Zachary LaFontaine Infant Well Visit Shadow health Objective Data Collection

•  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
• Zachary LaFontaine Infant Well Visit Shadow health Objective Data

•  Growth curve maintained
•  Growth curve decline

Ear Pain Maya Parker Preschooler Sick Visit Shadow Health Education & Empathy

•  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 decline

•  Pale
•  Pink
•  Erythematous

•  Thin white mucus present
•  Thick yellow mucus present

•  Patent
•  Obstructed, not patent single sided
• Zachary LaFontaine Infant Well Visit Shadow health Objective Data

•  Ears set appropriately
•  Ears low set, posteriorly rotated

•  Pinna flexible
•  Pinna stiff

•  Frenulum intact
•  Frenulum thick

•  Palate intact
•  Palate open

•  Tongue smooth
•  Tongue rough

•  Uvula midline
•  Uvula absent

•  Cyanosis
•  Jaundice
•  Pallor
•  Congruent with genetic background

•  Smooth
•  Rough

•  Warm
•  Cool

•  Elastic
•  Tenting
•  Sluggish turgor

•  No visible lesions
•  Laceration/wounds
•  Erythema
•  Ecchymosis
•  Birthmark
•  Discolorations

•  Moist
•  Dry

•  Intact
•  Cracked
•  Blistered

•  Pink
•  Pale
•  Erythematous

•  No lesions present
•  Macerated
•  Edema
•  Erythema

•  Urethral meatus midline
•  Hypospadias
•  Ambiguous genitalia

•  Testes present bilaterally
•  Testes not palpable

•  Smooth
•  Rough

•  No masses
•  Mass palpable
•  Swelling

•  Circumcised
•  Uncircumcised

•  Positive
•  Negative

•  Positive
•  Negative

•  Round
•  Abnormal shape

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

•  Clear
•  Cloudy

•  Absent
•  Present

•  Equal color bilaterally
•  Unequal color bilaterally

•  Opacity absent
•  Opacity present

•  Follows object in both directions
•  Does not follow object in both directions
• Zachary LaFontaine Infant Well Visit Shadow health Objective Data

•  Moves all extremities
•  Does not move all extremities

•  Movement symmetrical
•  Movement asymmetrical

•  Intact
•  Not Evident

•  Strong
•  Weak

•  Symmetrical
•  Asymmetrical
•  Absent

•  Normal Response
•  Weak response
•  Absent response

•  Hearing intact
•  Hearing absent

•  Symmetrical
•  Asymmetrical
•  Absent

•  Present
•  Absent

•  Regular
•  Irregular

•  Equal bilaterally
•  0
•  +1
•  +2
•  +3

•  Normal response
•  Weak response
•  Absent response

•  Normal response
•  Weak response
•  Absent response

•  Normal response
•  Absent response

•  Present
•  Absent

•  Soft
•  Firm
•  Distended
•  Mass
•  Bulges

•  Nontender
•  Tender

•  Sunken
•  Flat
•  Bulging

•  Sunken
•  Flat
•  Bulging

•  Protuberant
•  Flat
•  Scaphoid

•  Absent
•  Hypoactive
•  Normoactive
•  Hyperactive

•  Regular Rate
•  Irregular Rate

•  Regular rhythm
•  Arrhythmia

•  S1
•  S2
•  S3
•  S4
•  Murmurs

•  Symmetrical chest rise
•  Asymmetrical chest rise

•  Clear to auscultation
•  Wheezing
•  Stridor
•  Grunting
•  Absent

•  Smooth, even respirations
•  Nasal flaring
•  Retractions
• Zachary LaFontaine Infant Well Visit Shadow health Objective Data

Objective Data Collection for Zachary LaFontaine’s Infant Well Visit

Objective Data Collection Score: 24.33 out of 25 (97.32%)

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Growth Chart: Head Circumference
– Head Circumference Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Head Circumference Growth Curve: Growth curve maintained, Growth curve decline

Growth Chart: Weight and Length
– Length Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Length Growth Curve: Growth curve maintained, Growth curve decline
– Weight Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Weight Growth Curve: Growth curve maintained, Growth curve decline
– Weight For Length Percentile: Below 5th percentile, Between 5th and 95th percentile, Above 95th percentile
– Weight For Length Growth Curve: Growth curve maintained, Growth curve 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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