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Head To Toe Assessment Bagus

This document summarizes a head-to-toe assessment of a patient conducted on August 29, 2021. The assessment found the patient was alert and oriented, with normal vital signs. A physical examination identified no abnormalities except for a scar on the right leg. The patient reported sharp pain in the right lower extremity when walking that was relieved by rest.

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618 views2 pages

Head To Toe Assessment Bagus

This document summarizes a head-to-toe assessment of a patient conducted on August 29, 2021. The assessment found the patient was alert and oriented, with normal vital signs. A physical examination identified no abnormalities except for a scar on the right leg. The patient reported sharp pain in the right lower extremity when walking that was relieved by rest.

Uploaded by

syahrudi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Head-to-Toe Assessment Date: August 29, 2021

Assessment conducted by: Bagus Kurnia Hariyadi Time:11.00 Am


LOC
□ Alert □Drowsy □Lethargic Temp vs. trunk (warm / cool)
□Stuporous □Coma Grip equal and strong Yes
Orientation Capillary refill <3 sec Yes
Person Perfect Orientation Vein filling rapid
Place Perfect Orientation
Time Perfect Orientation
Situation Perfect Orientation
Vitals
Temp 36.6 o C □ R 24x / m Neck
BP 112/88 MmHg □ Pulse Ox 100% Lower Extremities
Head Hair present thin and black
Hair Black, Thick, and distributed well Edema Edema not found in both extremities
PERLA Symetris, Right and Left 2,5mm Foot strength
Nose Symetris, without any Alteration Homain's (+ / -) Claudication (+ / -)
Ears Symetris, without any Alteration Temp vs. Trunk (warm / cool)
Mouth Moist texture, soft with normal color Nails □ Yellowed □ Thickened □ Ingrown
o Midline tongue
Perfect positioned
Pedal pulse R(palp / doppler) L(palp / doppler)
o Moist
ROM / Strength
Good Moisture
Upper R Normal □ Upper R Normal
o Lesions
Upper L Normal □ Upper L Normal
No lesions
o Dentition Lower R Normal □ Lower R Normal
Full, without any discoloration and cavity Lower L Normal □ Lower L Normal
Sensation
Carotid pulse 98 tpm □ JVD + □Trachea midline
Chest General Assessment
Apical Pulse 98 tpm □Muffled □Arrhythmia Weight/Height 59kg / 160cm
Breath Sounds - Anterior BM 23,3 Kg/m
Posterior Vesicular Lateral Vesicular Pain Assessment
Chest Symmetry Chest Position perfect without Acute/Chronic □ Intensity (0-10) 2
alteration Location Right Lower Extremity
Skin Turgor (clavicle) Turgor Normal Duration 1-2 minutes
Abdomen Characteristics Sharp pain
Inspection No Lesions found Precipitation Punctured by nails
Auscultation Frequency when walking
o LUQ (active / hyper / absent) Non-verbals Patient walking by one leg
o RUQ (active / hyper / absent) Relief factors take a rest
o LLQ (active / hyper / absent) Sleep patient can sleep well
o RLQ (active / hyper / absent) Skin Assessment
Palpation Description:
Not found any enlargement in size of liver, spleen, Patient skin free from lesion, scar found on the right
kidneys and gallbladder leg and skin turgor normal.

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