Zachary LaFontaine Infant Well Visit Shadow health Objective Data

Zachary LaFontaine Infant Well Visit Shadow health Objective Data

1. Growth Chart: Head Circumference
– Head size: It’s below average, between average, or above average.
– Growth trend: Is his head size staying consistent, getting smaller, or not growing enough?

2. Growth Chart: Weight and Length
– Length: Is he shorter, average, or taller than other babies his age?
– Weight: Is he lighter, average weight, or heavier than other babies his age?

3. Inspecting the Nose
– Checking the nose: Is it pale, pink, or red?
– Mucus: Is there thin or thick mucus, or is it clear?

4. Inspecting Ears
– Looking at the ears: Are they in the right place, or are they set strangely?
– Pinna: Is the outer part of the ear flexible or stiff?

5. Inspecting Mouth
– Checking the mouth: Is everything normal with the tongue, palate, and frenulum (the piece of skin under the tongue)?

6. Inspecting Skin
– Looking at the skin: Is it the right color and texture, and does it have any marks or injuries?

7. Inspecting Diaper Area
– Checking the diaper area: Is the skin healthy, or does it have any issues like redness or irritation?

8. Inspecting Genitalia
– Looking at the genitalia: Are there any abnormalities, and are the testes present as they should be?

9. Assessing Musculoskeletal: Barlow and Ortolani
– Checking hips: Are there any signs of hip joint issues?

10. Assessing Eyes: Pupils
– Looking at the eyes: Are the pupils normal in size and reaction to light?

11. Assessing Eyes: Red Reflex
– Checking the eyes: Is the red reflection at the back of the eye normal?

12. Assessing Eyes: Tracking
– Testing vision: Can the baby follow objects with their eyes?

13. Assessing Extremities
– Checking limbs: Do the arms and legs move properly and evenly?

14. Assessing Grasp
– Testing grip: Can the baby grab onto things like they should?

15. Assessing Moro Reflex
– Testing startle reflex: Does the baby react normally when startled?

16. Assessing Tonic Reflex
– Checking muscle reflex: Does the baby’s body respond as expected to certain movements?

17. Assessing Pulse
– Checking heartbeat: Is the heartbeat regular and strong?

18. Assessing Rooting Reflex
– Testing sucking reflex: Does the baby instinctively turn towards something to suck?

19. Assessing Sucking Reflex
– Testing sucking strength: Can the baby suck well?

20. Assessing Neurological: Stepping/Walking Reflex
– Testing leg reflex: Does the baby show reflexes related to walking?

21. Palpating Abdomen
– Feeling the belly: Is it soft and normal, or does it feel unusual?

22. Palpating Fontanelles
– Feeling the soft spots on the head: Are they normal or raised/sunken?

23. Auscultating Abdomen and Heart/Lungs
– Listening to the belly and heart/lungs: Are the sounds normal, and is there any unusual movement or activity?

These checks help ensure Zachary is healthy and developing as he should be.

Infant Well Visit Shadow health documentation

Zachary LaFontaine Infant Well Visit Shadow health Objective Data

 Growth Chart: Head Circumference
1 of 1 point
Head Circumference Percentile (1/2 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Head Circumference Growth Curve (1/2 point)
  •  Growth curve maintained
  •  Growth curve decline
 Growth Chart: Weight and Length
0.83 of 1 point
Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
  • Zachary LaFontaine Infant Well Visit Shadow health Objective Data
Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
Weight Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight Growth Curve (No point)
  •  Growth curve maintained
  •  Growth curve decline
Weight For Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight For Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
 Inspected Nose
1 of 1 point
Nares Inspection (1/3 point)
  •  Pale
  •  Pink
  •  Erythematous
Mucus (1/3 point)
  •  Thin white mucus present
  •  Thick yellow mucus present
Nares (1/3 point)
  •  Patent
  •  Obstructed, not patent single sided
  • Zachary LaFontaine Infant Well Visit Shadow health Objective Data
 Inspected Ears
1 of 1 point
Inspection (1/2 point)
  •  Ears set appropriately
  •  Ears low set, posteriorly rotated
Pinna (1/2 point)
  •  Pinna flexible
  •  Pinna stiff
 Inspected Mouth
1 of 1 point
Frenulum (1/4 point)
  •  Frenulum intact
  •  Frenulum thick
Palate (1/4 point)
  •  Palate intact
  •  Palate open
Tongue (1/4 point)
  •  Tongue smooth
  •  Tongue rough
Uvula (1/4 point)
  •  Uvula midline
  •  Uvula absent
 Inspected Skin
1 of 1 point
Color (1/8 point)
  •  Cyanosis
  •  Jaundice
  •  Pallor
  •  Congruent with genetic background
Texture (1/8 point)
  •  Smooth
  •  Rough
Temperature (1/8 point)
  •  Warm
  •  Cool
Skin Hydration (1/8 point)
  •  Elastic
  •  Tenting
  •  Sluggish turgor
Lesions (1/8 point)
  •  No visible lesions
  •  Laceration/wounds
  •  Erythema
  •  Ecchymosis
  •  Birthmark
  •  Discolorations
Mucous Membrane: Hydration (1/8 point)
  •  Moist
  •  Dry
Mucous Membrane: Appearance (1/8 point)
  •  Intact
  •  Cracked
  •  Blistered
Mucous Membrane: Color (1/8 point)
  •  Pink
  •  Pale
  •  Erythematous
 Inspected Diaper Area
1 of 1 point
Inspect Skin Diaper Area (1/1 point)
  •  No lesions present
  •  Macerated
  •  Edema
  •  Erythema
 Inspected Genitalia
1 of 1 point
Appearance (1/5 point)
  •  Urethral meatus midline
  •  Hypospadias
  •  Ambiguous genitalia
Palpation (1/5 point)
  •  Testes present bilaterally
  •  Testes not palpable
Rugae (1/5 point)
  •  Smooth
  •  Rough
Masses (1/5 point)
  •  No masses
  •  Mass palpable
  •  Swelling
Circumcision (1/5 point)
  •  Circumcised
  •  Uncircumcised
 Assessed Musculoskeletal: Barlow and Ortolani
1 of 1 point
Barlow (1/2 point)
  •  Positive
  •  Negative
Ortolani (1/2 point)
  •  Positive
  •  Negative
 Assessed Eyes: Pupils
1 of 1 point
Shape (1/3 point)
  •  Round
  •  Abnormal shape
Light Reaction (1/3 point)
  •  No reaction to light
  •  Reacts to light symmetrically
  •  Reacts to light asymmetrically
Opacity (1/3 point)
  •  Clear
  •  Cloudy
 Assessed Eyes: Red Reflex
1 of 1 point
Red Reflex (1/3 point)
  •  Absent
  •  Present
Color (1/3 point)
  •  Equal color bilaterally
  •  Unequal color bilaterally
Opacity (1/3 point)
  •  Opacity absent
  •  Opacity present
 Assessed Eyes: Tracking
1 of 1 point
Vision Screening (1/1 point)
  •  Follows object in both directions
  •  Does not follow object in both directions
  • Zachary LaFontaine Infant Well Visit Shadow health Objective Data
 Assessed Extremities
1 of 1 point
Movement (1/2 point)
  •  Moves all extremities
  •  Does not move all extremities
Symmetry (1/2 point)
  •  Movement symmetrical
  •  Movement asymmetrical
 Assessed Grasp
1 of 1 point
Grasp (1/3 point)
  •  Intact
  •  Not Evident
Tone (1/3 point)
  •  Strong
  •  Weak
Symmetry (1/3 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
 Assessed Moro Reflex
1 of 1 point
Moro Reflex (1/2 point)
  •  Normal Response
  •  Weak response
  •  Absent response
Hearing (1/2 point)
  •  Hearing intact
  •  Hearing absent
 Assessed Tonic Reflex
1 of 1 point
Neck Range Of Motion (1/2 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
Tonic Reflex (1/2 point)
  •  Present
  •  Absent
 Assessed Pulse
0.5 of 1 point
Pulse (1/2 point)
  •  Regular
  •  Irregular
Amplitude (No point)
  •  Equal bilaterally
  •  0
  •  +1
  •  +2
  •  +3
 Assessed Rooting Reflex
1 of 1 point
Rooting Reflex (1/1 point)
  •  Normal response
  •  Weak response
  •  Absent response
 Assess Sucking Reflex
1 of 1 point
Sucking Reflex (1/2 point)
  •  Normal response
  •  Weak response
  •  Absent response
Tongue Range Of Motion (1/2 point)
  •  Normal response
  •  Absent response
 Assessed Neurological: Stepping/Walking Reflex
1 of 1 point
Stepping Relfex (1/1 point)
  •  Present
  •  Absent
 Palpated Abdomen
1 of 1 point
Light Palpation (1/2 point)
  •  Soft
  •  Firm
  •  Distended
  •  Mass
  •  Bulges
Tenderness (1/2 point)
  •  Nontender
  •  Tender
 Palpated Fontanelles
1 of 1 point
Anterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
Posterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
 Auscultated Abdomen
1 of 1 point
Appearance (1/2 point)
  •  Protuberant
  •  Flat
  •  Scaphoid
Auscultation (1/2 point)
  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive
 Auscultated Heart
1 of 1 point
Rate (1/3 point)
  •  Regular Rate
  •  Irregular Rate
Rhythm (1/3 point)
  •  Regular rhythm
  •  Arrhythmia
Heart Sounds (1/3 point)
  •  S1
  •  S2
  •  S3
  •  S4
  •  Murmurs
 Auscultated Lungs
1 of 1 point
Appearance (1/3 point)
  •  Symmetrical chest rise
  •  Asymmetrical chest rise
Breath Sounds (1/3 point)
  •  Clear to auscultation
  •  Wheezing
  •  Stridor
  •  Grunting
  •  Absent
Respiratory Effort (1/3 point)
  •  Smooth, even respirations
  •  Nasal flaring
  •  Retractions
  • Zachary LaFontaine Infant Well Visit Shadow health Objective Data