Zachary LaFontaine Infant Well Visit Shadow health Objective Data

Zachary LaFontaine Infant Well Visit Shadow health Objective Data

Objective Data Collection: 24.33 of 25 (97.32%)

– Growth Chart: Head Circumference
– Head Circumference Percentile:
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Head Circumference Growth Curve:
– Maintained
– Decline

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– Growth Chart: Weight and Length
– Length Percentile:
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Length Growth Curve:
– Maintained
– Decline
– Weight Percentile:
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight Growth Curve:
– Maintained
– Decline
– Weight For Length Percentile:
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight For Length Growth Curve:
– Maintained
– Decline

– Inspected Nose
– Nares Inspection:
– Pale
– Pink
– Erythematous
– Mucus:
– Thin white mucus present
– Thick yellow mucus present
– Nares:
– Patent
– Obstructed, not patent single-sided

– Inspected Ears
– Inspection:
– Ears set appropriately
– Ears low set, posteriorly rotated
– Pinna:
– Pinna flexible
– Pinna stiff

– Inspected Mouth
– Frenulum:
– Frenulum intact
– Frenulum thick
– Palate:
– Palate intact
– Palate open
– Tongue:
– Tongue smooth
– Tongue rough
– Uvula:
– Uvula midline
– Uvula absent

– Inspected Skin
– Color:
– Cyanosis
– Jaundice
– Pallor
– Congruent with genetic background
– Texture:
– Smooth
– Rough
– Temperature:
– Warm
– Cool
– Skin Hydration:
– Elastic
– Tenting
– Sluggish turgor
– Lesions:
– No visible lesions
– Laceration/wounds
– Erythema
– Ecchymosis
– Birthmark
– Discolorations
– Mucous Membrane: Hydration:
– Moist
– Dry
– Mucous Membrane: Appearance:
– Intact
– Cracked
– Blistered
– Mucous Membrane: Color:
– Pink
– Pale
– Erythematous

– Inspected Diaper Area
– Inspect Skin Diaper Area:
– No lesions present
– Macerated
– Edema
– Erythema

– Inspected Genitalia
– Appearance:
– Urethral meatus midline
– Hypospadias
– Ambiguous genitalia
– Palpation:
– Testes present bilaterally
– Testes not palpable
– Rugae:
– Smooth
– Rough
– Masses:
– No masses
– Mass palpable
– Swelling
– Circumcision:
– Circumcised
– Uncircumcised

– Assessed Musculoskeletal: Barlow and Ortolani
– Barlow:
– Positive
– Negative
– Ortolani:
– Positive
– Negative

– Assessed Eyes: Pupils
– Shape:
– Round
– Abnormal shape
– Light Reaction:
– No reaction to light
– Reacts to light symmetrically
– Reacts to light asymmetrically
– Opacity:
– Clear
– Cloudy

– Assessed Eyes: Red Reflex
– Red Reflex:
– Absent
– Present
– Color:
– Equal color bilaterally
– Unequal color bilaterally
– Opacity:
– Opacity absent
– Opacity present

– Assessed Eyes: Tracking
– Vision Screening:
– Follows object in both directions
– Does not follow object in both directions

– Assessed Extremities
– Movement:
– Moves all extremities
– Does not move all extremities
– Symmetry:
– Movement symmetrical
– Movement asymmetrical

– Assessed Grasp
– Grasp:
– Intact
– Not evident
– Tone:
– Strong
– Weak
– Symmetry:
– Symmetrical
– Asymmetrical
– Absent

– Assessed Moro Reflex
– Moro Reflex:
– Normal response
– Weak response
– Absent response
– Hearing:
– Hearing intact
– Hearing absent

– Assessed Tonic Reflex
– Neck Range Of Motion:
– Symmetrical
– Asymmetrical
– Absent
– Tonic Reflex:
– Present
– Absent

– Assessed Pulse
– Pulse:
– Regular
– Irregular
– Amplitude:
– Equal bilaterally
– 0
– +1
– +2
– +3

– Assessed Rooting Reflex
– Rooting Reflex:
– Normal response
– Weak response
– Absent response

– Assess Sucking Reflex
– Sucking Reflex:
– Normal response
– Weak response
– Absent response
– Tongue Range Of Motion:
– Normal response
– Absent response

– Assessed Neurological: Stepping/Walking Reflex
– Stepping Reflex:
– Present
– Absent

– Palpated Abdomen
– Light Palpation:
– Soft
– Firm
– Distended
– Mass
– Bulges
– Tenderness:
– Nontender
– Tender

– Palpated Fontanelles
– Anterior:
– Sunken
– Flat
– Bulging
– Posterior:
– Sunken
– Flat
– Bulging

– Auscultated Abdomen
– Appearance:
– Protuberant
– Flat
– Scaphoid
– Auscultation:
– Absent
– Hypoactive
–

Normoactive
– Hyperactive

– Auscultated Heart
– Rate:
– Regular Rate
– Irregular Rate
– Rhythm:
– Regular rhythm
– Arrhythmia
– Heart Sounds:
– S1
– S2
– S3
– S4
– Murmurs

– Auscultated Lungs
– Appearance:
– Symmetrical chest rise
– Asymmetrical chest rise
– Breath Sounds:
– Clear to auscultation
– Wheezing
– Stridor
– Grunting
– Absent
– Respiratory Effort:
– Smooth, even respirations
– Nasal flaring
– Retractions

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