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Zachary LaFontaine Infant Well Visit Shadow health Objective Data Collection
Zachary LaFontaine’s infant well-visit involves a comprehensive assessment of various health indicators. The correctness of the gathered data is crucial for understanding the infant’s growth and development. Below is an evaluation of different aspects of the assessment:
Growth Chart: Head Circumference
– Head Circumference Percentile: Between 5th and 95th percentile
– Head Circumference Growth Curve: Growth curve maintained
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Growth Chart: Weight and Length
– Length Percentile: Between 5th and 95th percentile
– Length Growth Curve: Growth curve maintained
– Weight Percentile: Between 5th and 95th percentile
– Weight Growth Curve: Growth curve maintained
– Weight For Length Percentile: Between 5th and 95th 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, Appearance, Color: Moist, Intact, 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: Circumcised
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
Assessed Hearing
– Hearing: Hearing intact
Assessed Tonic Reflex
– Neck Range Of Motion: Symmetrical
– Tonic Reflex: Present
Assessed Pulse
– Pulse: Regular
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
– Appearance: Protuberant
– Auscultation: Normoactive
Auscultated Heart
– Rate: Regular Rate
– Rhythm: Regular rhythm
– Heart Sounds: S1, S2
Liam Fitzgerald Telehealth Follow Up Sick Visit Shadow Health Transcript
Auscultated Lungs
– Appearance: Symmetrical chest rise
– Breath Sounds: Clear to auscultation
– Respiratory Effort: Smooth, even respirations
This detailed assessment provides a comprehensive overview of Zachary LaFontaine’s health status during the infant well-visit, ensuring a thorough understanding of various vital signs and developmental milestones.
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Zachary LaFontaine Infant Well Visit Shadow health Objective Data Collection
- Correct
- Partially correct
- Incorrect
- Missed
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