Head to toe assessment

Ralph Marrero

South University


Dec 6, 2021

The following is a complete head to toe assessment of 32-year-old women, presenting to the office for a wellness checkup. I performed hand hygiene and introduced myself to the patient. Asked orientation questions as well as some subjective questions. Patient states having no distress or pain currently. Vital signs: Height 5’4’’, weight 195 pounds, B/P: 120/80 mm Hg, Breathing: 16 breaths per minute, Pulse: 85 beats per minute, Temperature: 98.3°F. The patient’s vital signs are within normal limits. General appearance: Patient seems to be in overall good health and good hygiene. Patient is alert and oriented x4. Skin, nails, and hair: Skin pink, warm, dry and elastic. No lesions or excoriations noted. Hair brown, shoulder length, clean, shiny. Normal distribution of hair on scalp. Nails are hard, smooth, and clean cut. Nailbeds pink without clubbing. Cuticles smooth. Hands well- manicured with clear enamel. HEAD AND NECK: Head and neck are symmetrical. Patient dienes any tenderness, bumps nor burses on the head or neck. Head symmetrically round and smooth without lesions or bumps. Face oval, smooth, and symmetrical. Neck symmetric with centered head position and no bulging masses. Has smooth, controlled, full range of motion of neck. Trachea in midline. Lymph nodes nonpalpable. EYES AND EARS: No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. Irises are round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils converge evenly. Ears are equal in size bilaterally. Denies ear pain, discharge, problems in general. external ear intact. Skin smooth, no lumps, lesions, nodules. No discharge. Nontender on palpation. NOSE AND SINUSES: Patient denies any congestion, drainage, pain, nor discomfort. Upon inspection of nostrils appear symmetry. frontal and maxillary sinuses have no tenderness. Lips pink, smooth, and moist without lesions. Oral cavity pink, moist, and without exudates. 32 white to yellowish teeth present. Gums pink without redness or swelling. Equal bilateral strength in tongue noted. SHOULDERS AND UPPER EXTERMITIES: shoulders and clavicles ARE symmetry and NO deviation, Brachial, and radial arteries +2, strength 5/5. CHEST AND LUNGS: Patient denies chest pain, palpitations, edema, tachycardia. Chest movements are bilateral and symmetric. Noted no bruits, murmurs, or clicking. Noted to have regular rate and rhyme. Carotid pulse equal bilaterally, 2+. Distinct and strong. No presence of JVD. Apical pulse palpated in the fifth ICS at the left MCL. Breath sounds clear bilaterally. No wheezing, crackles, or rhonchi. ABDOMEN: There was no soreness, tenderness, or abdominal swelling. No aortic tenderness bowel sounds present in all four quadrants. Extremities: The patient’s handgrip and foot strength were symmetrical. There were no pressure areas on any of his limbs and their movement was coordinated. The pulses were uniform in rate and rhythm. Strength is 5/5. Gait smooth, with equal stride bilaterally. Normal curves of cervical, thoracic, and lumbar spine. Full smooth ROM of cervical and lumbar spine, no crepitus present. Upper and lower extremities symmetric without lesions, nodules, deformities, or swelling. Full smooth ROM against gravity and resistance.

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