Samantha Monroe Objective data Shadow health: 23 of 23 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve decline
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve declined
Supportive and interpersonal Psychotherapies
- No visible lesions
- Lacerations/wounds
- Erythema
- Ecchymosis
- Birthmark
- Discolorations
- Consistent with ethnic background
- Jaundice
- Cyanosis
- Pallor
- Smooth
- Rough
- Warm
- Cool
- Elastic
- Elastic Tenting
- Sluggish Turgor
- Upright posture without tension or rigidity
- Bent or hunched posture, tension or rigidity
- Clean clothing, appropriate for age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season or occasion
- Expected range of motion (approx. 45)
- Reduced range of motion
- Expected range of motion (approx. 45)
- Reduced range of motion
- Expected range of motion (approx. 40) on both sides
- Reduced range of motion on right
- Reduced range of motion on left
- Expected range of motion (approx. 70) on both sides
- Reduced range of motion on right
- Reduced range of motion on left
- Expected range of motion (approx. 75-90 degrees)
- Reduced flexion
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
- Expected range of motion (approx. 90 degrees)
- Reduced extension
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
- Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
- Reduced Extension
- Reduced Flexion
- Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
- Reduced Extension
- Reduced Flexion
- Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
- Reduced Pronation
- Reduced Supination
- Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
- Reduced Pronation
- Reduced Supination
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
- 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)
- 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)
- Symmetric
- Asymmetric
- Expected range of motion (approx. 180 degrees)
- Reduced range of motion
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
- 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)
- 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)
- Symmetrical
- Asymmetrical
- Present
- Not present
- Symmetric
- Asymmetric
- Symmetric
- Asymmetric
- Symmetric
- Asymmetric
- 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)
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
- No abnormal findings
- Nystagmus
- Fixed Pupil
- No abnormal findings
- Unequal bilaterally
- Fixed Pupil
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
- Maintains upright posture
- Difficulty remaining upright
- Clear in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- No bruit
- Bruit
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2 and S4 audible
- S1, S2, S3 and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- Regular rate and rhythm
- Irregular rate and rhythm
- Arrhythmia
- Equal height
- Unequal height
- Equal height
- Unequal height
- Expected curvature
- Decreased lordosis
- Increased lordosis
- Decreased kyphosis
- Increased kyphosis
- Symmetrical
- Asymmetrical
- Equal height
- Unequal height
- Expected range of motion (approx. 75-90 degrees)
- Reduced flexion
Samantha Monroe Objective Data in Shadow Health: 23 out of 23 (100%)
Growth Chart: Height & Weight
– Weight Percentile: Below 5th percentile
– Weight Growth Curve: Growth curve maintained
– Height Percentile: Below 5th percentile
– Height Growth Curve: Growth curve maintained
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Inspected Skin
– Lesions: No visible lesions
– Color: Consistent with ethnic background
– Texture: Smooth
– Temperature: Warm
– Skin Hydration: Elastic
Inspected General Appearance
– Posture: Upright posture without tension or rigidity
– Clothing: Clean clothing, appropriate for age, fit, season, and occasion
Assessed Cervical Spine Range of Motion
– Flexion: Expected range of motion (approx. 45)
– Extension: Expected range of motion (approx. 45)
– Lateral Bending: Expected range of motion (approx. 40) on both sides
– Rotation: Expected range of motion (approx. 70) on both sides
Assessed Spine Range of Motion
– Rotation: Expected range of motion (approx. 75-90 degrees)
Assessed Wrist Range of Motion
– Left Extension: Expected range of motion (approx. 90 degrees)
– Right Extension: Expected range of motion (approx. 90 degrees)
– Left Flexion: Expected range of motion (approx. 90 degrees)
– Right Flexion: Expected range of motion (approx. 90 degrees)
Assessed Elbow Range of Motion
– Left: Flexion And Extension: Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
– Right: Flexion And Extension: Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
– Left: Supination And Pronation: Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
– Right: Supination And Pronation: Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
Assessed Shoulder Range of Motion
– Adduction: Expected range of motion (approx. 50 degrees)
– Abduction: Expected range of motion (approx. 50 degrees)
– Strength: Active movement against gravity and resistance
Assessed Trapezius Strength
– Strength: Active movement against gravity and resistance
Assessed Deltoid Strength And Shoulder Rotation
– Strength & Rotation: Symmetric
– Forward Flexion: Expected range of motion (approx. 180 degrees)
– Extension: Expected range of motion (approx. 50 degrees)
Assessed Hand/Finger Range of Motion And Strength
– Left: Active movement against full resistance without fatigue (normal)
– Right: Active movement against full resistance without fatigue (normal)
Assessed Symmetry of Extremities
– Extremities: Symmetrical
Assessed Leg Symmetry, Knee or Ankle Effusion
– Effusion: Not present
– Leg Symmetry: Symmetric
– Knee Symmetry: Symmetric
Assessed Calf Symmetry, Leg Strength
– Calf Muscles: Symmetric
– Leg Strength: Active movement against full resistance without fatigue (normal)
Tested Hip, Knee and Ankle Range of Motion
– Hip Range Of Motion: Symmetric, full range of motion without limitations
– Knee Range Of Motion: Symmetric, full range of motion without limitations
– Ankle Range Of Motion: Symmetric, full range of motion without limitations
Tested 6 Cardinal Fields of Vision
– Cardinal Fields: No abnormal findings
– Convergence: No abnormal findings
Tested Peripheral Vision
– Observations: No abnormal findings
Tested Visual Acuity
– Right: 20/20
– Left: 20/20
Romberg Test
– Romberg: Maintains upright posture
Auscultated Breath Sounds
– Breath Sounds: Clear in all areas
– Adventitious Sounds: No adventitious sounds
Auscultated Abdominal Aorta
– Sounds: No bruit
Auscultated Heart Sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds
– Rate And Rhythm: Regular rate and rhythm
Screened Adam’s Forward Bend
– Iliac Crests: Equal height
– Scapula Prominence And Shape: Equal height
– Spine Contour: Expected curvature
– Spine Symmetry: Symmetrical
– Waistline: Equal height
– Flexion: Expected range of motion (approx. 75-90 degrees)
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