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    This Study Resource Was: Head-To - Toe Assessment Documentation Sample

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    A Sung
    A 25-year-old female presented with right ankle pain rated 2/10. Vital signs were normal. Physical exam found warm skin with freckles, pink nails, symmetric breathing, clear lungs, regular heart sounds, soft abdomen, full range of motion, 5/5 strength, and normal reflexes.

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    This Study Resource Was: Head-To - Toe Assessment Documentation Sample

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    A Sung
    6K views2 pages
    A 25-year-old female presented with right ankle pain rated 2/10. Vital signs were normal. Physical exam found warm skin with freckles, pink nails, symmetric breathing, clear lungs, regular heart sounds, soft abdomen, full range of motion, 5/5 strength, and normal reflexes.

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    HA_Head_to_toe_narrative_Sample__1_.docx

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    A 25-year-old female presented with right ankle pain rated 2/10. Vital signs were normal. Physical exam found warm skin with freckles, pink nails, symmetric breathing, clear lungs, regular heart sounds, soft abdomen, full range of motion, 5/5 strength, and normal reflexes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6K views2 pages

    This Study Resource Was: Head-To - Toe Assessment Documentation Sample

    Uploaded by

    A Sung
    A 25-year-old female presented with right ankle pain rated 2/10. Vital signs were normal. Physical exam found warm skin with freckles, pink nails, symmetric breathing, clear lungs, regular heart sounds, soft abdomen, full range of motion, 5/5 strength, and normal reflexes.

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    Head- to -Toe Assessment Documentation Sample

    25 year old white female. Vital signs: BP 126/82, P 78, R 20, T 98.8°F temporal, O2 sat 98% on
    room air. Patient reports pain in the right ankle, 2/10.

    General Survey: Alert, oriented X 4 (can also write it out if you want as oriented to person, place,
    and time. If abnormal could write something like-oriented to person only OR oriented to person
    and place, not oriented to time, believes it is 1996). Speech is clear and appropriate. Upright
    posture, good hygiene. Positive affect (affect is how the patient appears to others), states she is in
    a good mood (mood is subjective, it is what the patient is feeling. Affect and mood may actually
    contradict each other).

    Skin: warm, no lesions, multiple freckles over face, chest, and arms. Hair is clean, no lice or nits.

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    Nails are pink, well cared for, capillary refill less than 3 seconds in fingers and toes.

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    HEENT: Face is symmetric. Eyes with no redness or discharge. Pupils are 3 mm, PERRLA.

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    Extraocular eye movements intact. Visual fields by confrontation intact. Oral mucosa is moist, no

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    lesions or erythema. Teeth in good repair (this means there are fillings. You could also say teeth
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    clean and intact or if they are missing teeth in an area state that.) Uvula midline, tongue straight.
    ou urc
    No difficulty swallowing. Nose with discharge, nares patent, no deviations noted. Ears are
    aligned with eyes, no excess cerumen or discharge seen in external canal, no lesions, able to hear
    o

    whisper (or finger rubbing) without difficulty. (Could also say CN II-XII intact since you will
    aC s

    have tested those instead of the detailed version.). Lymph nodes of head and neck nonpalpable,
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    nontender.

    Thorax & Lung: Symmetric thorax, AP to lateral ratio 1:2. Respirations 20, regular, no accessory
    muscle use, regular depth (this could also be deep or shallow). Spine straight. Thoracic
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    expansion symmetric. Lungs clear in all fields.


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    Heart: Carotid pulses 2+, symmetric. Regular heart sounds, S1, S2, no other sounds.
    is

    GI/GU: Abdomen flat, normoactive bowel sounds X 4, no distention or tenderness on palpation,


    last BM this morning, brown, soft. Urinating without difficulty, clear yellow.
    Th

    MS/Neuro/Peripheral Vascular: Extremities without deformity. Even regular gait, Romberg


    negative. Full range of motion of neck, arms, and legs. Strength 5/5 in all extremities (this is a
    sh

    subjective measurement as 5/5 will vary from person to person-like a strong male vs an average
    female; think of 1/5 as being extremely little ability to press against you and then increasing
    effort from there but a normal person would be 5/5. It is also a comparison as one side may be
    weak and other normal). Able to detect light touch throughout. Radial, brachial, popliteal,
    posterior tibial, dorsalis pedis pulses all 2+ and symmetric. Biceps, triceps, brachioradialis,
    patellar reflexes 2+ bilaterally, negative Babinski, no ankle clonus.

    This study source was downloaded by 100000817788283 from CourseHero.com on 04-28-2021 19:00:19 GMT -05:00

    https://www.coursehero.com/file/38534506/HA-Head-to-toe-narrative-Sample-1docx/
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    This study source was downloaded by 100000817788283 from CourseHero.com on 04-28-2021 19:00:19 GMT -05:00

    https://www.coursehero.com/file/38534506/HA-Head-to-toe-narrative-Sample-1docx/
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