HISTORY TAKING

1. Name :
2. Age : (Precisely in months for small children) ; DOB
3. Sex :
4. Informant : (Reliable or not)
5. Address :
6. Religion : (usually not asked)
7. DOA :
8. DOE :

CHIEF COMPLAINTS

PEM

o Fever since ________ days

o Cough with sputum since ______days
o Pain abdomen since ______ days
o Generalised weakness ____ days

Pneumonia

o Fever
o Cough with sputum
o Chest pain
o Breathlessness in the form of fast breathing
o Feeding difficulty, Fits, Cyanosis, Head nodding – features of severe pneumonia
o Conjunctivitis, Arthralgia, Myalgia – Viral pneumonia

Congenital heart disease

o Cough
o Breathlessness
- Poor feeding ; Interrupted feeding
- Breathes better when held against shoulder
- Excessive sweating ( d/t increased symp. activity & large surface area of head to
maintain tissue perfusion )
o Failure to thrive
o Cyanosis
o During crying cyanosis worsens ( respiratory cause : improves )

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 Jaundice / Hepatosplenomegaly

o High coloured urine

o Yellowish discoloration of sclera
o Abdominal distension
o Fever

Diarrhoea

o Loose watery stools

Cerebral palsy

o Convulsions
o Involuntary movements
o Delayed milestones
o Fever & cough

HISTORY OF PRESENT ILLNESS

Patient was relatively well _____ days back and then developed _ _ _ _ _

 Onset
 Duration
 Progression
 Aggravating & relieving factors
 Associated symptoms
 Present status
 Negative history

Fever

 Onset
- Sudden : Pneumonia
 Duration
 Type
- Continuous
- Remittent
- Step ladder : Typhoid
- Relapsing
 Severity

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 - High grade
- Low grade
 Associated chills & rigor
 Aggravating & relieving factors (medication)
 Diurnal variation
 Activity of child during feverless period
- Active- viral
- Inactive- bacterial
 Normalising –
- Suddenly- pneumococcal pneumonia
- Gradually- typhoid
 Any h/o Vomiting , Diarrhoea - (Gastroenteritis)
 Rashes – (measles)
 Burning micturition , Haematuria , Oliguria – (UTI)
 Loss of weight, Decreased appetite , Evening rise of temperature – (TB)
 Bleeding gums –(Vit C def)
 Conjunctivitis , Night blindness – (Vit A def)
 Skin rash on extremities & Diarrhoea – (Pellagra)
 Palpitation , Cyanosis , Pedal oedema, SOB – CCF
 Seizures / Altered sensorium – (meningitis /Encephalitis)
 Food intake from outside
 Water intake
 Excessive cry
 Ear discharge

Cough

 Onset
 Duration
 Type
- Initially dry : Pneumonia
 Frequency
 Productive / Non productive
 Colour of sputum
- Rusty –Pneumonia
 Quantity & Odour of sputum
 Diurnal variation
 FB aspiration
 Postural variation
 Vomiting of sputum
 Associated factors

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 - Grunting respiration
- Cyanosis
- Feeding difficulties
 Complications
- Post tussive vomiting
- Disturbed sleep
- Whoop
- Affects breathing
- Subconjunctival h’ge
- Ulceration of frenulum
- Umbilical/ femoral hernia
- Cough syncope
- Rib #

Pain Abdomen

 Site
 Character
 Type
 Duration
 Severity
 Aggravating & relieving factors
 Radiation

Loose watery stools (Diarrhoea)

 Onset – very acute : food poisoning

 Duration- acute(<7d)/ persistent(>14d)/Chronic
 No. of episodes – assess dehydration
 Quantity – large volume / small volume
 Consistency
o Watery stool
 Lactose intolerance- also increased flatulence + perianal excoriation
 Cholera- rice water stool
 Rota virus – secretory + osmotic diarrhoea
o Pea soup stools – Typhoid
o Greasy +bulky+ foul smelling + difficult to flush – steatorrhoea
 Blood stained / not
o Dysentery – a/c +abdominal pain + tenesmus(painful urgency to pass stools)
o IBD – c/c
o Amoebiasis – c/c
o Intussusception – jelly like bright red blood + sausage shaped mass lateral to
umbilicus + exhausting cry in an infant of age group 6m-1yr
o Haematochezia- fresh blood in stools- lower GI bleed
o Malena – altered blood (tarry stools)

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  Green stools – rapid GIT transit
 Frothy / not
 Foul smell
 Worms in stools
 Signs of dehydration
- Thirst
- Urine output
- Seizures
- Tears
- Appearance of eye (sunken)
- Altered sensorium
- Malnourishment (decreased weight)
 Vaccination of Rotavirus
 Associated symptom
- Vomiting
- Abdominal distension
o Hypotonia of malnutrition
o Hypokalaemia
- Fever
- Weight loss – HIV infn(in c/c diarrhoea )
 H /o
- Weaning & artificial feeding
- Bottle feeding – rota virus
- Similar illness in the family
- Travel to outside
- Food from outside
- Previous infection
o UTI
o Pneumonia
o Otitis externa
- Drug intake
- Antibiotics ( decreases nl flora)
- Food allergy – cow’s milk, soy, wheat
- Diet during diarrhoea

Chest pain

 Onset
 Duration
 Progression
 Type
- Piercing type of pleural pain – pneumonia
 Severity

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 o Less severe- pneumonia
 Aggravating / Relieving factors
 Radiation to the shoulder or abdomen

Shortness of breath

 Onset : Gradual
 Mother noticed breathlessness in the form of fast breathing
 Frequency (Less frequent)
 Postural variation (Not much) Pneumonia
 Orthopnoea
 PND (usually not seen)

 Severity
o Unable to speak – words/ Phrases / Sentences
o Not able to drink
o Not able to eat
 Nebulisation
 Number of episodes per month
 Whether he was on inhaler
 5 Ps Br. asthma
o pest
o Pets
o Pollen
o Perfumes
o Passive smoking

Jaundice

 Onset
 Duration
 Progression
 Colour of urine
o High coloured – concentrated urine, Haematuria, Hemoglobinuria , Rifampicin
 Colour of stool
 Itching : mention about scratch marks if present

Colour of sclera Urine Stool Itching

Haemolytic Jaundice Lemon yellow Normal Normal 〷
Hepatic jaundice High Normal
Obstructive jaundice Greenish – yellow High Pale (acholic) / clay 
coloured stools

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  Haemolytic Jaundice
 H/o exertional dyspnoea , fatigue, Palpitation, Pallor - anaemia
 H/o blood transfusion – Transfusion dependent anaemia
 [Link] , [Link] - Splenomegaly
 Antimalarial drug intake – G6PD def
 Foot ulcer, chest, Bone pain – Sickle cell anaemia
 Oliguria, haematuria, diarrhoea, dysentery

 Hepatocellular Jaundice- any H/o

 Infections
a) Viral
o Hepatitis A
- Prodrome : Anorexia , Fatigue
- Fever – subsides- Jaundice
- H /o contact
o Hepatitis B,C
- H/o blood transfusion
o Others – CMV, IMN, Mumps, Measles, Rubella
b) Bacterial
o Leptospirosis
- High fever , rigor
- Conjunctival injection, myalgia
- Bleeding tendency
o Enteric fever
- Mild icterus
- Constipation (1st week)
- Diarrhoea ( 2nd week)
- Complications (3rd week)
o Disseminated TB
- h/o contact
c) Malaria
 Malignancy
o Loss of appetite
o Weight loss
o Haematological
 Leukaemia
- Bleeding manifestations
 Lymphoma
- Joint pain
- Petechial rashes
- Progressive pallor
 Collage vascular d/s ( PAN, Kawasaki d/s)
- Rash
- Arthralgia

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  Drugs
o Paracetamol
o Anti TB drugs

 Obstructive Jaundice
o Itching
o Cholangitis
- Fever with rashes
- Colicky pain

Edema

 Abdominal/ Pedal/ Facial puffiness – C/c liver failure

 Bleeding manifestations – A/c liver failure
 Altered sensorium
 Sleep rhythm fulminant hepatic failure

 Swelling of face
o Onset – sudden / gradual
o More in the morning?
o First over the face & then on legs?
 H /o decreased urine output , Blood in urine, Pain during micturition
 H/o breathlessness , Palpitations, fever with joint pain & sore throat (CVS)
 H/o yellowish discolouration of skin & mucous membrane, Blood in vomiting and
High coloured urine (Hepatic)
 H/o drug injection / Blood transfusion (HBV)
 H/o symptoms /signs suggestive malnutrition
 H/o of intake of drugs
o NSAID
o Penicillamine
o Captopril

PAST HISTORY

 Any h/o similar illness in the past

 Previous hospitalization
 Any h/o vaccine preventable illness in the past
o Measles
o Mumps
o TB
o Pertussis
 Any h/o childhood infection, joint pain or sore throat (Rheumatic infn)

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  H/o allergies, TB, asthma, jaundice, seizures, Diarrhoea

ANTENATAL HISTORY

 Consanguineous marriage
 Married since____
 How many children
 Any infertility Rx
 Age at the time of pregnancy
 Booked case /not
 No of antenatal visits

1st trimester

 Fe & folic acid taken

 TT taken
 Hyperemesis
 Spotting PV
 Fever with rashes
 Close contact with cuts (Toxoplasmosis)
 Genital vesicles (Herpes)
 Drug intake
 X-ray exposure
 Results of HBsAg , VDRL

2nd trimester

 Time of quickening
 Weight gain
 Maternal illness
o GHTN – IUGR
o GDM – CHD
o APH

3rd trimester

 Spotting PV
 Discharge
 H/o UTI
 Abdominal tenderness
 Ultrasound scan- number & any abnormalities
o 9-11m : Danlos syndrome
o 3rd trimester : IUGR
o Ask Oligamnios – infection
o Polyhydramnois- poor lung maturity

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  Past obstetric history
o Abortions
o Neonatal death
o NICU admissions
o Any illness, complications

NATAL HISTORY

 Hospital delivery/ Home delivery

 Term /Pre term
 Normal Labour/ C.S – mention indication
 Labour pain – Spontaneous / Induced
 Instrumentation – forceps /vacuum

POST NATAL HISTORY

 Cried soon after birth (CSAB)

 Birth weight
 NICU admission needed /not
 Any O2/ IV medication/ umbilical catheterization / Blood transfusion/ Phototherapy
 When breast fed? – ideally within ½ an hr / 4 hrs in CS
 When urine passed? – 48 hr
 When meconium passed? – 24 hrs
 Respiratory distress / jaundice/ seizures/ vomiting / poor feeding/ cyanosis
 Date of discharge from hospital – 3 days usually

IMMUNISATION HISTORY
 Fully immunized to date according to National immunisation schedule
 If not taken , why –
o Lack of faith
o Ignorance
o ADR to previous doses
o Lack of easy availability
o Illness at the time of vaccination
 BCG scar seen
 Last vaccine taken
 Any optional vaccines taken –
o MMR
o Hib(now included under pentavalent in NIS )
o Conjugate pneumococcal vaccine
o Hepatitis B
o Hepatitis A

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 o Varicella
o Typhoid
o Rotaviral vaccines (relevant in diarrhoea)
Age National Immunizn Schedule
At birth BCG, OPV (0), HBV (0 or birth dose)
6 weeks(1½ months) DPT(1), OPV(1), HBV(1), Hib (1)
10 weeks (2½ months) DPT(2), OPV(2), HBV(2), Hib (2)
14 weeks (3½ months) DPT(3), OPV(3), HBV(3), Hib (3)
9 months Measles, Vitamin A
15 months MMR
18 months(1½ yrs) DPT (1 booster)
OPV (1 booster)
Hib (1 booster)
Measles (2nd dose if MMR not given)
5 yrs DPT
10 yrs TT
16 yrs TT

DEVELOPMENTAL HISTORY
 No h/o developmental delay
Gross motor Fine motor Social &adaptive Language
1 month -------------- ----------- ----------- Alerts to sound
2 month `-------------- ----------- Social smile -----------------
3 month Neck holding ------------ Recognises mother Koos (musical
vowel sounds)
4 month -------------- Bidextous reach ---------- Lough loud
5 month Rolls over ------------ ---------- ------------
6 month Sits with own Unidexrous reach; Recognizes Ba, da, pa-
support(tripod) Transfer of objects strangers monosyllables
8 month Sitting without support ------------- ------------ ----------
9 month Stands with support Immature pincer Waves bye bye Mama, dada-
grasp bisyllables
12 month Stands without Mature pincer grasp Comes when called 1-2 words with
support; meaning
Creeps well
15 month Walks alone; Imitates scribbling; Jargon -------------
Creeps upstairs Tower of 2 blocks
18 month Runs ; Tower of 3 blocks; Copies parents in 8 – 10 word
Explores drawers Scribbles task (eg sweeping) vocabulary
2 yrs Walks up &downstairs Tower of 6 blocks; Ask for food ,drinks, 2- 3 word
(2 feet/step); Vertical circular stroke toilet ; sentences;
Jumps Pulls people to Uses – I ,Me, You
show toys
3 yrs Rides tricycle; Tower of 9 blocks ; Share toys; Ask questions;
Alternate feet going Copies circle Knows full name& Knows full name &
upstairs gender gender

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4 yrs Hops on one foot; Bridge with blocks; Plays cooperatively Says song /poem;
Alternate feet going Copies cross in a group; Tell stories
downstairs Goes to toilet alone
5 yrs ------------- Gate with blocks; Helps in household Ask meaning of
Copies triangle tasks; words
Dresses &
undresses

3 yrs 4yrs 4½ yrs 5 yrs 6yrs

7 yrs 8 yrs 9 yrs 11 yrs

Age - months Gross motor Fine motor Social Language

1–3 Head holding while Coordinate head & Social smile Cooing sounds
prone eyes follow object
3–6 Head control Grasp object; Enjoy mirror Vocalize vowels
Brings to mouth
6–9 Self-sitting Hand transfer Play , peek Imitate speech
9 – 12 Self-standing Pincer grasp; Waves bye bye Dada ,mama
Walking with Drinks from a cup specific
support
12 – 18 Self-walking Tower 2 -3 cubes; Use spoon , house 3 – 6 words
(1½ yrs) Scribble work
18 – 24 Runs, Walks up Tower 4 -6 cubes; Removes & put on Point to body parts&
(2 yrs) steps Imitates vertical cloth pictures
lines
24 – 36 Broad jump, Pedal Tower 8 -9 cubes; Group play Name pictures;
(3 yrs) tricycle Copy O Give name
36 – 48 Balance on 1 foot Copy +; draw a Dress & brush with Name colours
(4 yrs) man no help
Gender identity
48 – 60 Hops, walks up step Copy □ ; Locate persons Gives names & age;
(5 yrs) with alternate feet Cuts with scissors; places; Tell a story
Throw ball overhead Group play

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DIETARY HISTORY

 Exclusively breast fed/ not

 Complimentary feeding started at ____
 Breast feeding continued until _____
 Any food allergy
 Is diet rich in – fruits , Green leafy vegetables

 Child is getting ____ calories

o Expected calories =
o Deficit =
 Child is getting ____ gms of protein
o Expected protein =
o Deficit =
 Any diet modification advised

Item Quantity Kcal Protein

Cooked rice 1cup 175 4
Uncooked rice 6tsp 100 2
Dosa 1 70 2
Idly 1 50 2
Chappathi 1 70 2
Puri 1 35 1
Uppuma 1 cup 250 2
Bread 1 slice 70 6
Pathiri 1 50 1
Porotta 1 100 3
Biscut 1 20 0.5
Puttu 1 50 2
Banana 1 100 1
Egg 1 80 6
Mutton 1 50 6
Beef 1 30 6
Fish 1 ounce (8-10pieces) 80 6
Mathi(sardine) 1 30 3
Cow’s milk 100ml 70 3.5
Human milk 100 ml 70 1.5
Pappadam 1 tsp 20 0.5
Cooked dhal 1 tsp 8 0.5
Potato 50 g 40 0
Upperi 1 cup 10 0.5
Sambar 100 g 50 2.5
Fruits 100 g 60 0.5
Coconut 1 tsp 444 4.5
Sugar 1 tsp 20 0
Oil / Ghee 1 tsp 36 0
Lactogen 100 g ( 6 tsp) 100 2
Ragi 100 g ( 6 tsp) 100 3

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 Amritam 100 g ( 6 tsp) 130 3.5

REVISED ICMR RECOMMENDATION 2010

Age group Calories Protein
0 – 6 months 92 cal/kg/day 1.6g/kg/day
6 – 12 months 80 cal/kg/day 1.69 g/kg/day
1 – 3 yrs 1060 16.7 g/day
4 – 6 yrs 1350 20.1 g/day
7 – 9 yrs 1690 29.5 g/day
10 – 12 yrs 2190 (boys) 39.9 (boys)
2010 (girls) 40.4 (girls)
Male adult (sedentary/ moderate/ heavy work) 2030/2730/3490 60 g/day
Female adult (sedentary/ moderate/ heavy work) 1900/2230/2850 55 g/day
Pregnancy + 350 cal 82.2
Lactation + 600 cal 77.9

FAMILY HISTORY
Modified Kuppuswamy Scale of Social Classification
 Age of patients at the time of conception
 Consanguinity
 Pedigree chart
 Similar illness in the family
 Chronic illness in the family
 Family custom / beliefs/ routine
 Any recent death in the family

SOCIOECONOMIC STATUS

 Occupation of parents
 Income
 Housing
 Own/ Rented
 Kutcha / Pukka
 No of rooms in the family
 Overcrowding
 Does kitchen smoke pollute inside the house
 Atmospheric pollution
 Any pets at home
 Source of drinking water? Sanitary well + Boiled/ Filtered
 Sanitary latrine

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  Nearest Anganwadi – beneficiaries
 Financial support – RSBY
 Any h/o of developmental / metabolic disorders
 Any h/o neonatal deaths in the family

GENERAL EXAMINATION

I. General survey
 Conscious , Oriented , playful & active (Asthma)
 Drowsy / ill- looking/ tachypnoeic / dyspnoeic
 Anxious / dull & uninterested (kwashiorkor)/ restless (pain)
 Glasgow coma scale – if head injury
II. Vitals (express in even numbers)
a. Pulse
– Rate : ____/min on the right radial artery
- Rhythm
- Character
- Volume
- Peripheral pulses – felt equally on both sides
- Radio femoral delay

Age Pulse rate

New born 120-160/min Tachycardia
Up to 1 yr 120/min New born : >200/min
Up to 5 yrs 100/min Infants : >150/min
Up to 10 yrs 90/min Old child : >120/min
> 10 yrs 80/min

b. Blood Pressure
 ( CVS case : both upper limbs & lower limb)
____ mm of Hg in the right upper limb in in the supine position using the
appropriate cuff size
o Systolic BP =
o

c. Respiratory rate
o Rate : ____ /min
o Rhythm : regular
o Type : Abdominothoracic
o Upto 6 yrs – Male + female
o > 6yrs - Male

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 o Accessory muscles not active

Age Normal RR
Age RR(Tachypnoea )
New born 40/min
> 2 months 60 or more
Up to 1 yr 30/min
Up to 5 yrs 20/min 2 – 12 months 50 or more
Up to 10 yrs 18/min 1 – 5 yrs 40 or more
> 10 yrs 18/min > 5yrs > 30

d. Temperature
o Normal = 37°C = 98.4°

o Evening = 37.7°C= 100°F

o Rectal > oral (1 min) > Axillary (3 min) [ difference = 0.5°C = 1°F]

III. PICCLE
a. Pallor
b. Icterus
c. Cyanosis
d. Clubbing
e. Lymphadenopathy
f. Edema
IV. Anthropometry (Auxology)

a. Weight

o Birth – 3kg - Newborns – loses weight during first 7 days

o 5m - 6 kg - 7 -10 days : regain
- Doubles : 4 months
o 1 yr - 9 kg
- Triples : 1 year

Weight gain
 1-3m : 30g/day:
 4-6m : 20g/day
 7-9m :15g/day
 10-12m :12g/day

Formulas

 3m-1yr :

 1-6 yrs :

 7-12 yrs :

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 IAP Classification of Malnutrition
Grade of PEM % of weight expected for
age
Normal >80%
Grade I 71- 80 %
Grade II 61-70 %
Grade III 51-60 %
Grade IV < 50
Post fix ‘K’ : if there is edema = kwashiorkor
Eg grade IV K

b. Height
o Birth- 50 cm
o 3m – 60 cm
o 6m – 65 cm
o 9m – 70 cm
o 1 yr – 75 cm
o 4 yrs – 100 cm

Weech formula (after 2 yrs – till 12 yrs)

WATERLOW CLASSIFICATION OF STUNTING

Degree of stunting % height for age

No stunting > 95 %
I Degree 90 – 95 %
II Degree 85 – 89 %
III Degree < 85 %

c. Upper segment : lower segment ratio

UL : LL Age
1.7 : 1 Newborn
1.6 : 1 1 Yr
1:1 7 – 10 yrs
0.9 : 1 Adult

d. Head circumference (2months increment – 4+3+2+1+1+1 )

o Birth – 34 cm
o 2m – 38 cm
o 4m – 41 cm
o 6m – 43 cm
o 8m – 44 cm
o 10m – 45 cm
o 1 yr – 46 cm

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 Dine’s formula

( )

e. Mid arm circumference (6months – 5yrs)

- Midway b/n acromion & olecranon
MAC Shakir tape
13.5 Normal Green
12.5 – 13.5 Moderate PEM Blue Yellow
Below 12.5 Severe PEM Red

f. Chest circumference
g. Skin fold thickness
h. Arm span
i. Teeth
j. BMI
V. Assessment of Development
VI. Head to foot examination
a. Head
o Microcephaly (reduction HC less than 3 SD)
o Macrocephaly (increase HC more than 2 SD)
b. Hair & hair line
o Hypopigmentation
o Sparseness
o Pediculosis
o Seborrhic dermatitis
o Low hairline – turner syndrome
c. Fontanelle
o McEwen’s sign
o Anterior( closes at 7 – 19 months)
o Posterior ( closes at 2 months)
- Open in Down’s syndrome
d. Face
o Dysmorphism
o Coarseness
o Mid- face hypoplasia
o Micrognathia
o Retrognathia
o Thick/thin lip
o Long philtrum
o Prominence of maxilla
o Hypoplasia of maxilla
e. Eyes

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 o Pallor
o Icterus
o Canthal index
o Hypertelorism
o Hypotelorism
o Upward / downward slant
o Mangoloid slant
o Microphthalmia
o Coloboma
o Synophrys
o Corneal clouding
o Cataract
o Nystagmus
o Strabismus
o Conjunctival congestion
o Evidence of vitamin deficiencies
o Sunken eyes (diarrhoea)
f. Mouth
o Oral hygiene
o Dentition
o Tongue
o Throat & tonsils
o Cleft lip/ palate
o High arched palate
o Inverted V shaped upper lip
o Number of teeth
o Abnormal shape or colour of teeth
o Evidence of vitamin deficiencies
g. Tongue
h. Ears
o Anomalies
o Low set ears
o Pre auricular tag
o Sinus
o Discharge ear
i. Nose
o Flat nasal bridge
o Upturned nostrils
j. Neck
o Short neck
o Webbing
o Low hairline
o Lymph nodes
k. Limbs
o Over – riding of fingers & toes

19 | P a g e #ideals
 o Arachnodactyly
o Brachydactyly
o Polysyndactyly
o Clinodactyly
o Camptodactyly
o Short / long limbs
o Broad thumb
o Dystrophic nails
o Hypermobility of joints
o Arches of foot
l. Chest
o Pectus carinatum
o Pectus excavatum
o Absent pectoralis major
o Absent clavicle
o Wide spaced nipples
o Shield chest
m. Abdomen
o Distension
o Umbilical hernia
o Divarication of rectus muscle
o Dilated veins
o Skin turgor(diarrhoea )
n. Genitalia
o Hernia
o Hydrocele
o Micro penis
o Undescended testes
o Macro – orchidism
o Ambiguous genitalia
o Precocious puberty
o Phimosis
o. Spine
o Dimples
o Hairy patches
o Swellings
o Kyphosis
o Scoliosis
o Excess lordosis
p. Skin
o Changes suggestive of PEM
o Neurosubcutaneous markers
o Subcutaneous emphysema
o Skin turgor
SYSTEMIC EXAMINATION

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