NIMH PEDIATRICS and DEVELOPMENTAL NEUROPSYCHIATRY BRANCH PHYSICAL EXAM & NEUROLOGIC EVALUATION

Subject Name: Age: Date Examined: Place Examined: Examiner:

Subject ID number:

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

VITAL SIGNS

Blood Pressure: Pulse:

____________ ____________

Unable to obtain Unable to obtain Unable to obtain

Respiratory Rate: ____________ GROWTH PARAMETERS Pubertal status

tanner stage ____________

Measurement Percentile %

Weight (record in lbs) Head Circumference (record in cm) Height (record in cm)

_________(lbs) Unable to obtain _________(cm) Unable to obtain ________(cm) Unable to obtain

HEAD

Abnormality Noted
Abnormal head shape

No

Yes

Not Examined
Brachycephaly Dolicocephaly Trigonocephaly Post. Midline Scalp Defect(s)

Occiput, Flat or Prominent Frontal Bossing Plagiocephaly

EYES Abnormality Noted No Yes Not Examined

Ptosis Colobomata Iris Patterning: Stellate Macrocornea / Microcornea Corneal Opacity (on gross inspection) Conjunctivitis or Discharge Telangiectasias

Hypertelorism / Hypotelorism Microphthalmia Epicanthal folds Slanted Palpebral fissures Shallow orbital ridges Prominent superior-orbit ridge Prominent Eyes Abnormal Red Reflex

EARS Abnormality Noted No Yes Not Examined

Preauricular Tags

Small or large/long ears

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

Low Set Posteriorly angulated Prominent Preauricular Pits

Simple ears (lack of usual fold of helix) Serous Otitis R/C Acute Otitis R/C PE Tubes

NOSE

Abnormality Noted

No

Yes

Not Examined
Bulbous tip of nose Nasal Salute Nasal Discharge Turbinate Pallor/ Edema

Low Nasal Bridge Prominent Nasal Bridge Broad Nasal Bridge Small / short nose Upturned nose

FACE

Abnormality Noted
Midface hypoplasia Long Narrow Facies

No

Yes

Not Examined
Micrognathia Prognathia

OROPHARYNX Abnormality Noted

No

Yes

Not Examined
Micro or macrostomia Oral frenula Cleft/irregular tongue Macroglossia / Microglossia Tonsil Hypertrophy Tonsil Inflammation

Bifid Uvula High-arched palate Abnormal philtrum Cleft lip / palate Prominent or thin lips Lip pits Down-turned corners of mouth

TEETH

Abnormality Noted

No

Yes

Not Examined
Dental Cupping Prominent Central Incisors Dental Flattening (from bruxism)

Hypodontia (missing teeth) Enamel dysplasia Gingivitis

SPINE

Abnormality Noted
Scoliosis Kyphosis

No

Yes

Not Examined
Lordosis Deep sacral dimple or sinus

NECK

Abnormality Noted
Web neck Short neck Thyroidmegaly

No

Yes

Not Examined
Redundant neck skin Torticollis

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

TORSO

Abnormality Noted
Abnormal nipples Hypoplastic clavicles Pectus carinatum

No

Yes

Not Examined
Short sternum Shield chest Pectus excavatum

ARMS & HANDS Abnormality Noted No Yes Not Examined

Proximal thumb Broad thumb Abnormal Fingers Prominent finger pads Single palmar crease Nail hypoplasia

Short arms proximal, distal or proportionate Radial hypoplasia Radial- ulnar synostosis Short/small or long/large hands Metacarpal hypoplasia (short metacarpals) Thumb hypoplasia

JOINTS

Abnormality Noted

No

Yes

Not Examined
Hypermobile / ligamentous laxity

Joint Limitation / Contractures

LEGS & FEET Abnormality Noted

No

Yes

Not Examined
Hypoplastic nails Broad first toes/toenails Overlapping toes Equinovarus feet Pes Planus

Short legs proximal, distal or proportionate Patellar dysplasia Short/small or long feet Short metatarsals 2,3 metatarsals syndactyly Syndactyly other

SKIN & HAIR

Abnormality Noted No Woods lamp exam done?

Yes No

Not Examined Yes

Telangiectasias Hemangiomata Hirsuitism Allopecia Fine hair Coarse or kinky hair Brittle/fragile hair White forelock Low frontal hairline Low posterior hairline

Woods Lamp Exam Abnormal Unusual Skin (loose, thick, elastic) Rash Bruising, abrasions, calluses Dry skin, ecrema Caf-au-lait #___________ Axilary/ inguinal freckling Ash-leaf spots #__________ Other hyper/hypopigmentation Neurofibromas

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

Subcutaneous nodules Shagreen Patches Adenoma sebaceum Vitiligo

Absent eyelashes or eyebrows Long eyelashes Med Eyebrow Flare Synophrys

RESPIRATORY

Abnormality Noted

No

Yes

Not Examined

Abnormal lungs on auscultation

Abnormal breathing pattern

CARDIOVASCULAR

Abnormality Noted
Irregular rhythm Cyanosis or pallor Murmur

No

Yes

Not Examined

Extra heart sounds Abnormal pulses

GASTROINTESTINAL Abnormality Noted

No

Yes

Not Examined

Splenomegaly / Hepatomegaly Hernias (Umbilical and inguinal) Abdominal mass Abdominal distention

Anal fissure Anal tag Diastasis recti Abdominal tenderness

GENITOURINARY

Abnormality Noted
Hypospadias Micropenis (small) Cryptorchidism Abnormal scrotum

No

Yes

Not Examined

Macro-orchidism Hypoplasia of labia majora Hypo or hyperplasia of clitoris Vaginal discharge

~ NEUROLOGIC EVALUATION ~ CRANIAL NERVES Abnormality Noted LEFT

Pupillary reflexes Anisocoria(>1mm) Extra-ocular movements Nystagmus No Full Dysconj Esotrop Normal Horiz Rotatory Yes Conjugate Exotro NX End-gaze Vertical Pend NX Not Examined Full Conjugate Dysconj Exotro Esotrop NX Normal End-gaze Horiz Vertical Rotatory Pend NX

No

Yes

Not Examined RIGHT

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

Facial symmetry Palate motion Tongue bulk Tongue motion Shoulder shrug

Normal Abnormal Normal Abnormal Not Examined Not Examined Symmetrical Asymmetrical Not Examined Normal Normal Normal Abnormal Abnormal Abnormal Not Examined Not Examined Not Examined

MUSCLE BULK

Abnormality Noted

No

Yes

Not Examined

If yes, please specify

Upper LEFT ATROPHY HYPERTROPHY
Proximal Distal Proximal Distal

Upper RIGHT
Proximal Distal Proximal Distal

Lower LEFT
Proximal Distal Proximal Distal

Lower RIGHT
Proximal Distal Proximal Distal

MUSCLE STRENGTH Abnormality noted in limbs No Yes If yes, please specify ( all, if global weakness)
Upper LEFT
Proximal Distal

Not Examined

Upper RIGHT
Proximal Distal

Lower LEFT
Proximal Distal

Lower RIGHT
Proximal Distal

Abnormality noted in trunk MUSCLE TONE Abnormality Noted

No No

Yes Yes

Not Examined Not Examined

If yes, please specify

Upper LEFT HYPOTONIA HYPERTONIA
Proximal Distal Proximal Distal

Upper RIGHT
Proximal Distal Proximal Distal

Lower LEFT
Proximal Distal Proximal Distal

Lower RIGHT
Proximal Distal Proximal Distal

ABNORMAL MOVEMENTS Abnormality Noted If yes, please specify

Tics No

No

Yes

Not Examined

Yes

Not Examined
NIMH PDN draft 7.25.06 Adapted from ATN
Physical Exam / Neurologic Evaluation

Intention tremor Resting tremor Chorea Athetosis Ballismus Dystonia Myotonia

No No No No No No No

Yes Yes Yes Yes Yes Yes Yes

Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined

REPETITIVE MOVEMENTS Abnormality Noted If yes, please specify

Hand flapping Finger flicking Knocking/tapping Body rocking Head banging Hand wringing Hand posturing Bouncing/jumping Other: No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes

No

Yes

Not Examined

Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined

SENSORY

Abnormality Noted

No

Yes

Not Examined

If yes, please specify

Upper LEFT Upper RIGHT
Proximal Distal

Lower LEFT
Proximal Distal

Lower RIGHT
Proximal Distal

Light Touch

Proximal Distal

REFLEXES

Abnormality Noted
Right

No

Yes

Not Examined
Left

Deep Tendon Reflexes (scaled 0-4)

Brachioradialis Biceps Triceps Patella Achilles

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

NX NX NX NX NX

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

NX NX NX NX NX

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation

Pathological Reflexes
Babinski (Plantar extensor) Present Absent NX Present Absent NX

COORDINATION
Dysmetria

Abnormality Noted
Present

No
Absent

Yes
NX

Not Examined
Present Absent NX

STANCE & GAIT

Abnormality Noted
Present Present Present Present Present Present

No

Yes
Absent Absent Absent Absent Absent Absent

Not Examined
Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined

Romberg sign Toe-walking Wide-based Ataxia Asymmetrical arm swing Spastic

NIMH PDN draft 7.25.06 Adapted from ATN

Physical Exam / Neurologic Evaluation