Documentation of a Head-to-Toe Assessment

Paper Info
Page count 3
Word count 917
Read time 4 min
Topic Health
Type Essay
Language 🇺🇸 US

Patient Data

Mr. X is a 51-year-old man of the African American race. He retired as a teacher 5-years- ago. He is not married but insured. The patient was born on January 01, 1969. The patient came into the clinic accompanied by the brother with whom they stay with. He complains of left eye irritations, which started three days ago. The eye discomfort is characterized by a sharp pain that is intermittent in its presentation. It is associated with blurred vision, photophobia, and headache. The symptoms worsen when the patient stays for long periods working on his computer. He rates the severity of the irritation at 8/10.

Physical Examination

  • General Survey: The patient is well-groomed, articulates normal posture when sitting down though he looked stressed. He rarely keeps eye contact during the exam but responds well to questions.
  • Neurological assessment: The patient is alert and oriented to time, place, person, and situation. He assumes an upright posture when sitting and has a steady gait. The patient articulates words well with no difficulties in reading observed. No motor deficits were observed with full muscle strength of 5/5 bilaterally. The patient has the intact sensation of pain bilaterally. The functioning of the cranial nerves is intact. The patient has no delusions or hallucinations. The cerebellar function is intact. The recent, remote and immediate memory is intact.
  • Skin: the skin is of dark color throughout the body with no scars, edema, rashes, or wounds. The skin feels warm and moist on palpation. The scalp is covered with hair. The extremities are also covered with hair.
  • Head: on inspection, the head is rounded in shape, symmetrical and normocephallic. Hair is evenly distributed on the head. The hair is dark in color and has a fine texture. No scars or pustules were observed.
  • Eyes: they are bilaterally symmetrical. The conjunctiva appears reddened. The pupil is dark, equally round, and reactive to light. The assessment of the visual acuity is 20/20 on Snellen’s chart. The presence of tears from the eyes was noted. The eyes are bilaterally symmetrical in size and shape. The patient can turn her eyes in all.
  • Mouth: the lips are pink in color with no dryness. The patient has white teeth with four missing. No dentures. The tongue is pinkish in color with no oral trash. The tongue is centrally located. There are full non-painful movements at the temporomandibular joint.
  • Ears: no abnormal discharge or cerumen impaction noted. The auricles are present, and they are in the same alignment with the outer canthus of the eyes. The sense of hearing is intact.
  • Neck: no jugular vein distension or enlarged cervical or tonsil lymph nodes observed.
  • Chest: rises and falls with respirations. The breast is present and at a level position. The respirations are irregular. The respiratory rate is 16 breaths per minute. Palpation of the thorax shows no crepitus or deformities. No pain or tenderness on palpation. The subclavian and the pectoral lymph nodes are not enlarged. The auscultation of the lungs found a wheezing sound at the bronchus. On auscultation of the heart, s1 and s2 sound heard with no extra heart sounds. The apical pulse is 70 beats per minute. Lung sounds are clear.
  • Arms: they are bilaterally symmetrical. Palms are pinkish in color. No absent fingers noted. The capillary refill time is less than 2 seconds. They are no curved nails. The range of motion at the wrist and elbow joints was full with no limitations. Brachial and radial pulses are felt. The radial pulse is 72 beats per minute. The axillary lymph node is not enlarged on palpation. The muscles strength at the upper extremities is equal and strong. The axillary temperature is 36.3 degrees Celcius.
  • Abdomen: no scars or organomegaly observed. No bruits auscultated on the abdominal artery. It rises and falls with respirations. The skin turgor is less than 2 seconds. On palpation, there was no tenderness or masses felt. The bowel sounds are present. In a minute, 15 bowel sounds were auscultated.
  • Lower extremities: the legs are bilaterally symmetrical. No deformities are present. There are no reddened or edematous areas inspected. All the toes are present. No scars were observed on the feet. The patella is centrally located at the knees with no edema at the joint. The leg muscles are strong and equally resistant to force. The range of motion at the knee and the ankle joints is full. The legs feel warm on palpation. The popliteal, dorsalis pedis and posterior tibia pulses can be felt. The inguinal lymph node is non-distended.
  • Back: The spine is centrally located with a concave curvature at the lumbar and cervical vertebrae. The vertebrae are uniform with no deformities.
  • Genitourinary assessments: There are no lesions or scars on the perineal area. Urinary meatus is present and opens at the midline. Absent secretions or a foul smell from the urethra were observed. On palpation, there were no masses or tenderness observed. The anus is present and perforates with no bleeding or hernias observed.

Potential problems

The patient appears to have problems with his eyesight. This is due to the findings of excessive tearing of the eye. The eye also appears reddened, indicating an underlying eye problem. Tearing of the conjunctiva’s eyes and reddening are indicative of allergic disease (Wilson & Giddens, 2021). The wheezing on the auscultation of the lungs indicates a probable limitation in breathing due to the bronchus’s narrowing. The irregular also evidences respiratory problems and decreased respiratory rate of 16 breathes per minute.

References

Wilson, S. F., & Giddens, J. F. (2021). Health Assessment for Nursing Practice. Mosby.

Cite this paper

Reference

NerdyBro. (2022, August 1). Documentation of a Head-to-Toe Assessment. Retrieved from https://nerdybro.com/documentation-of-a-head-to-toe-assessment/

Reference

NerdyBro. (2022, August 1). Documentation of a Head-to-Toe Assessment. https://nerdybro.com/documentation-of-a-head-to-toe-assessment/

Work Cited

"Documentation of a Head-to-Toe Assessment." NerdyBro, 1 Aug. 2022, nerdybro.com/documentation-of-a-head-to-toe-assessment/.

References

NerdyBro. (2022) 'Documentation of a Head-to-Toe Assessment'. 1 August.

References

NerdyBro. 2022. "Documentation of a Head-to-Toe Assessment." August 1, 2022. https://nerdybro.com/documentation-of-a-head-to-toe-assessment/.

1. NerdyBro. "Documentation of a Head-to-Toe Assessment." August 1, 2022. https://nerdybro.com/documentation-of-a-head-to-toe-assessment/.


Bibliography


NerdyBro. "Documentation of a Head-to-Toe Assessment." August 1, 2022. https://nerdybro.com/documentation-of-a-head-to-toe-assessment/.