Brief Head to Toe Assessment Notes

Vital Signs: The patient presented with a temperature of 37.2°C, pulse rate of 78 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 120/80 mmHg, and oxygen saturation of 98% on room air. The patient was alert and oriented, with a pain score of 2 out of 10, indicating mild discomfort. HEENT (Head, Eyes, Ears, Nose, Throat): Examination revealed a symmetrical scalp with no lesions. Pupils were equal, round, and reactive to light and accommodation. Conjunctivae were clear, and vision was intact. Hearing was normal bilaterally. The nasal passages were clear without congestion or drainage. Oral mucosa was moist, and the pharynx was non-erythematous with no tonsillar enlargement. Respiratory: The patient exhibited a regular respiratory rate and rhythm with no use of accessory muscles. Breath sounds were clear on auscultation bilaterally, and there were no signs of respiratory distress such as dyspnoea, wheezing, or coughing. Chest symmetry and air entry were normal. Cardiac: The cardiovascular assessment showed a regular heart rate and rhythm with no murmurs, gallops, or rubs. Peripheral pulses were palpable and strong, with a capillary refill time of less than 2 seconds. There were no signs of circulatory compromise such as cyanosis, oedema, or pallor. Abdominal: The abdomen was soft and non-tender with normal bowel sounds present in all quadrants. There was no distension or palpable masses. No surgical scars or stomas were noted. Musculoskeletal: The patient demonstrated full range of motion in all joints with no tenderness or swelling. There were no gross deformities, and limb symmetry was maintained. Gait was steady, and balance was intact. Skin: Skin inspection revealed normal colour and temperature with no excessive moisture. Skin integrity was intact with no rashes, lesions, bruising, or pressure areas observed. There were no wounds present.