Zachary LaFontaine Objective data

Zachary LaFontaine Objective data

Objective Data Collection: 24.33 of 25 (97.32%)

Growth Chart: Head Circumference

– Head Circumference Percentile: Below 5th percentile
– Head Circumference Growth Curve: Growth curve maintained

Growth Chart: Weight and Length

– Length Percentile: Below 5th percentile
– Length Growth Curve: Growth curve maintained
– Weight Percentile: Below 5th percentile
– Weight Growth Curve: Growth curve maintained
– Weight For Length Percentile: Below 5th percentile
– Weight For Length Growth Curve: Growth curve maintained

Inspected Nose

– Nares Inspection: Pink
– Mucus: Thin white mucus present
– Nares: Patent

Inspected Ears

– Inspection: Ears set appropriately
– Pinna: Pinna flexible

Inspected Mouth

– Frenulum: Frenulum intact
– Palate: Palate intact
– Tongue: Tongue smooth
– Uvula: Uvula midline

Inspected Skin

– Color: Congruent with genetic background
– Texture: Smooth
– Temperature: Warm
– Skin Hydration: Elastic
– Lesions: No visible lesions
– Mucous Membrane: Hydration – Moist
– Mucous Membrane: Appearance – Intact
– Mucous Membrane: Color – Pink

Inspected Diaper Area

– Inspect Skin Diaper Area: No lesions present

Inspected Genitalia

– Appearance: Urethral meatus midline
– Palpation: Testes present bilaterally
– Rugae: Smooth
– Masses: No masses
– Circumcision: Uncircumcised

Assessed Musculoskeletal: Barlow and Ortolani

– Barlow: Negative
– Ortolani: Negative

Assessed Eyes: Pupils

– Shape: Round
– Light Reaction: Reacts to light symmetrically
– Opacity: Clear

Assessed Eyes: Red Reflex

– Red Reflex: Present
– Color: Equal color bilaterally
– Opacity: Opacity absent

Assessed Eyes: Tracking

– Vision Screening: Follows object in both directions

Assessed Extremities

– Movement: Moves all extremities
– Symmetry: Movement symmetrical

Assessed Grasp

– Grasp: Intact
– Tone: Strong
– Symmetry: Symmetrical

Assessed Moro Reflex

– Moro Reflex: Normal Response
– Hearing: Hearing intact

Assessed Tonic Reflex

– Neck Range Of Motion: Symmetrical
– Tonic Reflex: Present

Assessed Pulse

– Pulse: Regular
– Amplitude: Equal bilaterally

Assessed Rooting Reflex

– Rooting Reflex: Normal response

Assess Sucking Reflex

– Sucking Reflex: Normal response
– Tongue Range Of Motion: Normal response

Assessed Neurological: Stepping/Walking Reflex

– Stepping Reflex: Present

Palpated Abdomen

– Light Palpation: Soft
– Tenderness: Nontender

Palpated Fontanelles

– Anterior: Flat
– Posterior: Flat

Auscultated Abdomen

– Auscultation: Normoactive

Auscultated Heart

– Rate: Regular Rate
– Rhythm: Regular rhythm
– Heart Sounds: S1, S2

Auscultated Lungs

– Appearance: Symmetrical chest rise
– Breath Sounds: Clear to auscultation
– Respiratory Effort: Smooth, even respirations

Zachary LaFontaine Objective data