CEPHALOCAUDAL ASSESSMENT

Head
Head is round in shape, proportionate to the body, normocephalic, bony prominences felt on
temporal, frontal and occipital area. With head circumference of _____. Head is able to move
from left to right. Scalp: light brown, mobile, no lice or dandruff noted. Hair: evenly distributed,
adequate, between black and brown in color, short, not too dry nor too oily. Temporal Arteries
symmetrical in pulsation, no bruits auscultated. Frontal and maxillary sinuses no masses or
swelling palpated.

Eyes
Eyes are symmetrical, normally spaced in relation to the nose, properly aligned, eyeballs not
sunken or protruding from the sockets eyebrows adequate amount, free of any scaling,
eyelashes long and curled outward, conjunctiva pink, anicteric sclerae no sclerae seen above
pupul, no nodules palpated, no excessive tearing. PERRLA. No signs of frequent blinking,
crusting, squinting or rubbing noted.

Ears
Ears are symmetrical and line up with the eyes. Pinna flexible and returns to original shape <1
second. No discharges noted.

Nose
Nose at midline and proportional to the face. Color the same as the color of the face. Nasal
septum at midline, no deviations noted. No discharges noted, No nasal flaring noted. No polyps
noted. Mucosa and turbinates light red. No lesions noted. Both nostrils patent.

Mouth
Jaw aligned as upper teeth slightly override the lower teeth. Facial muscles mobile as
characterized by ability of toddler to smile. Lips light pink, smotth. Oral mucosa pink, moist,
glistening and soft. Teeth smooth, ivory-colored and shiny. Nine lower teeth and eight upper
teeth. No cavities noted. Hard palate light pink, soft palate light pink, smooth and soft. Tongue at
midline, llight pink in color, watery on dorsal side. Ventral side smooth, veins slightly visible.

Neck
Symmetrical, size and head centered. No masses palpated. Lymph nodes not palpable. Carotid
pulse palpable and symmetrical. Jugular vein not distended. Trachea at midline, above
suprasternal notch.

Chest
Breathing normal, relaxed and chiefly abdominal. Nipple and areola darker in color compared to
the chest. No edema, erythema, wrinkling, retraction or dimpling of the skin. No retractions, or
indentations of intercostals spaces or the suprasternal and substernal area. PMI not vsisble.
Respiratory rate of ____, Chest circumference of ____, Symmetrical expansion of anterior
chest. Apical pulse of ____.

Back
No abnormal curvatures noted. Clear breath sounds noted on all lung fields, no wheezing or any
adventitious lung sound noted. Symmetrical expansion of posterior chest. No heart murmurs
noted.

Abdomen
Pot-bellied, abdominal circumference of _____ no hair noted, color light brown, umbilicus
inverted and in midline, Tympany heared upon percussion of stomach area Normoactive sound
heared upon auscultation of four quadrants, abdominal circumference. Other parts: not
assessed.

Extremities
Light brown in color, symmetrical, warm to touch with equal temperature on both sides of the
extreminities both the upper and lower, Cappillary refill less than 1 second. Brachial, ulnar,
radial, popliteal, dorsalis pedis, posterior tibialis and femora pulses palpable.

Genito-anal
Penis and scrotum darker in color. Scrotum slightly symmetrical, creases numerous, testciles
present, no masses or swelling noted upon palpation. Urethral opening is slit like at the center
tip of the penis. Foreskin slightly retractible. Anal opening darker in color. A five-peso sized
Mongolian spot noted on the upper portion of the right buttock.

Skin
Skin is light brown, moist and well hydrated, warm to touch, smooth, good skin turgor, skin went
back to original position in <1 second. No lesions noted but presence of red, raised mosquito
bites noted on several areas in the lower extremities. No signs or cyanosis or pallor or edema
noted. Hair: evenly distributed on head, between black and brown in color. Nails: complete set,
10 on the hands and 10 on the feet, pink, smooth and convex, hard to touch and not brittle