Detailed Version
VITALS & BMI: Reviewed.
GEN: Normal general appearance. NAD.
HEENT
-Head: NC/AT.
-Eyes: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
-Ears: Normal external ears, normal TMs.
-Nose: Normal nares
-Mouth and Throat: MMM. Normal gums, mucosa, palate. Good dentition.
NECK: Supple, with no masses.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: Normal genitalia.
SKIN: Warm & well perfused. No skin rashes or abnormal lesions.
MSK: Normal extremities & spine. No deformities. Normal gait. No clubbing, cyanosis, or edema.
NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
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Tanner Stage (for 8-11 year olds)
Brief Version
VITALS & BMI: Reviewed
GEN: Normal general appearance. NAD.
HEENT
-Head: NC/AT.
-Eyes: No redness or discharge.
-Ears: Normal external ears.
-Nose: Normal nares.
-Mouth and Throat: MMM. Normal gums, mucosa, palate. Good dentition.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: N/A
SKIN: Warm & well perfused. No skin rashes or abnormal lesions.
MSK: Normal gait. No clubbing, cyanosis, or edema. Normal extremities. No deformities.
NEURO: No focal deficits.