Head-to-Toe Examination Write Up

Biographic Data

Date: 11/8/13 | Name: L.C. | Gender: Male | Race: Hispanic | Date of Birth: 04/15/1972 | Age: 42 | Marital Status: married | Contact Person: J.C. ( Wife) | Occupation: Aircraft mechanic | Source of Data: Patient |

HISTORY
Reason for Seeking Care/Presenting Problem

Cirrhosis Congestive
Heart Failure

Coronary Heart Disease Diverticular Disease Depression Diabetes, Type 1 x Diabetes, Type 2

Emphysema Glaucoma Gout

Hemophilia Hernia Hypertension Irritable Bowel
Syndrome

Multiple
Sclerosis

Osteoporosis Parkinson’s
Disease

Psoriasis

Renal Failure Seizure Disorder Thyroid Disease Venous
Insufficiency

Vision
Disturbance
Female:

Dysfunctional
Uterine Bleeding

Other (describe):asthma

Fibrocystic
Breast Disease

Premenstrual
Syndrome

Male:

Prostate Disease

Current medications (include prescription, over-the-counter, herbs, and vitamins):

Name of Drug | Dosage/Frequency | Last Dose Taken | Reason for Taking | Ventolin INH | 2 puffs PRN | 3 years ago | Asthma | Metformin | 500 mg PO BID | 11/8/13 started on 10/28/13 | Diabetes T 2 | Multivitamin | 1 tab PO daily | 11/8/13 | Supplement | | | | |

Allergies to Medication/Foods/Medical Products/Other (e.g., latex, contrast, tape):

Allergic To | Type of Reaction | PCN | Hives, difficulty breathing | | | | | | |

Current medical treatments (e.g., breathing treatments, dialysis, wound dressing):

Past Health History

Childhood illnesses (check all that apply):

Measles Mumps | Rubella | X Chicken pox | Pertussis x Influenza | Ear infections | Throat infections | Other (describe): | | |

| Name and Type | Date / Year | Residual Problems | Previous MedicalConditions orProblems | NIDDMAsthma | 03/20001982 | Diet and PO medication controlled. Requires rescue INH PRN | PreviousHospitalizations | | | | Surgeries | Third molars extraction under IV sedation | 2005 | | Serious Injuries | | | |

Immunizations:

Immunization | Date/s | Immunization | Date/s | Diphtheria | 02/2009 | Pneumococcal | | Pertussis | 02/2009 | Measles, mumps, rubella(MMR) | | Tetanus | 02/2009 | Varicella | | Inactivated poliomyelitis (IPV) | | Influenza vaccine | | Haemophilus influenza type b(Hib) | 09/2012 | Hepatitis A | | Hepatitis B | | Human papillomavirus (HPV) | | Meningococcal conjugate vaccine (MCV) | | Other | | Rotovirus | | Other | |

Last examinations:

Last Examination | Date | Outcome | Last Physical | 10/28/2013 | Pt was started on Metformin 500 mg. BID. | Last Vision | 09/2013 | Normal | Last Dental | 2012 | Couple of caries fixed | Other (describe) | | | Women Only | | | Last Menstrual Period | | | Last Pregnancy | | GravidaParaAbortion / Miscarriage | Last Pap Smear | | | Last Mammogram | | |

Family History (Indicate age and current health. If deceased, indicate age and cause of death.)

Person | Age Current Health A&W = alive and wellDeceasedChronic Problem (describe) Unk = Unknown | Mother | 57 | Asthma, arthritis (A) (C) | Father | 78 | Renal cell carcinoma (D) | Maternal Grandmother | 82 | Macular degeneration (A) (C) | Maternal Grandfather | | HTN, Parkinson’s (D) | Paternal Grandmother | | Diabetes (D) | Paternal Grandfather | | Unk (D) | Maternal Aunts / Uncles | | Unk | Paternal Aunts / Uncles | | Unk | Sister 1 | | | Sister 2 | | | Sister 3 | | | Brother 1 | 37 | None | Brother 2 | | | Brother 3 | | | Other (describe) | | |

Personal and Psychosocial History
Family/Social Relationships (significant others, individuals in home, role within family, etc.)
Patient is married has three children ages 13, 12, and 4 making a total of five individuals in home.
Patient and wife work full time. Currently taking online classes to obtain a Bachelors degree in Information Technology.

Diet/Nutrition (include appetite, typical food intake, etc.)
Patient is NIDDM controlled with diet and PO medications. Patient follows 1800 ADA diet since he was diagnosed in 03/2000. He also practices physical exercise in a local gym at least four days a week. Appetite is normal. He consumes six small meals/ day.

Functional Ability (indicate ability to independently perform following self-care activities*):

ACTIVITY | Perform Independently(yes or no) | Challenges (describe) | Dressing | yes | | Toileting | Yes | | Bathing | Yes | | Eating | Yes | | Ambulating | Yes | | Shopping | Yes | | Cooking | Yes | | Housekeeping | Yes | | | | |

Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies)
Pt stated in the health history interview that his coping strategies include going to the gym and talking with his wife.

Personal Habits

Tobacco use: | Y | N | Packs per day: | Alcohol intake: Illicit drug use: | Y Y | N N | Drinks per day: Describe: |

Health Promotion
Exercise (type/frequency): Pt stated in previous interview he does weight lifting and cardiovascular exercise four days a week.

Self-examination (type/frequency): Pt state he performs testicular examination monthly. Also in previous interview patient said he performs finger stick blood sugar checks when feeling hypoglycemic.

Oral hygiene practice (frequency of brushing/flossing):
Patient verbalized in previous interview that he brushes his teeth twice a day and flosses every night.

Screening examinations (blood pressure, prostate, breast, glucose, etc.):
Finger stick blood sugar PRN.

Environment (including living and work environment)

Patient lives in a house build I 2007. Works as aircraft mechanic at Robins air force base.

Review of Systems (check all symptoms that apply, and comment below)

General Symptoms: Pain Fatigue Weakness Fever

Problems sleeping

Unexplained changes in weight

Comments: Denies

Integumentary System:
Change in skin color/texture

Excessive bruising

Itching Skin lesions

Sores that do not heal
Do you use sunscreen? Change in mole Recent hair loss Change in nails or hair texture
How much sun exposure do you experience?

Comments: Patient stated in previous interview that he has daily exposure to sun for at least one hour when working.

Head: Headaches Head injury Dizziness Fainting spells

Comments: Denies

Eyes: Change in vision Discharge Excessive tearing

Eye pain

Sensitivity to light
Wear corrective lenses?

Flashing lights Halos around lights If yes: how long? last date evaluated?

Difficulty reading

Comments: Denies

Ears: Ear pain Drainage Recurrent infections

Excessive ear wax

Changes in hearing Ringing in ears Sensitivity to noises

Comments: Denies

Nose, Nasopharynx, Sinuses: Nasal discharge Frequent nosebleeds

Sneezing Nasal obstruction

Sinus pain Postnasal drip Change in smell Snoring

Comments: Denies.

Mouth/Oropharynx: Sore throat Sore in mouth Bleeding gums Change in taste

Trouble chewing Trouble swallowing

Dental prosthesis

Change in voice

Comments: Denies.

Neck:
Lymph node enlargement

Swelling or mass in neck

Neck pain Neck stiffness

Comments: Neck is symmetric, no lumps, no pulsations. No palpable cervical nodes. Carotid pulse strong and equal. Trachea is midline. Good ROM.

Upper extremities: Good ROM, no palpable epitrochlear nodes noted. Good and symmetric elevation of shoulders against resistance.
Breasts:
Pain Swelling Lumps or masses

Change in appearance

Nipple discharge Do you perform breast self- examinations? If yes: how often?

Comments: skin is intact and shoulders symmetrical. Symmetric expansion, no masses, no tenderness, spinous process. Flank area is on tender.

Respiratory System: Frequent colds Shortness of breath Cough Coughing up blood

Wheezing Pain with breathing
Night sweats

Comments: No adventitious breath sounds anterior and posteriorly. Dry cough noted.

Cardiovascular System: Chest pain Palpitations Dyspnea Edema

Coldness to extremities Paresthesia

Discoloration Varicose veins Leg pain with activity
Comments:
No pulsations noted. Apical pulse is at six ICS midclavicular line. No ectopic heart sounds.
Gastrointestinal System: Pain Heartburn Nausea/ vomiting Vomiting blood

Jaundice Change in appetite Diarrhea Constipation

Change in bowel habits

Comments: abdomen rounded symmetric, skin intact, no pulsations, umbilicus midline and inverted. Active bowel sounds X 4 quads. No vascular sounds. No pain or organs noted during light and deep palpation. Aorta is not palpable. Negative Blumberg sing. Negative Murphy sign. Negative Iliopsoas sign.

Urinary System: Hesitancy Frequency Change in stream

Nocturia

Pain with urination Decreased urinary volume

Comments: Patient denied any complaints on previous interview.

Flank pain Blood in urine Excessive urinary volume

Reproductive System: Lesions Discharge Pain or masses

Females:
Pain during menses

Heavy or prolonged menses

No menses

Are you currently involved in a sexual relationship(s)? Yes No

If yes, what is the nature of the relationship(s) (heterosexual, homosexual, bisexual)? Number of sexual partners in last 3 months?
Patient state been heterosexual and having only one partner. Do you protect yourself from sexually transmitted disease (STD)? Yes No
If yes, method(s) used:

Do you use birth control? Yes No
If yes, method(s) used:

Painful intercourse Change in sex drive Infertility Impotence

Comments: Denies

Musculoskeletal System: Muscle pain Weakness Joint swelling Joint pain

Stiffness Limitations in range of motion

Limitations in mobility

Back pain

Comments: Patient has good ROM in all four extremities. Denies any symptoms. No palpable inguinal nodes. Good femoral pulses. Bilateral lower extremities are symmetric. Skin is intact. Normal hair distribution. No varicose veins. 2+ posterior tibial pulse. 2+ dorsalis pedis pulse. Temperature is warm. No edema. Spaces between toes normal. Good strength.

Neurologic System: Pain Seizures Fainting Changes in cognition

Changes in memory
Changes in sensation

Problems with coordination Tremor Spasms

Comments: Position sense of finger test is normal. Stereognosis test is normal. Babinsky reflex is positive. Heel down opposite shin test is normal.Sensation in selected area is normal.Superficial pain test is normal.Light touch test normal. Vibration test is normal. Patellar and Brachoradialis reflex are normal.Roemberg’s test is normal.

Examination Examination Technique | Findings (document findings below) | Vital Signs and Baseline MeasurementMEASURE Heart & Respiratory rate MEASURE height and weight. | Vital Signs and Baseline MeasurementHeart rate: 62Respiratory rate:16Height: 5’7”Weight: 175 lbs.BMI: 24.9 | General InspectionOBSERVE appearance of the client, including hygiene and skin color.ASSESS level of orientation.OBSERVE body stature and nourishment. OBSERVE posture and mobility.NOTE the mood or affect of the client. Note ability to hear and speak. | General Inspection: Patient does not look anxious, depressed, or irritable. Patient is awake, alert, oriented. Mood and affect are appropriate. Good eye contact. Dressed appropriately. Posture is symmetrical. Mobility with no difficulty. Able to hear and speak. Normal stature and nourishment. Skin warm, dry, and intact. | | |

Examine HandsINSPECT skin surface characteristics, temperature, and moisture of hands.INSPECT hands for symmetry.INSPECT and PALPATE nails for shape, contour, consistency, color, thickness, and cleanliness.TEST capillary refill.OBSERVE for clubbing of fingers. | Examine Hands: Skin warm and dry, symmetrical, nails are clean, normal, color is pink, capillary refill <3sec. No clubbing of fingers. | Examine Head and FaceINSPECT skull for contour and hair for color and distribution.If indicated, palpate hair for texture. If indicated, palpate scalp.PALPATE temporal pulses for amplitude. INSPECT for facial features andsymmetry.INSPECT bony structures of face for size, symmetry, and intactness.If indicated, ask client to clench teeth.If indicated, ask client to clench eyes tightly, wrinkle forehead, smile, stick out tongue, and puff out cheeks.If indicated, evaluate sensitivity of forehead, cheeks, and chin to light touch.INSPECT skin for color and lesions.If indicated, palpate skin surfacesfor texture, tenderness and lesions. If indicated, palpate facial bones forsize, intactness and tenderness. | Examine Head and Face: No deformity or bumps, normal hair color and distribution, normal hair texture. Symmetrical expressions. Bony structures are intact and symmetrical.Temporal artery pulse 2+. TMJ articulation with no clicking or pain. Denies pain on maxillary and frontal sinuses. Skin is sensitive to light touch, tongue is midline, skin is warm dry and intact. | | |

Examine Eyes
ASSESS peripheral vision.
INSPECT eyebrows for hair distribution, underlying skin, and symmetry.
INSPECT eyelids and eyelashes for symmetry, position, closure, blinking, and color.
INSPECT conjunctiva and sclera for color and clarity; inspect cornea for transparency.
INSPECT symmetry of eye movements. test extraocular eye movements in six cardinal fields of gaze.
INSPECT iris for shape and color. ASSESS pupillary response, consensual reaction, corneal light reflex, accommodation, and red reflex.

Examine Peripheral vision is normal. Eye brows, eye lids and lashes are normal, symmetrical, and hair distribution is even. Eye lids and lashes are symmetrical, closure is normal, blinking normal, color recognition is normal. Conjunctiva and sclera are clear, cornea is transparent. Six cardinal positions followed with no difficulties and symmetrically. Light reflex at 30 cm. is symmetrical. Iris is round clear. Pupils are equal, round, reactive to light and accommodation. Pupillary response is consensual. Red reflex is normal.

Examine Ears
INSPECT external ear for alignment, position, size, shape, symmetry, intactness, and skin color.
INSPECT external auditory canal for discharge or lesions.
INSPECT skin over superficial lymph nodes for edema, erythema, and red streaks.
PALPATE lymph nodes of the head for size and tenderness.
PALPATE external ear and mastoid areas for tenderness, edema, or nodules.
Perform whisper test to evaluate gross hearing.
Otoscopic examination: inspect characteristics of external canal, cerumen, eardrum.

Examine Ears: External ears structure is normal in size, shape, and symmetry. Skin is warm, dry, intact, no drainage noted. Lymph nodes are non-palpable. Mastoid area is normal and non-tender. Ear canals with minimum amount of wax noted, tympanic membrane intact, cone light reflex noted. Whisper test is normal.

Examine Nose, Mouth, and
Oropharynx
INSPECT nasal structure and septum for symmetry.
INSPECT nose for patency, turbinates, and discharge.
If indicated, evaluate sense of smell. INSPECT lips, buccal mucosa, and gums for color, symmetry, moisture, and texture.
INSPECT teeth for number, color, position, alignment, hygiene, and condition.
INSPECT floor of mouth and hard and soft palates for color and surface characteristics.
INSPECT oropharynx for odor, anterior and posterior pillars, uvula, tonsils, and posterior pharynx.
If indicated, grade tonsils. INSPECT tongue for symmetry, movement, color, and surface characteristics.
Palpate tongue and gums. Test temporomandibular joint for movement.

Examine Nose, Mouth, and
Oropharynx: Nasal structure is symmetrical. Septum is midline and intact. Both nares are patent with no discharge noted.

Oral mucosa is pink and moist, uvula midline and mobile, good gag reflex, back of teeth and gums with no bumps, ulcers, or hard areas. Tongue is midline, with no ulcerations. Floor of mouth is intact, Palate, 1+ tonsils

Examine NeckOBSERVE symmetry of neck, trachea, and thyroid.INSPECT neck for range of motion.Test range of motion of head and neck; shrug shoulders against resistance.PALAPTE carotid pulses, one at a time, for amplitude and presence of bruits.PALPATE lymph nodes of the neck for size and tenderness.OBSERVE for jugular venous distention. | Examine Neck | Examine Upper ExtremitiesINSPECT client’s arms for skin characteristics, symmetry, and deformities.PALPATE arms, elbows, and wrists for temperature, tenderness, and deformities.PALPATE brachial or radial pulse for presence and amplitude.Palpate epitrochlear lymph nodes for size and tenderness.Test range of motion, muscle strength, and sensation.Test deep tendon reflex (brachioradialis reflex). | Examine Upper Extremities |

Assess Posterior ChestOBSERVE posterior and lateral chest for symmetry of shoulders, muscular development, scapular placement, spine alignment, and posture.INSPECT skin for color, intactness, lesions, and scars.PALPATE vertebrae for alignment and tenderness.OBSERVE respiratory movement for symmetry, depth, and rhythm of respirations.Palpate posterior chest and thoracic muscles for tenderness, bulges, and symmetry.Palpate posterior chest wall for thoracic expansion.Palpate down vertebral column for alignment and tenderness.Percuss with fist along costovertebral angle for tenderness.AUSCULTATE posterior and lateral chest walls for breath sounds. | Assess Posterior Chest | Assess Anterior ChestINSPECT skin for color, intactness, lesions, and scars.OBSERVE respiratory movement for symmetry, client’s ease with | Assess Anterior Chest |

respirations, and posture.OBSERVE precordium for pulsations or heaving.PALAPTE left chest wall to locate point of maximum impulse (PMI).AUSCULTATE anterior chest for breath sounds.AUSCULTATE heart for rate, rhythm, intensity, frequency, timing, and splitting of S1 or S2 or presence of S3, S4, or murmurs. | |

Assess Anterior Chest in RecumbentPositionELEVATE head of bed 45 degrees to inspect for jugular vein pulsations.If indicated, measure jugular venous pressure for height seen above sternal angle.PALPATE anterior chest wall for thrills, heaves, and pulsations.If indicated, measure blood pressure with client lying to compare with earlier reading. | Assess Anterior Chest in RecumbentPosition | Assess AbdomenOBSERVE skin characteristics from pubis to midchest region for scars, lesions, vascularity, bulges, and navel. | Assess Abdomen | INSPECT abdominal contour. OBSERVE for movement of abdomen,peristalsis, and pulsations. AUSCULTATE abdomen (all quadrants)for bowel sounds, bruits, and venous hums.PALPATE lightly all quadrants for tenderness, guarding, and masses. | |

If indicated, deeply palpate all quadrants for tenderness, guarding, and masses.
If indicated, deeply palpate left costal margin for splenic border.
If indicated, deeply palpate abdomen for right and left kidneys

Client raises head to evaluate flexion and strength of abdominal muscles and inspect for umbilical hernia.

Assess Lower ExtremitiesINSPECT legs, ankles, and feet for skin characteristics, vascular sufficiency, hair distribution, and deformities.PALPATE lower legs and feet for temperature, pulses, tenderness, and deformities.Test range of motion, motor strength, and sensation of hips, legs, knees, ankles, and feet.Test for deep tendon reflex (patellar reflex). | Assess Lower Extremities | Assess Remaining Neurologic SystemOBSERVE client moving from lying to sitting position; note use of muscles, ease of movement, and coordination.ASSESS client’s gait: observe and palpate client’s spine for alignment as client stands and bends to touch toes.Evaluate hyperextension, lateral bending, and rotation of upper trunk.Bilaterally test and compare vibratory sensation.Test proprioception by moving the toe up and down | Assess Remaining Neurologic System |

Test stereognosis and graphesthesia
Test fine motor functioning and coordination of upper extremities by instructing client to perform at least two of the following:
Alternating pronation and supination of forearm
Touching nose
Rapidly alternating finger movements to thumb
Rapidly moving index finger between nose and examiner’s finger
Assess cerebellar and motor functions by using at least two of the following:
Romberg’s test (eyes closed) Walking straight heel-to-toe formation Standing on one foot and then other (eyes closed)
Hopping in place on one foot and then other
Knee bends

Nursing Diagnoses and Collaborative Problems: Based on the subjective and objective data collected above, identify applicable nursing diagnoses and collaborative problems. Nursing Diagnoses | Collaborative Problems | | |

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Grade on documentation of finding : Satisfactory__ or Unsatisfactory____
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Faculty Comments____________________________________________
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Faculty Signature_________________________________
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Grade on documentation of finding : Satisfactory__ or Unsatisfactory____
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Faculty Comments____________________________________________
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Faculty Signature_________________________________