Neurologi 0 1 2 3 4 5

c Signs
Posture Wrist arms Wrist bent Elbows hips Elbows hips Elbows and NA
hips and and legs and legs bent and legs legs drawn
legs straight slightly bent but do not bent to 90° close to body
reach 90°

Square 90° 60° 45° 30° 0° NA

window
(wrist)

Ankle 90° 75° 45° 20° 0° NA

dorsiflexio
n

Arm recoil 180° 90 - 180° < 90° NA NA NA

Leg recoil 180° 90 - 180° < 90° NA NA NA

Popliteal 180° 160° 130° 110° 90° < 90°

angle

Heel to ear Leg straight Leg straight Knee slightly Knee Knee bent to NA
toes reach toes reach bent heel bent heel 90° heel
ear chin reaches 140° reaches 120° reaches 90°
from prone from prone from prone
Scarf sign Elbow to Elbow to Elbow to Elbow to NA NA
opposite opposite midline axillary line
axillary line midclavicula
r line

Head lag Head lags Head Head in line Head bent NA NA

without slightly with body axis forward
forward forward but beyond body
movement at does not axis
90° to body reach body
axis axis

Ventral Head droops Head Heads raised Head in line Head raised NA
suspension down and slightly but not to body with body above body
back greatly raised and axis back axis back axis back
arched arms back less slightly curved straight straight
& legs curved
straight
External 0 1 2 3 4
Signs
Edema Obvious No obvious No edema NA NA
edema of edema of
hands and hands and
feet pitting feet pitting
over tibia over tibia
Skin texture Very thin Thin and Smooth Slight Thick &
gelatinous smooth medium thickening parchment
thickness; rash superficial like
or superficial crack-ing & superficial or
peeling peeling deep cracking
especially
hands and feet
Skin color Dark red Uniformly Pale pink; Pale; only pink NA
pink variable over over ears, lips,
body palms or soles
Skin opacity Numerous Veins & A few large A few large No blood
veins & tibutaries vessels seen vessels seen vessels seen
venules seen seen over the indistinctly
especially abdomen over the
over abdomen
abdomen
Lanugo None Abundant; Hair thinning Small amount At least half
long & thick especially over of lanugo & of back
over whole lower back bald areas devoid of
back lanugo
Plantar No skin Faint red Definite red Indentations Definite deep
creases creases marks over marks over > over more than indentations
anterior half anterior 1/3; anterior 1/3 over more
of sole indentations than anterior
over < anterior 1/3
1/3
Nipple Nipple Nipple well- Areola stippled Areola stippled NA
formation barely defined are- edge not raised edge raised
visible no ola smooth diameter < diameter < 0.75
areola & flat 0.75 cm cm
diameter <
0.75 cm
Breast size No breast Breast tissue Breast tissue Breast tissue on NA
tissue on one or on both sides 1 both sides 1 or
palpable both sides < or both 0.5 - both > 1.0 cm
0.5 cm 1.0 cm
diameter

Ear form Pinna flat Incurving of Partial Well-defined NA

and part of edge incurving incurving
shapeless of pinna entire upper entire upper
little or no pinna pinna
incurving of
edge
Ear firmness Pinna soft Pinna soft Cartilage to Pinna firm NA
easily folded easily folded edge of pinna cartilage to
no recoil slow recoil but soft in edge instant
places ready recoil
recoil
Genitals of Labia Labia majora Labia majora NA NA
female majora almost completely
widely covers labia covers labia
separated, minora minora
labia minora
protruding
Genitals of Neither At least one At least one NA NA
male testis in testis high in testis right
scrotum scrotum down