Head to Toe Assessment

[Emart]

I'm sharing these examples of a head to toe assessment with negative and positive findings. Please post any suggestions on what you think is important to add.

 

NEGATIVE FINDINGS 

General Appearance

• Observation: The patient appears alert, oriented, and well-nourished, sitting comfortably with a relaxed posture and good eye contact. No signs of distress.

Head and Face

• Skull and Scalp: Normocephalic and atraumatic. Scalp is clean and free of lesions.

• Facial Symmetry: Symmetrical facial movements with no drooping or abnormalities.

• Eyes: Pupils are equal, round, and reactive to light and accommodation (PERRLA). Sclera is white, and conjunctiva is pink and moist.

• Ears: External ears are symmetrical and free of lesions. Ear canals are clear with no discharge; tympanic membranes are intact and pearly gray. Hearing is intact bilaterally.

• Nose: Nasal passages are patent without septal deviation; mucosa is pink and moist. No sinus tenderness on palpation.

Mouth and Throat

• Lips: Pink, moist, and free of lesions.

• Oral Mucosa: Pink, moist, and intact with no lesions. Tongue is midline and well-papillated. No signs of thrush.

• Teeth and Gums: Teeth are in good repair; gums are pink and firm without swelling or bleeding.

• Pharynx: Pharynx is clear, with no erythema, swelling, or exudates. Tonsils are not enlarged.

Neck

• Trachea: Midline with no visible swelling.

• Thyroid: Non-palpable and without enlargement or nodules.

• Lymph Nodes: No cervical lymphadenopathy; lymph nodes are non-tender and not palpable.

Respiratory System

• Inspection: Symmetrical chest expansion with normal respiratory effort; no use of accessory muscles.

• Auscultation: Clear breath sounds bilaterally in all lung fields without wheezes, crackles, or rhonchi.

• Percussion: Resonant throughout lung fields.

• Palpation: No tenderness or masses.

Cardiovascular System

• Auscultation: Regular rate and rhythm (RRR) with no murmurs, gallops, or rubs.

• Peripheral Pulses: 2+ (normal) in all extremities bilaterally; no carotid bruits.

• Edema: No peripheral edema.

Abdomen

• Inspection: Flat and symmetrical with no visible masses or lesions.

• Auscultation: Normoactive bowel sounds in all four quadrants.

• Percussion: Tympanic throughout with no areas of dullness.

• Palpation: Soft, non-tender, and without organomegaly or masses.

Musculoskeletal System

• Inspection: Normal curvature of the spine; no swelling, redness, or deformities in joints.

• Palpation: No tenderness over the spine or joints.

• Range of Motion (ROM): Full ROM in all extremities without pain or crepitus.

Neurological System

• Mental Status: Alert and oriented to person, place, and time. Speech is clear and coherent.

• Motor Function: 5/5 muscle strength bilaterally in upper and lower extremities.

• Reflexes: 2+ reflexes bilaterally and symmetrical. No clonus.

• Cranial Nerves: Cranial nerves II-XII are intact.

Skin

• Inspection: Skin is warm, dry, and intact with uniform color. No rashes, lesions, or bruising.

• Temperature and Moisture: Normal temperature; skin is not excessively dry or moist.

• Wounds: No open wounds or signs of pressure ulcers.

 

POSITIVE FINDINGS 

General Appearance

• Observation: The patient appears lethargic and disoriented, with slumped posture and minimal eye contact.

Head and Face

• Skull and Scalp: No visible lumps, lesions, or abnormalities.

• Facial Symmetry: Facial asymmetry noted; the left side of the face appears droopy.

• Eyes: Pupils are unequal (anisocoria); the left pupil is 4 mm and sluggish to light, while the right pupil is 3 mm and reactive.

• Eyelids: Slight ptosis of the left eyelid.

• Conjunctiva and Sclera: Conjunctiva is pale, suggesting possible anemia; sclera is yellowish, indicating jaundice.

• Ears: Mild erythema and discharge from the right ear canal; decreased hearing on the right side.

• Nose: Nasal congestion with a deviated septum to the right; slight tenderness on palpation of the maxillary sinuses.

Mouth and Throat

• Lips: Dry and cracked, indicating dehydration.

• Oral Mucosa: Pale with white patches on the tongue and inner cheeks, suggestive of oral thrush.

• Teeth and Gums: Several dental caries noted; gums are red, swollen, and bleed upon light palpation.

• Pharynx: Erythema and swelling present; tonsils are enlarged with white exudates.

Neck

• Trachea: Midline but there is noticeable swelling on the right side of the neck.

• Thyroid: Enlarged, with palpable nodules.

• Lymph Nodes: Anterior cervical and submandibular lymph nodes are tender and enlarged.

Respiratory System

• Inspection: Asymmetrical chest expansion noted on inspiration.

• Auscultation: Diminished breath sounds in the right lower lobe; crackles heard on both bases, suggestive of fluid accumulation.

• Percussion: Dullness over the right lower lung field.

• Palpation: Tenderness over the left upper anterior chest wall.

Cardiovascular System

• Auscultation: Irregular heart rhythm; grade 3/6 systolic murmur heard at the left sternal border.

• Peripheral Pulses: Diminished dorsalis pedis and posterior tibial pulses bilaterally.

• Edema: Pitting edema observed in the bilateral lower extremities (2+).

Abdomen

• Inspection: Distended abdomen with visible veins.

• Auscultation: Hypoactive bowel sounds present in all four quadrants.

• Percussion: Tympany noted throughout with dullness in the flanks, suggestive of ascites.

• Palpation: Rebound tenderness in the right lower quadrant; positive Murphy's sign indicating possible cholecystitis.

Musculoskeletal System

• Inspection: Swelling and erythema noted in the right knee joint.

• Palpation: Tenderness over the lumbar spine.

• Range of Motion (ROM): Limited ROM in the right knee with pain on movement.

Neurological System

• Mental Status: Disoriented to time and place; speech is slurred.

• Motor Function: Weakness noted in the left upper and lower extremities (3/5 strength).

• Reflexes: Hyperreflexia in the right upper extremity.

• Cranial Nerves: Cranial nerve VII deficit (facial nerve) on the left side; drooping of the mouth.

Skin

• Inspection: Jaundice present; several bruises on the arms and legs at varying stages of healing.

• Temperature and Moisture: Skin is cool and clammy.

• Wounds: Pressure ulcer on the sacrum, stage 2.

 

 

 

 

 

 

 

[JKL33]

What is the context of this?

[hppygr8ful, ASN, RN, EMT-I]

JKL33 said:

What is the context of this?

I concur. Is this for school? Most head to toes I've done in practice as an RN allow you to chart by exception. I do psych now so mostly mental status and ambulation skills are stressed. 

Hppy