COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
\nWeek 9
\nShadow Health Comprehensive SOAP Note Template<\/p>\n
Patient Initials: _______\t\tAge: _______\t\t\tGender: _______<\/p>\n
SUBJECTIVE DATA:<\/p>\n
Chief Complaint (CC):<\/p>\n
History of Present Illness (HPI):<\/p>\n
Medications:<\/p>\n
Allergies:<\/p>\n
Past Medical History (PMH):<\/p>\n
Past Surgical History (PSH):<\/p>\n
Sexual\/Reproductive History:<\/p>\n
Personal\/Social History:<\/p>\n
Health Maintenance:<\/p>\n
Immunization History:<\/p>\n
Significant Family History:<\/p>\n
Review of Systems:<\/p>\n
General:
\nHEENT:
\nRespiratory:
\nCardiovascular\/Peripheral Vascular:
\nGastrointestinal:
\nGenitourinary:
\nMusculoskeletal:
\nNeurological:
\nPsychiatric:
\nSkin\/hair\/nails:<\/p>\n
OBJECTIVE DATA:<\/p>\n
Physical Exam:
\nVital signs:
\nGeneral:
\nHEENT:
\nNeck:
\nChest\/Lungs:.
\nHeart\/Peripheral Vascular:
\nAbdomen:
\nGenital\/Rectal:
\nMusculoskeletal:
\nNeurological:
\nSkin:<\/p>\n
Diagnostic results:<\/p>\n
ASSESSMENT:<\/p>\n
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.<\/p>\n
Comprehensive Assessment SH Transcript, Sub, Obj & Documentation
\nTranscript
\nHello, my name is . I will be conducting an interview and later perform a physical exam. Hey.
\nWhat is your name? Tina Jones
\nYour date of birth? February 17th.
\nHow old are you? I\u2019m 28.
\nWhat brought you into the clinic today? I came in because I\u2019m required to have a recent physical exam for the health insurance at my new
\njob.
\nDo you have any current health problem? I don\u2019t have anything specific going on today. I mean, I still have asthma and diabetes, but both
\nof those are under control. I\u2019m taking good care of my health these days.
\nWhat is your new job? I\u2019m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I\u2019ll be helping a more
\nexperienced accountant with her clients, and then eventually I\u2019ll get more responsibility, and build my own client list. I start in two weeks\u2013
\nI\u2019m really excited!
\nThat is great. Empathize
\nThanks.
\nWhen was your last physical exam? Let\u2019s see . . . I had two doctor\u2019s appointments earlier this year. About five months ago, I came
\nin here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
\nWhat did your gynecologist say?
\nShe said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it
\nseems to be helping things.
\nHow often do you take birth control? I take it every morning, with breakfast.
\nWhat is the name of the birth control pill you took? They\u2019re called Yaz.
\nHas your menstrual cycle improved since taking Yaz? Now that I\u2019m on the pill I\u2019m getting my period every month.
\nThat is great. I am glad you are having your period every month. Empathize
\nThanks.
\nHow long have you had asthma. I\u2019ve had asthma a long time. . . since I was really little.
\nWhat age were you diagnosed with asthma? My doctor told me when I was pretty little\u2026 I think I was about two and a half? I used
\nto have a lot of trouble with asthma attacks back then.<\/p>\n
______________________
\nComprehensive Physical Assessment: A Head-to-Toe Examination
\nA comprehensive physical assessment, also known as a head-to-toe examination, is an important part of primary care. By gathering both subjective and objective health data, providers can identify any existing medical conditions, monitor chronic illnesses, screen for new issues, and ensure patients are up-to-date on preventive care. This paper will outline the components of a thorough physical exam based on the case of a 28-year-old female patient.
\nSubjective Data
\nThe subjective portion involves collecting the patient’s chief complaint, history of present illness, past medical and surgical histories, medications, allergies, social history, and a review of systems. In this case, the chief complaint was a required physical for new health insurance. Her history was notable for well-controlled asthma and diabetes diagnosed in childhood. She took metformin and oral contraceptive Yaz daily. No significant family history or allergies were reported.
\nObjective Exam
\nVital signs provide an initial assessment of physiological status. The patient’s temperature, pulse, respirations, and blood pressure were all within normal limits (1). A general exam found her to be well-nourished and in no distress. Head, eye, ear, nose, and throat exam revealed no abnormalities. The neck was supple without lymphadenopathy. Lung auscultation was clear bilaterally. Cardiac exam found a regular rate and rhythm without murmurs. Abdomen was soft, non-tender, with no organomegaly. Extremities had no edema, clubbing, or cyanosis, and strength and sensation were intact on neurological exam. Skin appeared normal.
\nComprehensive exams allow providers to monitor chronic conditions and screen for complications or new issues. For example, diabetes patients should be assessed for signs of neuropathy, nephropathy, or retinopathy (2). Asthma patients may develop wheezing or decreased breath sounds on exam (3). Thyroid, heart, and lung exams help identify underlying causes of metabolic disorders. Well-woman visits incorporate breast and pelvic exams to screen for cancers and infections (4).
\nDocumentation of exam findings provides a baseline for future comparison and demonstrates thorough evaluation. It supports medical decision making and justifies billing (5). Standardized templates like the one used here ensure consistency and comprehensiveness. Subjective and objective data together form the basis for clinical assessment and plan of care.
\nIn conclusion, head-to-toe physical assessments are a core component of primary care practice. They provide an opportunity to address preventive health, manage chronic conditions, identify new problems early, and document the encounter. With regular exams, providers can monitor patients\u2019 health over time, encourage healthy behaviors, and intervene promptly if issues arise.
\nReferences
\nVital signs. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 40. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK351\/
\nComplications of diabetes. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, editors. Williams Textbook of Endocrinology. 13th edition. Philadelphia: Elsevier; 2016: 2024 – Do my homework – Help write my assignment online. Chapter 34.
\nAsthma diagnosis and management. American Lung Association. Updated July 2022. https:\/\/www.lung.org\/lung-health-diseases\/lung-disease-lookup\/asthma\/diagnosis-and-management
\nWell-woman visits. Women’s Preventive Services Initiative. https:\/\/www.womenspreventivehealth.org\/recommendations\/well-woman-visits
\nDocumentation in the medical record. American Medical Association. https:\/\/www.ama-assn.org\/practice-management\/documentation-medical-records<\/p>\n","protected":false},"excerpt":{"rendered":"
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