Essay on Assessment Write Up

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HEAD-TO-TOE ASSESSMENT WRITE UP SAMPLE
VITAL SIGNS/PSYCHOLOGICAL/NEURO
Patient’s name: M. P
Temperature: 98.5F
Blood pressure: 112/70
Respiratory rate: 16 bpm
Pulse rate: 70 bpm
Patient was oriented of person, place, and time (A&0*3)
Patient appeared erect, with voluntary body movements. Dressing is appropriate for setting and patent appears to be clean and well groomed.
INTERGUMENTARY SYSTEM
Patient’s skin felt dry and warm. No form of nodal enlargement were found. Skin uniformly tan-brown in color, intact. No lesions, edema, swelling. Normal distribution and texture of hair, No clubbing, biting, or discolorations of the nails. Nail beds pink and firm with prompt capillary refill under 2 seconds.
HEAD & HAIR
Patient’s hair is evenly distributed, no form of alopecia was seen, no infestations or lesions were observed
No lumps or masses were palpated on patient’s scalp
FACE
Patient’s face was symmetrical, no facial drooping, lashes and eyebrows are well distributed. Patient reports feeling no pain or tenderness when sinuses were palpated. No periorbital edema
EYES
Patient’s eyes are symmetrical and conjunctiva are clear,white sclera, no lesion or redness.
EARS
No drainage, lesions, or edema were seen in patient’s ears. Pre and post auricular nodes were not palpable

NOSE
Patient reported that she had no form of trauma to nose, no deviated septum or polyps, patent nostrils
MOUTH
No lesions or bleeding, tongue is symmetric and protrudes midline, no tremor. Mucosa and gingivae pink. Pharynx pink, no exudate. Uvula rises in midline, tonsils visible 1+
NECK
Patient was able to perform full range of motion. Neck is symmetric with no masses, or tenderness. No tracheal deviation, no jugular vein distention at 45 degree angle. RESPIRATORY SYSTEM
Chest expansion is symmetric, tactile fremitus bilaterally equal, easy respiratory effort, A-P is less than transverse diameter, no pain reported during palpation of anterior and posterior chest, normal
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