Essentials Of Pathophysiology Head to Toe Assessment

Head to Toe Assessment 1 Head to Toe Assessment Head to Toe assessment background for final patient Head to Toe Assessment 2 George Whitelake Client: 62 y/o male, 175# 6’1” VS: BP 120/80, HR 65, R 16, O2 sat 98% Temperature 97.6 F Allergies: PCN, bees Medication: daily MV, iron supplement, and Motrin PRN pain Hx: Had tonsils removed as a child related to multiple ear and throat infections, twisted his right knee tripping over a tree root when hiking last week not fully recovered. Has a runny nose and sneezing on an off for the past 2 days. Just came back from a trip in South America and has not had a bowel movement for 2 days. Pain: Right shoulder related to fall; states he fell against a tree (scale 3-10) and abdominal discomfort. Background: wears glasses for distance, has a girlfriend and a Labrador, hobbies are hiking and swimming. Nutrition: low protein diet but likes an occasional steak, eats mostly organic vegetables and fruit, drinks water, fruit juice and coffee (for breakfast). Family History: He was adopted as a baby, and he is researching his history. History: Retired marine, served in Afghanistan, and works part-time as a Japanese liaison for the military. 1. General survey (appearance & mental status) (1 pts) Vital signs: BP 120/80, HR 65, R 16, O2 sat 98% Temperature 97.6 F G.W. is a 62 year old male who appears stated age, not currently under the influence of alcohol or other drugs.G.W. level of consciousness is a 3+, who articulates clearly and Head to Toe Assessment 3 posture and hygiene is appropriate. 2. HEENT (head, ears, eyes, nose, throat) and neck (5pts) Normocephalic, no lesions, bumps or parasites. Hair distribution quality is appropriate. Face is symmetric with no weakness or involuntary movements. CN V and Vll are intact. Acuity by snellen chart: 20/20: left eye with glasses. 20/20 -2 right eye with glasses. Visual fields full of confrontation. CN ll intact. PERRLA. Conjunctiva clear. Pupils: 3mm resting, 2 mm constricted and equal bilaterally. G.W. pinna shows no discharge, lesions or excessive cerumen. CN Vlll intact on both left and right ear. Nose: Discharge present, mucous membrane irritated no deviations in shape. Nasal patency performed with ese in both nostrils. CN l intact. Mouth: Mucosa and gingiva pink no lesions present. No bleeding or the gums. Two cavity repairs on the lower right side. Tonsils 0. Tongue present in the midline, CN Xll intact. Uvula rises with phonation, CN X and IX intact. Neck supple with full ROM CN Xl intact. Symmetric; no masses, tenderness, lymphadenopathy. Trachea midline. Thyroid nonpalpable, not tender. Carotid arteries 2+ and = bilaterally; no bruits. 3. Thorax, lung, and back (2pts) Normal spinal profile; no scoliosis. No tenderness over spine; no CVA tenderness. 1.2 ratio with comparison of anteroposterior to transverse diameter. Chest expansion is symmetric. Tactile fremitus equals bilaterally. Lung fields resonant. Breath sounds diminished bilaterally. Expiratory rales and slight wheeze in the anterior chest bilateral. Cleared when coughing. 4. Heart and Central vessels (1.5pts) Carotid pulsations are normal. No bruits. S1 and S2 impulses are not diminished or accentuated, no S3 or S4. Diastolic murmur. 5. Gastrointestinal & genitourinary (1.5pts) Abdomen is flat symmetric. Bowel sounds hypoactive. Tenderness and discomfort in lower right and left quadrants. No inguinal lymphadenopathy. 6. Musculoskeletal, neurologic & peripheral vascular assessment (5pts) Skin color appropriate to ethnicity, no redness or cyanosis. Body temperature is symmetrical. Scar on left knee and shoulder from military history. No edema. Particle ROM on Right arm and knee with tenderness on the right knee from a twisted fall. Romberg test negative. Limp when walking. Capillary refills on all 10 fingers and toes. All extremities show strength. Deep tendon reflexes intact. Pulses are symmetric and produce the same strength. Head to Toe Assessment 7. Potential and actual risk: detailed description of one actual and one potential risk based on assessment findings and reason for selection. (4pts) G.W. is at potential risk for chronic constipation. Due to his recent travels, abdominal pain and not using the bathroom in 2 days it could put him at a potential risk for chronic constipation. G.W. is at actual risk for pain in his right shoulder. G.W. falling agsant a tree has led to a 3/10 actual body pain. 4