Zachary LaFontaine Objective data Collection

Accuracy:
– Right
– Partly right
– Wrong
– Missed

Growth Chart for Head Circumference:
– 1 out of 1 point
– Percentile of Head Circumference (1 out of 2 points)
– Below the 5th percentile
– Between the 5th and 95th percentiles
– Above the 95th percentile
– Head Circumference Growth Curve (1 out of 2 points)
– Growth curve maintained
– Growth curve declining

Growth Chart for Weight and Length:
– 0.83 out of 1 point
– Percentile for Length (1 out of 6 points)
– Below the 5th percentile
– Between the 5th and 95th percentiles
– Above the 95th percentile
– Length Growth Curve (1 out of 6 points)
– Growth curve maintained
– Growth curve declining
– Percentile for Weight (1 out of 6 points)
– Below the 5th percentile
– Between the 5th and 95th percentiles
– Above the 95th percentile
– Weight Growth Curve (No points)
– Growth curve maintained
– Growth curve declining
– Weight For Length Percentile (1 out of 6 points)
– Below the 5th percentile
– Between the 5th and 95th percentiles
– Above the 95th percentile
– Weight For Length Growth Curve (1 out of 6 points)
– Growth curve maintained
– Growth curve declining

Nose Inspection:
– 1 out of 1 point
– Examination of Nares (1 out of 3 points)
– Pale
– Pink
– Reddened
– Mucus (1 out of 3 points)
– Thin white mucus present
– Thick yellow mucus present
– Nares (1 out of 3 points)
– Open
– Obstructed, not open on one side

Ear Examination:
– 1 out of 1 point
– Inspection (1 out of 2 points)
– Ears appropriately positioned
– Ears positioned low and rotated backward
– Pinna (1 out of 2 points)
– Flexible
– Stiff

Mouth Examination:
– 1 out of 1 point
– Frenulum (1 out of 4 points)
– Frenulum intact
– Thick frenulum
– Palate (1 out of 4 points)
– Palate intact
– Palate open
– Tongue (1 out of 4 points)
– Smooth tongue
– Rough tongue
– Uvula (1 out of 4 points)
– Uvula in the middle
– Absent uvula

Skin Examination:
– 1 out of 1 point
– Color (1 out of 8 points)
– Bluish coloration
– Yellowing of the skin
– Paleness
– Consistent with genetic background
– Texture (1 out of 8 points)
– Smooth
– Rough
– Temperature (1 out of 8 points)
– Warm
– Cool
– Skin Hydration (1 out of 8 points)
– Elastic
– Tenting
– Slow skin recoil
– Lesions (1 out of 8 points)
– No visible injuries
– Cuts/wounds
– Redness
– Bruising
– Birthmark
– Skin discoloration
– Mucous Membrane: Hydration (1 out of 8 points)
– Moist
– Dry
– Mucous Membrane: Appearance (1 out of 8 points)
– Intact
– Cracked
– Blisters
– Mucous Membrane: Color (1 out of 8 points)
– Pink
– Pale
– Reddened

Diaper Area Inspection:
– 1 out of 1 point
– Skin Examination in Diaper Area (1 out of 1 point)
– No visible injuries
– Moisture-induced skin breakdown
– Swelling
– Redness

Genitalia Examination:
– 1 out of 1 point
– Appearance (1 out of 5 points)
– Urethral opening in the middle
– Hypospadias
– Ambiguous genitalia
– Palpation (1 out of 5 points)
– Testicles present on both sides
– Testicles not felt
– Rugae (1 out of 5 points)
– Smooth
– Rough
– Masses (1 out of 5 points)
– No lumps
– Palpable lump
– Swelling
– Circumcision (1 out of 5 points)
– Circumcised
– Uncircumcised

Musculoskeletal Assessment: Barlow and Ortolani:
– 1 out of 1 point
– Barlow (1 out of 2 points)
– Positive
– Negative
– Ortolani (1 out of 2 points)
– Positive
– Negative

Eye Examination: Pupils:
– 1 out of 1 point
– Shape (1 out of 3 points)
– Round
– Abnormal shape
– Light Reaction (1 out of 3 points)
– No response to light
– Symmetrical response to light
– Asymmetrical response to light
– Opacity (1 out of 3 points)
– Clear
– Cloudy

Eye Examination: Red Reflex:
– 1 out of 1 point
– Red Reflex (1 out of 3 points)
– Not visible
– Visible
– Color (1 out of 3 points)
– Equal color in both eyes
– Unequal color in both eyes
– Opacity (1 out of 3 points)
– No opacity
– Opacity present

Eye Examination: Tracking:
– 1 out of 1 point
– Vision Screening (1 out of 1 point)
– Follows object in both directions
– Does not follow object in both directions

Extremities Assessment:
– 1 out of 1 point
– Movement (1 out of 2 points)
– Moves all extremities
– Does not move all extremities
– Symmetry (1 out of 2 points)
– Symmetrical movement
– Asymmetrical movement

Grasp Assessment:
– 1 out of 1 point
– Grasp (1 out of 3 points)
– Normal grip
– Grip not apparent
– Tone (1 out of 3 points)
– Strong
– Weak
– Symmetry (1 out of 3 points)
– Symmetrical
– Asymmetrical
– Absent

Moro Reflex Assessment:
– 1 out of 1 point
– Moro Reflex (1 out of 2 points)
– Typical reaction
– Weak reaction
– No reaction
– Hearing (1 out of 2 points)

– Hearing normal
– Hearing impaired

Tonic Reflex Assessment:
– 1 out of 1 point
– Neck Range Of Motion (1 out of 2 points)
– Symmetrical
– Asymmetrical
– Absent
– Tonic Reflex (1 out of 2 points)
– Present
– Absent

Pulse Assessment:
– 1 out of 1 point
– Pulse (1 out of 2 points)
– Regular
– Irregular
– Amplitude (1 out of 2 points)
– Equal on both sides
– 0
– +1
– +2
– +3

Rooting Reflex Assessment:
– 1 out of 1 point
– Rooting Reflex (1 out of 1 point)
– Usual response
– Weak response
– No response

Sucking Reflex Assessment:
– 1 out of 1 point
– Sucking Reflex (1 out of 2 points)
– Usual response
– Weak response
– No response
– Tongue Range Of Motion (1 out of 2 points)
– Usual response
– No response

Neurological Assessment: Stepping/Walking Reflex:
– 1 out of 1 point
– Stepping Reflex (1 out of 1 point)
– Present
– Absent

Abdomen Palpation:
– 1 out of 1 point
– Light Palpation (1 out of 2 points)
– Soft
– Firm
– Distended
– Mass
– Bulges
– Tenderness (1 out of 2 points)
– Not tender
– Tender

Fontanelles Palpation:
– 1 out of 1 point
– Anterior (1 out of 2 points)
– Sunken
– Flat
– Bulging
– Posterior (1 out of 2 points)
– Sunken
– Flat
– Bulging

Abdomen Auscultation:
– 0.5 out of 1 point
– Appearance (No points)
– Protruding
– Flat
– Hollowed
– Auscultation (1 out of 2 points)
– Absent
– Reduced sounds
– Normal sounds
– Increased sounds

Heart Auscultation:
– 1 out of 1 point
– Rate (1 out of 3 points)
– Regular rate
– Irregular rate
– Rhythm (1 out of 3 points)
– Regular rhythm
– Arrhythmia
– Heart Sounds (1 out of 3 points)
– S1
– S2
– S3
– S4
– Murmurs

Lung Auscultation:
– 1 out of 1 point
– Appearance (1 out of 3 points)
– Symmetrical chest movement
– Asymmetrical chest movement
– Breath Sounds (1 out of 3 points)
– Clear breath sounds
– Wheezing
– Stridor
– Grunting
– Absent breath sounds
– Respiratory Effort (1 out of 3 points)
– Smooth, regular breathing
– Flaring nostrils
– Retractions

Zachary LaFontaine Shadow health Objective data

Zachary LaFontaine Objective data Collection