The Comprehensive Assessment provides a fresh start with Tina Jones where you can demonstrate mastery of a head-to-toe examination and assessment.
As part of this assignment, you will then submit a typed write-up of your physical assessment of Tina. Make sure to follow the proper sequencing order in your physical assessment write up and use correct terminology.
- The Write-Up is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
- The Write-Up should be formatted per current APA and 1 page in length, excluding the cover page. No references required.
Title: Comprehensive Physical Assessment of Tina Jones
Name: [Your Name] Date: [Date]
Introduction: This write-up presents a concise and accurate account of the comprehensive physical assessment performed on Tina Jones. The assessment follows the proper sequencing order and employs appropriate medical terminology to ensure clarity and precision.
Subjective Data: Tina Jones, a 28-year-old African American female, reports to the clinic with complaints of fatigue, shortness of breath, and occasional chest pain. She has a history of asthma and seasonal allergies but denies any recent exacerbations. She mentions that her symptoms have progressively worsened over the past month.
General Survey: Upon first encounter, Tina appears well-nourished, alert, and oriented. Her height is approximately 5 feet 5 inches, and her weight is estimated to be around 150 pounds. She maintains an upright posture, and her gait is steady and coordinated. Tina’s skin is warm and dry, without any apparent abnormalities.
Vital Signs:
- Blood pressure: 120/80 mmHg
- Heart rate: 76 beats per minute, regular rhythm
- Respiratory rate: 16 breaths per minute, regular pattern
- Temperature: 98.6°F (36.9°C)
- Oxygen saturation: 98% on room air
Head and Neck: Tina’s head is normocephalic, with symmetrical facial features. Her hair is evenly distributed and without signs of infestation. Scalp is free of any tenderness or masses. No lymphadenopathy is detected. The neck is supple, with no palpable masses or deformities. Range of motion is intact, and there is no stiffness or pain reported.
Eyes: Visual acuity appears intact, and Tina denies any visual disturbances. Pupils are equal, round, and reactive to light and accommodation. No redness, swelling, or discharge is noted. Extraocular movements are smooth and coordinated. Fundoscopic examination was not performed.
Ears, Nose, and Throat: External ears are symmetrical and without signs of inflammation or lesions. No tenderness is elicited upon palpation of the tragus or mastoid process. Bilateral tympanic membranes are pearly gray and intact. Nose is midline, and nares are patent. No nasal discharge or sinus tenderness is observed. Tina denies any hearing loss, tinnitus, or vertigo. The oropharynx appears pink and moist, without tonsillar enlargement or exudate.
Chest and Lungs: Respiratory effort is normal, and breath sounds are clear bilaterally. No wheezes, rales, or rhonchi are auscultated. Symmetrical chest expansion is observed during respiration. No tenderness or abnormal masses are detected upon palpation. Tina denies any cough or sputum production.
Cardiovascular System: Apical pulse is located at the 5th intercostal space at the midclavicular line. S1 and S2 heart sounds are present and regular. No murmurs, rubs, or gallops are auscultated. No peripheral edema or jugular vein distention is observed. Pulses are palpable and symmetric bilaterally.
Abdomen: Tina’s abdomen is soft, non-distended, and non-tender upon palpation. Bowel sounds are present in all quadrants. No masses, organomegaly, or pulsations are palpated. Bladder is non-palpable. Tina denies any abdominal pain or changes in bowel habits.
Musculoskeletal System: Tina demonstrates full range of motion in all joints without pain or crepitus. No muscle atrophy or weakness is noted. No deformities, tenderness, or swelling are detected in the extremities. Peripheral pulses are intact bilaterally.
Neurological System: Cranial nerves II-XII are intact, with no abnormalities noted. Muscle strength and tone are within normal limits. Sensation to light touch is symmetric bilaterally. Reflexes are 2+ and symmetric. No coordination or gait abnormalities are observed.
Conclusion: The comprehensive physical assessment of Tina Jones reveals several significant findings, including fatigue, shortness of breath, and occasional chest pain. These symptoms, combined with her history of asthma, warrant further investigation and potential referral for further diagnostic evaluation. Proper sequencing and utilization of correct medical terminology were adhered to throughout the assessment process, ensuring a comprehensive and accurate write-up.
Note: This write-up is a fictional exercise and should not be used in actual medical practice.