6904 Advanced Health Assessment

Head to Toe Assessment Documentation

Name: Taylor
Age: 31
Sex: Male (Him/His)

Skin:
Caucasian male. Skin color is normal for race and ethnicity. Skin is uniform, symmetrical
throughout. Dry, warm skin. No redness, no irritation. Patient appears to be in good hygiene. No
odor noted. No open lesion, no cysts, no moles. Noted freckles diffused throughout upper body.
No tattoos, no piercings. Skin texture is smooth, no tenting. Good skin turgor and elasticity.

Nails:
Nails are clean, dry. Nailbed is smooth. No redness, swelling, signs of infection/irritation. Patient
denies pain, drainage. No clubbing of fingers noted. No missing nails or injured nails noted.
Cuticles, dry, no open sores noted. Proper vasculature. Color is appropriate for causation race.

Head:
Hair is coarse, thick brown. Scalp looks healthy, dry. Even distribution of hair. No recent hair
loss noted. Proper movement of scalp, symmetry. Skull is symmetrical, no lesions, masses,
tenderness. Patent, nontender Frontal and Maxillary.

Eyes:
Snellen vision chart completed. Bilateral eyes present 20/20 vision. Eyebrows are well
maintained, do not appear to extend past the eyelids. Orbital area is free from redness, irritation,
drainage. Eyelids negative on assessment for redness, swelling, flakiness. No tremors found
when patient closed eyes. Eyes also palpitated on found no irritation or pain. Conjunctivae is
pink, sclerae is white. Examined and found corneal clarity, sensitivity assessed with qutiup and
found proper sensitivity. Iris is blue, PERRLA with pupils 3cm bilaterally. Accommodation
present. Lacrimal gland intact. Corneal light reflex completed with no abnormal finding. Cover-
uncover test completed with no abnormal findings. Six cardinal fields of gaze completed with no
abnormal findings. Using ophthalmoscope, inspection showed lens had clarity, red reflex was
present, retinal color was pink/red, no lesions noted. No av nicking, cotton wool spots. Disc is
yellow. Patient looked directly into light and macula was assessed as wel

Ears:
Bilateral ears in proper landmark positions. Size, shape, color equal and appropriate for size and
age. No lesions, deformities, drainage, or nodules noted. Auditory canal has no discharge, foreign
bodies, or lesions. Color is appropriately pink. Bilateral tympanic membranes pearly, no signs of
redness/irritation. Patient able to hear questions and follow commands appropriately to assess for
hearing. Whisper test completed with no concerns.

Nose:
No tenderness, masses. Bone/Cartilage nondisplaced. Nares appear patient, no drainage, no
blockage, no redness.

Neck:
No masses, skin folds, or webbing. Neck with full ROM. Trachea midline, no protrusions. No
enlargement, no tenderness with thyroid. Positive bruit ascultated over temporal artery, bilaterael
eyes, and thyroid.

Mouth/Throat:
Lips are moist, non chapped. No edema, Teeth are well maintained and intact. Buccal mucosa
and gingivae appropriate pink color, no lesions, or tenderness. Tongue appropriately pink, taste
buds noted. Symmetrical with no swelling or ulcerations. Tonsils not noted on examination.
Uvula appears pink, slight red tinged. Palate remains intact. Gag reflex present.

Lymphatics:
Nontender, no masses noted x10

Breast (male):
No nipple abnormalities, shape is regular. Areola is round, bilateral symmetry. Color slightly
darker than skin color. Surface, smooth, no noted abnormalities. No masses noted. Patient denies
tenderness on palpation. No lumps or nodules noted on palpitation. Lymph nodes not palpable in
axillary lymph nodes.

Chest/Lungs (Respiratory):
Patient sitting in an upright position. No dyspnea, no retractions, no tripoding noted..
Respirations are 16, equal. Ap is less than lateral. Trachea is midline, substernal notch and angle
of louis present. Skin color is normal for ethnicity, no cyanosis noted. No clubbing noted. Breath
sound clear to auscultation, no adventitious breath sounds noted. Excursion symmetrical. Tactile
fremitus symmetrical. Percussion resonant. No crepitus noted. Vocal resonance present.

Heart (Cardiac):
Patient sitting upright in chair. Apical impulse is seen in fifth left intercostal space, apex, sternal
boarder and sternum identified. Precordium inspected, compared with carotid artery. Apical
impulse felt, no heaves/lifts noted. No thrill in base of heart. Apical, pulmonic, erb’s point,
tricuspid and mitral heart sounds with s1/s2 present. No gallop. No murmurs auscultated.

Blood Vessels (Peripheral Vascular):

Pulses palpated, +2 amplitude of carotid, brachial, radial, femoral, popliteal, dorsalis pedis,
posterior tibial arteries. Arteries symmetrical, contour is smooth, heart rate and rhythm equal. No
bruit heard over carotid, subclavian, abdominal aortal, renal, iliac, femoral arteries. No pain,
fatigue, cramps, claudication does not appear present. Capillary refill <3 seconds on bilateral
upper and lower extremities. No pain, pulselessness, paresthesia, paralysis, pallor,
poikilothermic. JVD not present. No redness, edema, or varicose veins on extremities noted.
Able to move all extremities appropriately.

Abdomen:
Abdomen soft, nondistended. Patient denies abdominal pain, or changes in bowel function. No
jaundice, cyanosis, no ascites noted. No bruises, redness. Skin color is appropriate for ethnicity,
unable to assess venous network. On inspection, no striae, lesions, nodules. Contour remains
smooth, symmetrical, no budges or masses appeared. No superficial wall masses seen or hernias
felt while examining rectus abdominus, smooth even movements of abdomen examined with
respirations. Borborygmi sounds auscultated in all four abdominal quadrants. Friction rubs not
heard. Soft, continuous venous hum heard over umbilicus. Tymphany and dullness felt on
percussion of all four quadrants. Liver measured at 6cm. No splenomegaly. bilateral kidneys
percussed over costovertebral angle. No guarding, rigidity, tenderness, or masses noted on light,
moderate, and deep palpation. Umbilical ring free of bulges, nodules, granulation. Liver palpated
at 11th rib, no hepatomegaly. Unable to palpate gallbladder, spleen. No CVT present over
bilateral kidneys . No bruits auscultated over abdominal arteries.

Neurological:
Patient alert and oriented. Speech clear, swallow present. No tremors noted. Cranial nerves I
through XII intact x12. Patient has no involuntary movements. Coordination and fine motor
skills present with no difficulty. Moves all extremities appropriately. Negative Romberg sign.
Proper gait sequence, simulates arms movements appropriately. Smooth, regular
rhythm/symmetric stride length. Sensory function intact and response appropriately. Cortical
sensory responses intact and appropriate. Abdominal reflex present in all four quadrants. Plantar
reflex present in bilateral toes. No Babinski sign, bilaterally. Bilateral bicep reflex 2+. Bilateral
brachioradialis reflex 2+. Bilateral Triceps reflex 2+, bilateral patellar reflex 2+, bilateral
Achilles reflex 2+, no ankle clonus, bilaterally.

Musculoskeletal:
Upon entry to exam, patient’s gait is noted to be equal, no inappropriate rising of extremities,
equal strides, balance present. Patient able to stand erect, even contour of shoulders, bilateral
scapulae level. Head is aligned over gluteal folds, extremities aligned. No crepitus, skin
discoloration, pain. Firm muscle tone. Phalangeal creases present, joints smooth, no nodules,
swelling body, tenderness. No masses noted. Hand and wrist symmetrical movement. Hand and
wrist range of motion 5/5. No signs of carpal tunnel. Bilateral elbows inspected noting
symmetry, no deviations between humerus/radius, No nodules, no gout. No tenderness, swelling,
thickening of synovial joint on palpation. Range of motion 5/5 bilateral. Temporomandibular
joint assessed with proper gliding motion. Patient denies pain. Natural S-curve inspected on
spine examination. No sign of step-off noted. Cervical spine appropriately concaved, thoracic
spine appropriately convex. Lumbar spine appropriately concaved. No lordosis, kyphosis,
scoliosis. No spasms or pain on vertebral palpation. No limb length discrepancy, no crepitus, no
tenderness. Range of motion 5/5. Appropriately range of motion. No pain or tenderness, with
flexion, extension, lateral and medial movements. Bilateral knee symmetrical, no bulges, masses,
crepitus, or cysts noted. Natural concavities noted. Range of motion 5/5. Bilateral feet five toes
each, proper alignment. Appropriate contour and alignment with tibia on weight baring and non-
weight baring. Range of motion 5/5.

Male Genitalia:
Genital hair coarse, abundant in public region, continuing to umbilicus. Dorsal vein present on
penis. Patient uncircumcised. Foreskin retracts easily, no smegma or signs of phimosis. External
meatus appears slit like, no pinpoint. Opening pink, glistening. No signs of redness, discharge.
Patient denies tenderness, induration or discharge on penile shaft. Penile texture is soft, free of
nodularity. No inflammation, no lumps, no edema of scrotal skin. Scrotum asymmetrical, left
testicle > right testicle. No bulges, no signs of herniation, bilaterally. Testes appropriately
sensitive, smooth, rubbery. No nodules. Epididymis smooth, nontender. Vas deferens smooth, no
lumps palpated. Cremasteric reflex present. Deferred prostate exam.

Psychological/Mini Mental Exam:

Patient appears to be speaking in full, coherent sentences. Patient is able to accurately state his
name, birthday, year, as well as the season. Patient is able to recall three words (penny, apple,
watch). Patient is able to spell ‘world’ backwards. Patient is able to draw two pentagons and
overlap them. Patient is able to read a sentence, write a sentence, follow a sentence. Patient is
able to identify objects showed to him. Patient is able to follow a multi-step command. Patient is
able to answer questions appropriately. Patient demonstrates adequate awareness and orientation.
MME 30/30.