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HEAD TO TOE WRITTEN ASSESSMENT EXAMPLE

 GENERAL APPEARANCE

JG is a 48 yo white male, Ht. 5’11”, Wt. 190 lbs. admitted for chest pain; R/O MI. Well groomed, appears stated age, well nourished, alert & oriented x 4, no acute signs of distress.  Wt. appropriate to ht.; erect posture, no obvious physical deformities.  Understandable speech; intact memory; mood appropriate to situation.  Smooth, even, well-balanced gait, no involuntary movements. Sedentary lifestyle.  Denies recent wt. changes; no appetite changes.  Denies alcohol or illegal or prescription drugs; no food allergies.  Complains of pain in right shoulder; pain rating 5/10. Dietary intake is adequate to protein and energy needs.  No clinical signs of nutrient deficiencies.  Family hx unremarkable.

 HEENT

 S.  Denies any unusually frequent or severe H/A.  No hx of head injury, dizziness, or syncope.  Denies frequent or severe H/A’s, dizziness, or vertigo. No neck pain, limitation of motion, lumps or swelling. Vision reported good with no recent change.  No eye pain, no inflammation, no discharge, no lesions.  Wears no corrective lenses.  Vision tested 1 yr ago, test for glaucoma at that time abnormal.  States hearing is good, no earaches, infections, discharge, hearing loss, tinnitus, or vertigo.  No work or leisure hazards.  No hx. of discharge, sinus problems, obstruction, epitasis, or allergy.  Colds 1-2/yr mild.  No mouth pain, bleeding gums, dysphasia, or hoarseness.  No apparent difficulty swallowing, or speaking.  Occasional sore throat with colds.  Tonsillectomy, age 8.  Visits dentist annually; flosses and brushes daily.  No dental appliance.

 O: Face-symmetric, no weakness or involuntary movements. Head-normocephalic, no lumps, lesions, or tenderness.  No ptosis.  Conjunctiva clear.  Sclera white.  No lesions. EOMs intact. No masses, lesions, tenderness, discharge.  PERRLA.  Nares patent.  No septal deviation or perforation.  Whispered words heard bilaterally.  Mucosa and gingivae pink, no masses or lesions.  Teeth in good repair.  Uvula rises in midline on phonation.  Tonsils not present.  Mucosa pink.  Tongue protrudes in midline. 

 NECK

S:  No past hx of stroke, seizures, alcoholism, drug use, or meningitis.  Denies neck pain or swelling.

O: Carotids 2+ & equal bilaterally, no bruits.  No significant lymphadenopathy or masses, trachea midline.  Neck-full ROM, no pain, symmetric, shoulder shrug & head movement intact & = bilaterally. Turgor < 2 seconds.

 LUNGS & THORAX

 S: No cough or chest pain with breathing.  Dyspnea on exertion; rates dyspnea as 7/10 on Borg dyspnea scale.  No past hx of respiratory diseases.  Has 1-2 colds/yr.  Smokes cigarettes 2 PPD x 20 years.  Last TB test 4 yrs ago – neg.  Never had chest x-ray.

O:   AP<transverse diameterRespirations 16/min; relaxed and even.  Chest expansion symmetrical.  Resonant to percussion over lung fields.  No adventitious sounds bilat.

HEART

S: Denies chest pain, dyspnea, orthopnea, cough, fatigue, edema, leg cramps, and skin changes.  No past hx of cardiac or vascular problems.  Family history:  father & grandfather died in their 40’s of heart attacks.  Personal habits:  diet balanced in 4 food groups, smokes 1 PPD x 15 yrs. 1-2 glasses wine on weekends, exercises 3x/wk with brisk walk.  Last ECG 2 years PTA, result normal.

O: PMI 5th ICS @left MCL, no significant pulsations, heaves, or thrills, S1 loudest at Mitral & S2 loudest at Pulmonic; no extra sounds, clicks, gallops or murmurs noted.  Apical - radial and apical - carotid pulses 2+ regular, & equal bilaterally at 84 BPM.

ABDOMEN

S: No hx of abd disease or surgery.  Denies recent bowel changes, usually has 1 formed BM/day.  Denies abd paid, N & V.

O: Abd flat, symmetric with no apparent masses upon inspection.  Skin smooth with no striae, scars or lesions.  Bowel sounds normoactive; no hums or bruits.  Tympany noted upon percussion in all 4 quadrants.  Soft, no tenderness, guarding, or masses upon light palpation.

UPPER EXTREMITIES

S. No hx of skin disease, no present change in pigmentation or in nevi, no pruritis, bruising, rash, or lesions. Denies tremors, weakness, numbness, tingling. States no change in hair color, texture, or distribution.  No change in nails.  No work related skin hazards. Uses sun block cream when outdoors. 

O. Skin pink, warm to touch, dry smooth, no edema, no bruises, no lesions.  Hair: normal distribution & texture, no scaling noted; cap. refill < 2 seconds; no clubbing or deformities.  Pulses 82 BPM; 2+ bilat, regular.  Hand grip strength grade 5 & equal bilaterally.

 LOWER EXTREMITIES

 S: States no hx. of muscle, bone, or joint disease.  No hx. of trauma or deformities.  No joint pain, stiffness, swelling, or limitation.  No muscle pain or weakness.  Usually able to manage ADLs and IADLs  with no physical limitations.  Occupation involves no musculoskeletal risk factors.  Exercise pattern is minimal.

 O.  Skin pink, warm to touch, dry smooth, no edema, no bruises, no lesions.  Hair: normal distribution & texture, no scaling noted; toenails thickening; cap. refill < 2 seconds.  No tenderness to palpation of joints; no heat, swelling, or masses. Joints and muscles symmetric; no edema, swelling, masses, or deformity.  Full ROM; movement smooth, no crepitance, no tenderness.  Negative Homans.  Muscle strength = 5 on a 0-5 scale.  Skin sensation intact at all dermatome levels.  Negative Babinski sign.

GU  

S: Last BM this am. dark brown, mod amt, formed.  Urine clear, straw colored, no odor. 

Copyright © T Pape 1998-2007 all rights reserved

      Last Updated 09/15/2007 Copyright © T. Pape 2002- 2007  All rights reserved. ATRANE home office Abilene TX

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