Samantha Monroe Objective data Shadow health

Samantha Monroe Objective data Shadow health

Growth Chart: Height & Weight

– Weight Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Weight Growth Curve: Growth curve maintained, Growth curve decline
– Height Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Height Growth Curve: Growth curve maintained, Growth curve declined

Inspected Skin

– Lesions: No visible lesions, Lacerations/wounds, Erythema, Ecchymosis, Birthmark, Discolorations
– Color: Consistent with ethnic background, Jaundice, Cyanosis, Pallor
– Texture: Smooth, Rough
– Temperature: Warm, Cool
– Skin Hydration: Elastic, Elastic Tenting, Sluggish Turgor

Inspected General Appearance

– Posture: Upright posture without tension or rigidity, Bent or hunched posture, tension or rigidity
– Clothing: Clean clothing, appropriate for age, fit, season, and occasion, Dirty, disheveled, or inappropriate clothing

Assessed Cervical Spine RoM

– Flexion: Expected range of motion, Reduced range of motion
– Extension: Expected range of motion, Reduced range of motion
– Lateral Bending: Expected range of motion on both sides, Reduced range of motion on right, Reduced range of motion on left
– Rotation: Expected range of motion on both sides, Reduced range of motion on right, Reduced range of motion on left

Assessed Spine Range of Motion

– Rotation: Expected range of motion, Reduced flexion

Assessed Wrist RoM

– Left Extension: Expected range of motion, Reduced flexion
– Right Extension: Expected range of motion, Reduced extension
– Left Flexion: Expected range of motion, Reduced flexion
– Right Flexion: Expected range of motion, Reduced flexion

Assessed Elbow RoM

– Left: Flexion and Extension: Expected range of motion, Reduced Extension, Reduced Flexion
– Right: Flexion and Extension: Expected range of motion, Reduced Extension, Reduced Flexion
– Left: Supination and Pronation: Expected range of motion, Reduced Pronation, Reduced Supination
– Right: Supination and Pronation: Expected range of motion, Reduced Pronation, Reduced Supination

Assessed Shoulder RoM

– Adduction: Expected range of motion, Reduced range of motion
– Abduction: Expected range of motion, Reduced range of motion
– Strength: 0 – No muscle contraction, 1 – Barely detectable contraction, 2 – Active movement with gravity eliminated, 3 – Active movement against gravity, 4 – Active movement against gravity and resistance, 5 – Active movement against full resistance without fatigue (normal)

Assessed Trapezius Strength

– Strength: 0 – No muscle contraction, 1 – Barely detectable contraction, 2 – Active movement with gravity eliminated, 3 – Active movement against gravity, 4 – Active movement against gravity and resistance, 5 – Active movement against full resistance without fatigue (normal)

Assessed Deltoid Strength and Shoulder Rotation

– Strength & Rotation: Symmetric, Asymmetric
– Forward Flexion: Expected range of motion, Reduced range of motion
– Extension: Expected range of motion, Reduced range of motion

Assessed Hand/Finger RoM and Strength

– Left: 0 – 5 muscle contraction levels
– Right: 0 – 5 muscle contraction levels

Assessed Symmetry of Extremities

– Extremities: Symmetrical, Asymmetrical

Assessed Leg Symmetry, Knee or Ankle Effusion

– Effusion: Present, Not present
– Leg Symmetry: Symmetric, Asymmetric
– Knee Symmetry: Symmetric, Asymmetric

Assessed Calf Symmetry, Leg Strength

– Calf Muscles: Symmetric, Asymmetric
– Leg Strength: 0 – 5 muscle contraction levels

Tested Hip, Knee and Ankle Range of Motion

– Hip Range Of Motion: Symmetric, full range of motion without limitations, Asymmetric range of motion with limitations
– Knee Range Of Motion: Symmetric, full range of motion without limitations, Asymmetric range of motion with limitations
– Ankle Range Of Motion: Symmetric, full range of motion without limitations, Asymmetric range of motion with limitations

Tested 6 Cardinal Fields of Vision

– Cardinal Fields: No abnormal findings, Nystagmus, Fixed Pupil
– Convergence: No abnormal findings, Unequal bilaterally, Fixed Pupil

Tested Peripheral Vision

– Observations: No abnormal findings, Reduced right visual field, Reduced left visual field

Tested Visual Acuity

– Right: Various visual acuity values
– Left: Various visual acuity values

Romberg Test

– Romberg: Maintains upright posture, Difficulty remaining upright

Auscultated Breath Sounds

– Breath Sounds: Clear in all areas, Diminished in some areas, Absent in some areas
– Adventitious Sounds: No adventitious sounds, Wheezing, Fine crackles, Stridor, Rhonchi, Rales

Auscultated Abdominal Aorta

– Sounds: No bruit, Bruit

Auscultated Heart Sounds

– Heart Sounds: S1 and S2 audible, S1, S2, and S3 audible, S1, S2 and S4 audible, S1, S2, S3 and S4 audible
– Extra Heart Sounds: No extra sounds, Gallops, Murmur, Friction rub, Valve clicks
– Rate And Rhythm: Regular rate and rhythm, Irregular rate and rhythm, Arrhythmia

Screened Adam’s Forward Bend

– Iliac Crests: Equal height, Unequal height
– Scapula Prominence And Shape: Equal height, Unequal height
– Spine Contour: Expected curvature, Decreased lordosis, Increased lordosis, Decreased kyphosis, Increased kyphosis
– Spine Symmetry: Symmetrical, Asymmetrical
– Waistline: Equal height, Unequal height
– Flexion: Expected range of motion, Reduced flexion

Objective data Shadow health – Samantha Monroe