General Head to Toe Physical Assessment Notes

Overview & History: The patient, a 45-year-old female, presented with complaints of persistent fatigue and occasional dizziness over the past month. She has a history of hypertension and hyperlipidemia, managed with medication. Recently, she reported a decrease in energy levels and difficulty concentrating. No recent changes in medication or lifestyle were noted. Hair, Skin & Nails: The patient's skin appeared pale with a slightly dry texture. No rashes, lesions, or pressure injuries were observed. Hair distribution was normal, and nails were intact with no signs of clubbing or cyanosis. Head & Neck: The head was symmetrical with no visible abnormalities. Facial movements were normal, and there was no tenderness upon palpation. Lymph nodes were non-palpable, and the neck exhibited a full range of motion without stiffness. Eyes & Vision: The eyes were aligned, and pupils were equal, round, and reactive to light. Conjunctiva was clear, and visual acuity was 20/20 with corrective lenses. Ears: The ear canals were clear with no wax build-up or discharge. Hearing was intact bilaterally, and tympanic membranes appeared normal. Nose & Sinus: Nasal mucosa was moist and pink, with no septum deviation or discharge. Sinus areas were non-tender upon palpation. Mouth & Throat: Lips, teeth, and gums were in good condition. The tongue and palate appeared normal, and the uvula was midline. Tonsils were not enlarged, and there was no odour. Swallowing was normal without discomfort. Thoracic – Cardiovascular, Respiratory, Breasts, Lymph: Heart sounds were regular with no murmurs. Peripheral pulses were strong, and capillary refill was less than 2 seconds. Respiratory rate was normal, with clear breath sounds and no wheezing or crackles. Breasts were symmetrical with no lumps or skin changes. Lymph nodes in the axillary and supraclavicular regions were non-tender and non-palpable. Abdomen: The abdomen was soft and non-tender with normal bowel sounds. No distension, organ enlargement, or masses were noted. There were no surgical scars or hernias. Genitourinary: Urination patterns were normal with no incontinence or discharge. No reproductive organ examination was indicated. Rectum: A digital rectal examination was not performed, and no abnormalities were reported. Extremities and Musculoskeletal System: Extremities were symmetrical with no swelling or deformities. Muscle strength and range of motion were normal. Gait was steady, and there were no signs of inflammation or joint tenderness. Neurological: The patient was alert and oriented to person, place, and time. Cranial nerve function was intact, reflexes were normal, and coordination was good. Motor strength and sensory response were within normal limits.