Zachary LaFontaine Visit Shadow health Objective data

Zachary LaFontaine Visit Shadow health Objective data
Objective Data Collection: 24.33 of 25 (97.32%)

 Correct
 Partially correct

 Incorrect
 Missed

 Growth Chart: Head Circumference
1 of 1 point

Head Circumference Percentile (1/2 point)

 Below 5th percentile
 Between 5th and 95th percentile
 Above 95th percentile

Head Circumference Growth Curve (1/2 point)

 Growth curve maintained
 Growth curve decline
Zachary LaFontaine Visit Shadow health Objective data

 Growth Chart: Weight and Length
0.83 of 1 point

Length Percentile (1/6 point)

 Below 5th percentile
 Between 5th and 95th percentile
 Above 95th percentile

Length Growth Curve (1/6 point)

 Growth curve maintained
 Growth curve decline

Weight Percentile (1/6 point)

 Below 5th percentile
 Between 5th and 95th percentile
 Above 95th percentile

Weight Growth Curve (No point)

 Growth curve maintained
 Growth curve decline

Weight For Length Percentile (1/6 point)

 Below 5th percentile
 Between 5th and 95th percentile
 Above 95th percentile

Weight For Length Growth Curve (1/6 point)

 Growth curve maintained
 Growth curve decline
Zachary LaFontaine Visit Shadow health Objective data

 Inspected Nose
1 of 1 point

Nares Inspection (1/3 point)

 Pale
 Pink
 Erythematous

Mucus (1/3 point)

 Thin white mucus present
 Thick yellow mucus present

Nares (1/3 point)

 Patent
 Obstructed, not patent single sided

 Inspected Ears
1 of 1 point

Inspection (1/2 point)

 Ears set appropriately
 Ears low set, posteriorly rotated

Pinna (1/2 point)

 Pinna flexible
 Pinna stiff

 Inspected Mouth
1 of 1 point

Frenulum (1/4 point)

 Frenulum intact
 Frenulum thick

Palate (1/4 point)

 Palate intact
 Palate open

Tongue (1/4 point)

 Tongue smooth
Zachary LaFontaine Visit Shadow health Objective data
 Tongue rough

Uvula (1/4 point)

 Uvula midline
 Uvula absent

 Inspected Skin
1 of 1 point

Color (1/8 point)

 Cyanosis
 Jaundice
 Pallor
 Congruent with genetic background

Texture (1/8 point)

 Smooth
 Rough

Temperature (1/8 point)

 Warm
 Cool

Skin Hydration (1/8 point)

 Elastic
 Tenting
 Sluggish turgor

Lesions (1/8 point)

 No visible lesions
 Laceration/wounds
 Erythema
 Ecchymosis
 Birthmark
 Discolorations

Mucous Membrane: Hydration (1/8 point)

 Moist
 Dry

Mucous Membrane: Appearance (1/8 point)

 Intact
 Cracked
 Blistered
Zachary LaFontaine Visit Shadow health Objective data

Mucous Membrane: Color (1/8 point)

 Pink
 Pale
 Erythematous

 Inspected Diaper Area
1 of 1 point

Inspect Skin Diaper Area (1/1 point)

 No lesions present
 Macerated
 Edema
 Erythema

 Inspected Genitalia
1 of 1 point

Appearance (1/5 point)

 Urethral meatus midline
 Hypospadias
 Ambiguous genitalia

Palpation (1/5 point)

 Testes present bilaterally
 Testes not palpable

Rugae (1/5 point)

 Smooth
 Rough

Masses (1/5 point)

 No masses
 Mass palpable
 Swelling

Circumcision (1/5 point)

 Circumcised
 Uncircumcised

 Assessed Musculoskeletal: Barlow and Ortolani
1 of 1 point

Barlow (1/2 point)

 Positive
 Negative

Ortolani (1/2 point)

 Positive
 Negative

 Assessed Eyes: Pupils
1 of 1 point

Shape (1/3 point)

 Round
Zachary LaFontaine Visit Shadow health Objective data
 Abnormal shape

Light Reaction (1/3 point)

 No reaction to light
 Reacts to light symmetrically
 Reacts to light asymmetrically

Opacity (1/3 point)

 Clear
 Cloudy

 Assessed Eyes: Red Reflex
1 of 1 point

Red Reflex (1/3 point)

 Absent
 Present

Color (1/3 point)

 Equal color bilaterally
 Unequal color bilaterally

Opacity (1/3 point)

 Opacity absent
 Opacity present

 Assessed Eyes: Tracking
1 of 1 point

Vision Screening (1/1 point)

 Follows object in both directions
 Does not follow object in both directions
Zachary LaFontaine Visit Shadow health Objective data

 Assessed Extremities
1 of 1 point

Movement (1/2 point)

 Moves all extremities
 Does not move all extremities

Symmetry (1/2 point)

 Movement symmetrical
 Movement asymmetrical
Zachary LaFontaine Visit Shadow health Objective data

 Assessed Grasp
1 of 1 point

Grasp (1/3 point)

 Intact
 Not Evident

Tone (1/3 point)

 Strong
 Weak

Symmetry (1/3 point)

 Symmetrical
 Asymmetrical
 Absent

 Assessed Moro Reflex
1 of 1 point

Moro Reflex (1/2 point)

 Normal Response
 Weak response
 Absent response

Hearing (1/2 point)

 Hearing intact
 Hearing absent

 Assessed Tonic Reflex
1 of 1 point

Neck Range Of Motion (1/2 point)

 Symmetrical
 Asymmetrical
 Absent

Tonic Reflex (1/2 point)

 Present
 Absent
Zachary LaFontaine Visit Shadow health Objective data

 Assessed Pulse
1 of 1 point

Pulse (1/2 point)

 Regular
 Irregular

Amplitude (1/2 point)

 Equal bilaterally
 0
 +1
 +2
 +3

 Assessed Rooting Reflex
1 of 1 point

Rooting Reflex (1/1 point)

 Normal response
 Weak response
 Absent response

 Assess Sucking Reflex
1 of 1 point

Sucking Reflex (1/2 point)

 Normal response
 Weak response
 Absent response

Tongue Range Of Motion (1/2 point)

 Normal response
 Absent response
Zachary LaFontaine Visit Shadow health Objective data

 Assessed Neurological: Stepping/Walking Reflex
1 of 1 point

Stepping Relfex (1/1 point)

 Present
 Absent

 Palpated Abdomen
1 of 1 point

Light Palpation (1/2 point)

 Soft
 Firm
 Distended
 Mass
 Bulges

Tenderness (1/2 point)

 Nontender
 Tender

 Palpated Fontanelles
1 of 1 point

Anterior (1/2 point)

 Sunken
 Flat
 Bulging

Posterior (1/2 point)

 Sunken
 Flat
 Bulging
Zachary LaFontaine Visit Shadow health Objective data

 Auscultated Abdomen
0.5 of 1 point

Appearance (No point)

 Protuberant
 Flat
 Scaphoid

Auscultation (1/2 point)

 Absent
 Hypoactive
 Normoactive
 Hyperactive

 Auscultated Heart
1 of 1 point

Rate (1/3 point)

 Regular Rate
 Irregular Rate

Rhythm (1/3 point)

 Regular rhythm
 Arrhythmia

Heart Sounds (1/3 point)

 S1
 S2
 S3
 S4
 Murmurs

 Auscultated Lungs
1 of 1 point

Appearance (1/3 point)

 Symmetrical chest rise
 Asymmetrical chest rise

Breath Sounds (1/3 point)

 Clear to auscultation
 Wheezing
 Stridor
 Grunting
 Absent

Respiratory Effort (1/3 point)

 Smooth, even respirations
 Nasal flaring
 Retractions
Zachary LaFontaine Visit Shadow health Objective data

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