EXAMINATION OF THE

CHILD
GENERAL PHYSICAL EXAMINATION
• The child is awake ,active ,afebrile.
• No pallor,no icterus , no cynosis, no clubbing, no
edema, no generalised palpable peripheral
lymphadenopathy.
• Pulse rate -90/min , regular, normal volume, in the
right radial artery.
• Blood pressure -____
• Respiratory rate- 36/min
• Capillary refill time – immediately [<3 sec].
• Temperature-_____
 ANTHROPOMETRY
Measurement Normal range Interpretation
HEIGHT 88 cm

WEIGHT 13kg
HEAD 45 cm
CIRCUMFERENCE
CHEST 50 cm
CIRCUMFERENCE
MID UPPER ARM 13 cm
CIRCUMFERENCE
 HEAD TO TOE EXAMINATION
• HAIR- brown colour ,normal strenth and thickness
• FONTANELLE- closed
• EYE- tear present, no bitot spot ,no corneal discharge
• EAR- no discharge
• ORAL CAVITY- dentition present, tongue is not clean
• SKIN- heat rash is present over neck and skin fold
region,skin pinch goes back immediately
• EXTREMITIES- actively moves all the limbs
• SIGNS OF VITAMIN DEFICIENCY – no signs of vitamin
deficiency
 SYSTEMIC EXAMINATION
CVS
• inspection: BL symmetrical , no scar , no visible pulsation , no dilated
veins
• Palpation: no local rise in temperature , no tenderness
• percussion: dullness in precordial region
• Auscultation : 1st and 2nd heart sound heard , no murmurs
RESPIRATORY
• Inspection: symmetrical chest movement, no scar, no chest deformity,
no chest indrawing
• Palpation: no local rise in temperature ,no tenderness, symmetrical
chest expansion
• Percussion: resonant sound
• Auscultation: BL normal vesicular breath sound
ABDOMINAL EXAMINATION
• Inspection: normal shape , no scar marks , no
pulsation, no dilated veins
• Palpation : no local rise in temperature , no
tenderness, no any mass palpable ,no
organomegaly
• Percussion: tympanic note is present ,no fluid
thrill
• Auscultation: bowel sound heard
 IMMUNIZATION HISTORY
• According to mother, child had all
immunization till date except zero dose of
opv ,birth dose of Hep B and 1st 2nd and 3rd
dose of vitamin A
• BCG scar was present in left upper arm
• Fever occurred following immunization and
resolve on its own after few hours
• Next due date is at 5th year of age for DPT
booster
 DEVELOPMENT HISTORY
• Assessed by TRIVANDRUM DEVELOPMENT SCREENING
CHART
• Broad jumps (both legs ) are present
• Copy circle
• Balance on one foot for one second
• Answer 2 questions ( hungry, cold )
• Name 1 colour
• Tell use of 2 object ( pencil, bed )
• So all the developmental milestone achieved as per
date
• GROSS MOTOR SKILL- ( synchronous gait , walk
upstairs) normal for age
• FINE MOTOR SKILL- ( copy circle) normal for
age
• PERSONAL-SOCIAL SKILL – ( join in play,
dresses ,undresses fully) normal for age
• LANGUAGE- ( says 3 word sentences) normal
for age
 PERSONAL HISTORY
• Hygiene : bath once daily
• Nails are unclipped
• Oral hygiene is poor ( don’t brush regularly)
• She play in dirt and sometimes wear chappals
• Overall appearance is dirty
• Wash: handwash before food and after defication with
soap
• Appetite is normal
• Sleep – adequate
• Bladder and bowel habbit – regular
 FAMILY HISTORY
• No history of
hypertension ,diabetes ,tuberculosis in the
family
• They visit registered practitioners preferably
for any treatment
• Deworming is not done
FEEDING PRACTICES AND DIET HISTORY
• Child was on exclusive brest feeding for 6 month ( colostrum
was given)
• Weaning started at 6 month( daal pani was used )
• No history of bottle feeding
• Hand washing is practised before cooking and feeding the child
• Food are covered
• Child have the habbit of eating packed food like biscuits
• The child is not breast feeding now
• Mother have the knowledge of foremilk and hind milk ,correct
positioning and attachment , impact of extra nutritious food
and stress on breast milk secretion
• The child have mixed diet and the food habbit
is regular
DIETARY ASSESSMENT BY 24 HRS RECALL
TIME FOOD ITEM MEASUREM FOOD ENERGY PROTEIN
ENT QUANTITY (Kcal) ( gm )
5:00 AM CHAI
BISCUIT
7: 00AM ROTI
KATHAL
ALOO
11:30AM RICE
PULSE
4:00PM BISCUIT
7:00PM ROTI
ALOO
BHUJIA