PEDIA

Past Medical History: (-) Asthma, (-) Allergies to food and/or drugs, (-) Viral Exanthematous Disease, (-) Previous operation, (-) Congenital disorders/abnormalities

Family history: (-) Hypertension, (-) Diabetes mellitus, (-) Asthma, (-) Heart disease, (-) Cerebrovascular Accident, (-) Malignancies, (-) Twinning (-) Congenital
disorders/abnormalities

Prenatal: Patient was born to a G_P_(_ _ _ _) mother via NSVD/CS delivery. There was no history of viralexanthematous diseases during pregnancy. There was no
exposure to environmental toxicants/ potential teratogens during pregnancy.

Feeding History: Patient was breastfed until ____ years. Semi-solid food was introduced at ____ months of age. The current and usual diet of the patient consists of the
following:

Immunization History : In/Complete for age as per EPI

Developmental History : At par with age

Social/ Environmental History: The patient lives in a bungalow-type/duplex-type building with (#) other family members, who do/do not manifest the same signs and
symptoms. The patient was/ was not exposed to environmental toxicants such as cigarette smoke or any other harmful chemicals.

Weight Height BMI

GENERAL SURVEY:
Awake, not in cardiorespiratory distress, good activity, good cry and good muscle tone
SKIN:
No jaundice, no cyanosis, pinkish, smooth and moist skin, with few, thin lanugo over most of the body surface area; warm to touch
HEAD/NECK:
No gross deformities, non bulging or sunken anterior fontanel, anicteric sclera; formed and well curved pinna, firm with instant recoil, no alar flaring, grunting, patent
nares, with no nasal discharge, and no ear discharges; moist lips and buccal mucosa, no circumoral cyanosis, no cleft palate/lip; no neck mass seen and palpated
THORAX:
Symmetrical chest wall expansion, no lagging, no subcostal and/or intercostal retractions, clear breath sounds; raised areola, 2-3mm bud, no discharges noted; (-)
heaves, (-) thrills, normal heart rate with regular rhythm, no murmurs
ABDOMEN:
Globular, non-distended, rare visible veins, umbilical stump intact with no signs of infection, normoactive bowel sounds, tympanitic, soft, no masses/organomegaly
Genitalia: Grossly male, no discharges
Anus: Patent, no sinuses, no fistula, no bleeding
Extremities:
Symmetrical, complete set of digits and toes, no club foot, with pinkish nail beds, creases over the entire sole were noted, capillary refill time of 1 to 2 seconds
Neurological Examination:
Motor: active limb movements, normotonic and symmetric
Sensory: cries to painful stimuli
Reflexes: positive rooting and grasp reflex, Babinski, moro/startle reflex and sucking

Past Medical History: (-) Asthma, (-) Allergies to food and/or drugs, (-) Viral Exanthematous Disease, (-) Previous operation, (-) Congenital disorders/abnormalities

Family history: (-) Hypertension, (-) Diabetes mellitus, (-) Asthma, (-) Heart disease, (-) Cerebrovascular Accident, (-) Malignancies, (-) Twinning (-) Congenital
disorders/abnormalities

Prenatal: Patient was born to a G_P_(_ _ _ _) mother via NSVD/CS delivery. There was no history of viralexanthematous diseases during pregnancy. There was no
exposure to environmental toxicants/ potential teratogens during pregnancy.

Feeding History: Patient was breastfed until ____ years. Semi-solid food was introduced at ____ months of age. The current and usual diet of the patient consists of the
following:

Immunization History : In/Complete for age as per EPI

Developmental History : At par with age

Social/ Environmental History: The patient lives in a bungalow-type/duplex-type building with (#) other family members, who do/do not manifest the same signs and
symptoms. The patient was/ was not exposed to environmental toxicants such as cigarette smoke or any other harmful chemicals.

Weight Height BMI

GENERAL SURVEY:
Awake, not in cardiorespiratory distress, good activity, good cry and good muscle tone
SKIN:
No jaundice, no cyanosis, pinkish, smooth and moist skin, with few, thin lanugo over most of the body surface area; warm to touch
HEAD/NECK:
No gross deformities, non bulging or sunken anterior fontanel, anicteric sclera; formed and well curved pinna, firm with instant recoil, no alar flaring, grunting, patent
nares, with no nasal discharge, and no ear discharges; moist lips and buccal mucosa, no circumoral cyanosis, no cleft palate/lip; no neck mass seen and palpated
THORAX:
Symmetrical chest wall expansion, no lagging, no subcostal and/or intercostal retractions, clear breath sounds; raised areola, 2-3mm bud, no discharges noted; (-)
heaves, (-) thrills, normal heart rate with regular rhythm, no murmurs
ABDOMEN:
Globular, non-distended, rare visible veins, umbilical stump intact with no signs of infection, normoactive bowel sounds, tympanitic, soft, no masses/organomegaly
Genitalia: Grossly male, no discharges
Anus: Patent, no sinuses, no fistula, no bleeding
Extremities:
Symmetrical, complete set of digits and toes, no club foot, with pinkish nail beds, creases over the entire sole were noted, capillary refill time of 1 to 2 seconds
Neurological Examination:
Motor: active limb movements, normotonic and symmetric
Sensory: cries to painful stimuli
Reflexes: positive rooting and grasp reflex, Babinski, moro/startle reflex and sucking