head to toe assessment documentation

Head-to-Toe Assessment

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Rasmussen College

COURSE#: NUR2180 Physical Assessment

Professor Casey Kelly

March 17, 2021

Objective Physical Examination

Age: 36, Female

Vital Signs: Oral Temp 36.8 C, HR 64 BPM, RR 18, BP 120/80 mmHg, SpO2 93% , Wt. 156 lb.,

Ht. 5.5 Ft, BMI 25.96

Integument

Skin: Uniformly light brown in color, warm to touch, dry, intact skin. Turgor good, no

lesions, and no edema. Hair is thick and evenly distributed with no parasites. Nails appears pink

with no clubbing, biting or discoloration and capillary refills are less than two seconds.

Head

Head is normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face is

symmetric with no weakness and no involuntary movements.

Eyes

Visual acuity by Snellen chart in right eye is 20/20 and left eye is 20/20. Visual fields full

by confrontation. Extraocular muscles intact, no nystagmus, no ptosis, no lid lag, no discharge,

or crusting. Corneal light reflex symmetric, no strabismus. Conjunctivae pink and moist, sclerae

white, no lesions or redness. Pupils are equal, round, reactive to light, and accommodate

(PERRLA).

Ears

Pinna has no mass, lesions, scaling, discharge, or tenderness with palpation. Canals clear

of cerumen and whispered words heard bilaterally.

Nose

No deformities or tenderness to palpation. Nares patent, mucosa pink and moist, no

lesions, no drainage. Septum midline, no perforation or deviation. No sinus tenderness.

Mouth

Mucous membrane pink and moist, no lesions or bleeding. Teeth in good repairs, gum

pink. Pharynx pink and no exudate. Tongue midline and pink, uvula midline and rises with

phonation. Tonsils 1+ and Gag reflex present.

Neck

Neck flexible with full ROM. Symmetric; no masses, tenderness, or lymphadenopathy.

Trachea midline. Thyroid nonpalpable, and not tender. Jugular veins not distended. Carotid

arteries 2+ and equal bilaterally. No bruit.

Spine and Back

Spine straight, no kyphosis, lordosis, or scoliosis. No tenderness over spine and no

costovertebral (CAV) tenderness.

Thorax and Lungs

Anteroposterior to transverse 1:2 diameter. Chest expansion symmetric. Tactile fremitus

equal bilaterally. Lung fields resonant. Breath sounds clear and equal bilaterally. No abnormal

breath sound heard on auscultation.

Breasts

Symmetric, no retraction, no discharge, or lesions. Contour and consistency firm and

homogeneous. No masses or tenderness, no lymphadenopathy.

Heart

No abnormal pulsations, no heaves at precordium. Apical impulse at 5th intercostal space

(ICS) in left midclavicular line (MCL), no thrills. S1 and S2 heard on auscultation. No S3 or S4

heard, and no murmur.

Abdomen

Flat and symmetric. Skin smooth with no lesions, scars, or varicose veins. Bowel sounds

present and normoactive in all four quadrants. No bruit. Abdomen soft, no organomegaly, no

masses, or tenderness, and no inguinal lymphadenopathy.

Extremities

Color light brown, no redness, no cyanosis lesions other than surgical sca r left lower leg,

anterior, 20 cm x 3 cm wide, well healed. No edema, no varicosities. No calf tenderness. All

peripheral pulses present, 2+ and equal bilaterally.

Musculoskeletal

No slipping or crepitation at temporomandibular joints. Neck full range of motion

(ROM), no pain. Vertebral column has no tenderness, no deformity, or curvature. Arms

symmetric, and have full ROM with no pain or crepitation. ROM limited on left lower extremity.

Muscle strength +5 and maintain flexion against resistance without tenderness.

Neurologic

Alert and oriented to person, place, and time. Speech smooth and logical and responds

appropriately. Dresses appropriately for weather. Cranial nerves I through XII intact. No atrophy,

weakness, or tremors. Steady gait and negative Romberg sign.

Genitalia

External genitalia have no lesions, or discharge. Internal genitalia (vagina walls) pink,

with no lesions. Cervix pink; nulliparous opening; no lesions and small amount non odorous

clear discharge. Specimens for Pap test, GC/chlamydia, trichom oniasis, moniliasis obtained.

Swabbing mucosa with acetic acid shows no acetowhitening. Bimanual: no pain on moving

cervix; uterus midline; no enlargement, masses, or tenderness. Adnexa : ovaries not enlarged, no

tenderness. Anus: no hemorrhoids, no fissures, or lesions. Rectal wall intact, no masses or

tenderness. Stool soft, brown and Hema test negative.

Risk Factors

Patient has a potential risk of becoming overweight with 25.96 BMI (Body Mass Index).

There are so many health issues associated with overweight. From diabetes, high cholesterol to

high blood pressure that can be life threatening. Therefore, patient needs to be educated about

being overweight and the risk factors. Patient also needs to know how to manage her weight to

complement her height.

The patient may also potentially be at risk for injury or immobility due to the exam finding of a

surgical scar on the left lower extremity and limited range of motion on that same extremity. The

patient stated that she has a basketball injury when she was younger requiring surgery, and since

the procedure that extremity has not been “as strong”. With decreased range of motion and

limitations to physical abilities, the patient could p otentially fall, injure the extremity again, or

have immobility.

Reference

Jarvis, C. (2020). Physical Examination and Health Assessment (8th Edition).

Story, L. (2018). Pathophysiology: A Practical Approach. (3rd ed.). Jones & Bartlett Learning.