The Head to Toe Assessment Essay

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Pages: 9

The Head to Toe Assessment
Principles of Assessment for RN’s

Edward is a 45 year old male who is present today for his Annual Physical Examination. He is asymptomatic and has no complaints.
History: The patient has a history of Chicken Pox at 5 years old. He has been a smoker for 25 years and currently smokes 2 packs a day. He consumes alcohol daily 2-4 glasses of wine. He reports of history of depression and anxiety 3 years ago after separating from his wife. His is not currently on any medications. He also has a history of a positive TB skin test with no active disease. The patient spent 15 years in the military traveling overseas. He had right rotator cuff surgery 10 years ago.
Objective: Head to toe Assessment:
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Uvula rises when he says ‘ahh’. Tonsils are present and 1+. He is able to stick his tong straight out so cranial nerve XII is intact.
The cervical lymph nodes are unremarkable. He has full range of motion, no lumps or swelling the lymph nodes is not enlarged or tender. I asked the patient to lift his neck and swallow while I was palpating the midline of the tracheal area and there was no enlargement of the thyroid. The carotid pulses were palpable bilaterally. Using a stethoscope for auscultation there was not bruit present. Jugular venous pressure (JVP) was tested by putting the patient in a 45 degree angle and watching for the jugular vein to fill. JVP was 3 cm.
Chest Anterior and Heart
With the stethoscope I was able to listen to heart sounds, Heart beat is 77 and regular with audible murmur. The bell of the stethoscope was used to check for heart murmur. There is no patient history of heart disease. No tenderness or lumps noted on palpation. Supporting the patients arms the axillary region and the epitrochlear areas were also palpated and unremarkable. Blood pressure is 155/88. I would recommend that the patient return for a follow up visit to have his blood pressure monitored. I would also recommend that he monitor his pressure at home for one week and keep a record to bring with him to his next visit. Apical pulses were equal and