Objective Data Collection: 23 of 23 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
Growth Chart: Height & Weight
1 of 1 point
Weight Percentile (1/4 point)
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
Weight Growth Curve (1/4 point)
- Growth curve maintained
- Growth curve decline
Height Percentile (1/4 point)
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
Height Growth Curve (1/4 point)
- Growth curve maintained
- Growth curve declined
Inspected Skin
1 of 1 point
Lesions (1/5 point)
- No visible lesions
- Lacerations/wounds
- Erythema
- Ecchymosis
- Birthmark
- Discolorations
Color (1/5 point)
- Consistent with ethnic background
- Jaundice
- Cyanosis
- Pallor
Texture (1/5 point)
- Smooth
- Rough
Temperature (1/5 point)
- Warm
- Cool
ORDER SHADOW HEALTH, EXAM OR WRITEN PAPER HERE
Skin Hydration (1/5 point)
- Elastic
- Elastic Tenting
- Sluggish Turgor
Inspected General Appearance
1 of 1 point
Posture (1/2 point)
- Upright posture without tension or rigidity
- Bent or hunched posture, tension or rigidity
Clothing (1/2 point)
- Clean clothing, appropriate for age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season or occasion
Assessed Cervical Spine RoM
1 of 1 point
Flexion (1/4 point)
- Expected range of motion (approx. 45)
- Reduced range of motion
Extension (1/4 point)
- Expected range of motion (approx. 45)
- Reduced range of motion
Lateral Bending (1/4 point)
- Expected range of motion (approx. 40) on both sides
- Reduced range of motion on right
- Reduced range of motion on left
Rotation (1/4 point)
- Expected range of motion (approx. 70) on both sides
- Reduced range of motion on right
- Reduced range of motion on left
Assessed Spine Range of Motion
1 of 1 point
Rotation (1/1 point)
- Expected range of motion (approx. 75-90 degrees)
- Reduced flexion
Assessed Wrist RoM
1 of 1 point
Left Extension (1/4 point)
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
Right Extension (1/4 point)
- Expected range of motion (approx. 90 degrees)
- Reduced extension
Left Flexion (1/4 point)
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
Right Flexion (1/4 point)
- Expected range of motion (approx. 90 degrees)
- Reduced flexion
Assessed Elbow RoM
1 of 1 point
Left: Flexion And Extension (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
- Reduced Extension
- Reduced Flexion
Right: Flexion And Extension (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)
- Reduced Extension
- Reduced Flexion
Left: Supination And Pronation (1/4 point)
- Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
- Reduced Pronation
- Reduced Supination
Right: Supination And Pronation (1/4 point)
- Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)
- Reduced Pronation
- Reduced Supination
Assessed Shoulder RoM
1 of 1 point
Adduction (1/3 point)
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
Abduction (1/3 point)
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
Strength (1/3 point)
- 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)
Assessed Trapezius Strength
1 of 1 point
Strength (1/1 point)
- 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)
Assessed Deltoid Strength And Shoulder Rotation
1 of 1 point
Strength & Rotation (1/3 point)
- Symmetric
- Asymmetric
Forward Flexion (1/3 point)
- Expected range of motion (approx. 180 degrees)
- Reduced range of motion
Extension (1/3 point)
- Expected range of motion (approx. 50 degrees)
- Reduced range of motion
Assessed Hand/Finger RoM And Strength
1 of 1 point
Left (1/2 point)
- 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)
Right (1/2 point)
- 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)
Assessed Symmetry of Extremities
1 of 1 point
Extremities (1/1 point)
- Symmetrical
- Asymmetrical
Assessed Leg Symmetry, Knee or Ankle Effusion
1 of 1 point
Effusion (1/3 point)
- Present
- Not present
Leg Symmetry (1/3 point)
- Symmetric
- Asymmetric
Knee Symmetry (1/3 point)
- Symmetric
- Asymmetric
Assessed Calf Symmetry, Leg Strength
1 of 1 point
Calf Muscles (1/2 point)
- Symmetric
- Asymmetric
Leg Strength (1/2 point)
- 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)
Tested Hip, Knee and Ankle Range of Motion
1 of 1 point
Hip Range Of Motion (1/3 point)
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
Knee Range Of Motion (1/3 point)
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
Ankle Range Of Motion (1/3 point)
- Symmetric, full range of motion without limitations
- Asymmetric range of motion with limitations
Tested 6 Cardinal Fields of Vision
1 of 1 point
Cardinal Fields (1/2 point)
- No abnormal findings
- Nystagmus
- Fixed Pupil
Convergence (1/2 point)
- No abnormal findings
- Unequal bilaterally
- Fixed Pupil
Tested Peripheral Vision
1 of 1 point
Observations (1/1 point)
- No abnormal findings
- Reduced right visual field
- Reduced left visual field
Tested Visual Acuity
1 of 1 point
Right (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Left (1/2 point)
- 20/100
- 20/70
- 20/50
- 20/40
- 20/30
- 20/25
- 20/20
- 20/15
- 20/13
- 20/10
Romberg Test
1 of 1 point
Romberg (1/1 point)
- Maintains upright posture
- Difficulty remaining upright
Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/2 point)
- Clear in all areas
- Diminished in some areas
- Absent in some areas
Adventitious Sounds (1/2 point)
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
Auscultated Abdominal Aorta
1 of 1 point
Sounds (1/1 point)
- No bruit
- Bruit
Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/3 point)
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2 and S4 audible
- S1, S2, S3 and S4 audible
Extra Heart Sounds (1/3 point)
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
Rate And Rhythm (1/3 point)
- Regular rate and rhythm
- Irregular rate and rhythm
- Arrhythmia
Screened Adam’s Forward Bend
1 of 1 point
Iliac Crests (1/6 point)
- Equal height
- Unequal height
Scapula Prominence And Shape (1/6 point)
- Equal height
- Unequal height
Spine Contour (1/6 point)
- Expected curvature
- Decreased lordosis
- Increased lordosis
- Decreased kyphosis
- Increased kyphosis
Spine Symmetry (1/6 point)
- Symmetrical
- Asymmetrical
Waistline (1/6 point)
- Equal height
- Unequal height
Flexion (1/6 point)
- Expected range of motion (approx. 75-90 degrees)
- Reduced flexion