy, trauma

H/o CSOM, ARV, dog bite

H/o drugs, surgery, OCPs, poisoning

Family History:

Consanguinity

Siblings

Any similar episodes

Personal History:
Smoking

Alcohol

Diet-->lathyrism, SACD

STD history

Treatment History

EXAMINATION:
Opening statement:

Vitals

Anthropometry

General physical examination:

any positive signs on head to toe examination ( pallor, icterus, cyanosis, clubbing, lymphadenopathy
and edema ), any neurocutaneous markers(Adenoma sebaceum, Ash leaf patches, Shagreen
patches, Cafe au lait spots, Multiple neurofibromas,Tuft of hair in the back- spina bifida, Capillary
haemangioma Sturge weber syndrome (port wine stain), Conjunctival haemangioma-Von Hippel
Lindau syndrome, (with cerebellar haemangioma)) , signs of vitamin deficiencies, signs of systemic
diseases like rash, alopecia, etc, signs of malnutrition , thickened peripheral nerves

Examination of CNS case:

Opening statement –

HMF assessment :

C- consciousness

O- orientation

M- memory

A-Aphasia

P- perceptions (delution, hallucination)

I-Insight

C-calculation

S-spatial perception

A- Appearance
B- Behaviour
C- Consciousness
 D- Delusions
E- Emotions

Cranial nerve examination:

 1-12
 Olfactory nerve:
o a. Clove
o b. Oil of peppermint -
o c. Asafoetida
 (Rt& Lt)

 Optic nerve:
o a.Visual acuity
o 1.Gross vision
o 2.Distant vision
o 3.Near vision
o b.Field of vision
o c. Colour vision
o d. Fundoscopy
 III, IV, VI Occulomotor, Trochlear, Abducent
o Extra ocular movements
o Pupil
o Size
o Reflexes
o Direct
o Consensual
o Accommodation
o Nystagmus
o Ptosis
 V Trigeminal
o Sensory- Sensation over face and buccal mucosa
o Motor -Clenching of teeth (masseter, temporalis, pterygoids)
o Reflex
o Corneal
o Conjunctival
o Jaw jerk
 VIl Facial nerve
o Motor
o Wrinkling of forehead
o Closing of eyelids
o Showing teeth
o Blowing of cheeks, whistling
o Nasolabial folds
o Platysma
o Hyperacusis (Stapedíus)
o Sensory
 o Taste of Ant. 2/3 of tongue
o (Sugar, salt, vinegar)
o Sensation over tongue
o Reflex
o Corneal
o Conjunctival
o Secretomotor
o Salivation
o Lacrimation(Shirmer's tear)

 VIll Vestibulocochlear nerve

o Cochlear
o Rinne's test
o Weber test
o Vestibular
o Caloric test

 IX X Glossopharyngeal, Vagus
o Taste (posterior 2/3 of tongue) IX
o Gag reflex
o Palatal reflex

 XI Spinal accessory nerve

o Shrugging of shoulders
o Turning head against resistance

 XII Hypoglossal nerve

o Tongue protrusion
o Fibrillation
o Wasting

Motor:

 Gait (In ambulatory ): hemiplegic/antalgic/spastic/ataxic/high stepping/ waddling gait

 Posture
 Bulk
1. Inspection
2. Palpation
3. UL 10 cm from acromion
4. - 10 cm below olecranon process
5. LL 18 cm from upper end of patella
6. 10 cm lower end of patella
 Tone: active and passive
 Power
 UL
1. Shoulder
 Flexion-extension
  Abduction-adduction
 Rotation
 2.Elbow
 Flexion-extension
 3.Wrist
 Flexion extension
 Adduction Abduction
 4.Fingers
 Flexion- extension
 Abduction Adduction
 5.Thumb
 Flexion- extension
 Abduction-Adduction
 Opposition
 Lower Limb
 1.Hip Jt
 Flexion- extension
 Abduction-adduction
 Rotation
 2.Knee It
 Flexion Extension
 3.Ankle Jt
 Dorsal plantar flexion
 Inversion Eversion
 4.Toes
 Flexion- extension
 Adduction Abduction
 Reflexes: sup and deep ; grading
 Superficial reflexes
1. Corneal (CN 5, 7)
2. Conjunctival (CN 5,7)
3. Pharyngeal (CN 9,10)
4. Abdominal (T8-T12)
5. Cremasteric (L1, L2)
6. Plantar (L5, S1)
 Deep reflexes
1. Jaw jerk (CN 5)
2. Biceps (CS, C6)
3. Triceps (C6, C7, C8)
4. Supinator (C5, C6)
5. Knee jerk (L3, L4) clonus
6. Ankle jerk (51, S2) clonus

Sensory: dermatome wise,from normal to abnormal area

 Superficial : Pain touch, temp

 Deep: deep pain, pressur,and vibration
  Cortical: tactile localisation, 2point discrimination, graphesthesia, astereognosis

Cerebellum:

Nystagmus

Cordination

Pendular jerks

Dysarthria- scanning

Gait- drunken broad based

Signs of meningeal irritation: Neck stiffness , Kernigs, Brudzinskis