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General
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Alert
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Well nourished
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Oriented
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BMI appropriate
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Distress
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Cooperative
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Notes:
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Verbal status
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Head
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Normocephalic
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Atraumatic
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Notes
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Eyes
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Pupil dilation normal
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EOMI grossly normal
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Strabismus
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Nystagmus
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Conjunctiv injection or discharge
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Swelling
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Allergic Shiners
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Notes:
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Ears
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auricles grossly normal w/o visible malformations
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Low set ears
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Visible microtia
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Notes:
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Nose
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Discharge
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Allergic crease visible
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Symmetric
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Notes:
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Mouth
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Excessive drooling
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Smooth philtrum
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Abnormal Lip Shape
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Micrognathia (recessed jaw)
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Notes:
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TABBY Tongue Assessment
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TABBY TOTAL ( 8-WNL, 6-7 borderline, 5 or > Tongue tied)
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Tongue tip attachment
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Gum fixation of frenulum
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Tongue lift with open mouth
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Tongue protrusion
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Notes
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Neck
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Swelling
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Visible goiter
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Full range of motion
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Notes:
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Chest
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Visible respiratory distress
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Tachypnea
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breathing unlabored
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Vocalizations unlabored
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Notes:
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Abdomen
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Gross bloating
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Scaphoid abdomen
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Notes:
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Musculoskeletal
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Normal gait
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Grossly normal bulk and tone
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Notes:
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Beighton Scale (1 pt each Yes)
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Beighton Scale
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Right thumb to forearm
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Left thumb to forearm
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Right pinky flexes >90 degrees
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Left Pinky flexes >90 degrees
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Active hyperextension of right elbow >10 degrees
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Active hyperextension of left elbow >10 degrees
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Active hyperextention of right knee > 10 degrees
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Active hyperextension of left knee > 10 degrees
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Able palms to floor without bending knees
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Skin
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Pallor
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Icterus
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Visible rashes
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Notes:
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Neurologic
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Gross cranial nerve deficits
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Gross focal deficits on observation
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Notes:
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Psychiatric
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Age appropriate engagement
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Answering questions
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Excessive agitation
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Flat affect
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Hyperactivity
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Appropriate eye contact
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Notes:
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