head to toe assessment

Head and Neck Examination

  • Cranial Nerve 7 (CN7) Intact Bilaterally (BL)

    • Inferred through facial expression assessment.

  • Normocephalic and Symmetric

    • Head shape and symmetry observed.

  • Jugular Vein Distention (JVD)

    • Absent.

  • Carotid Pulses

    • Present +2 bilaterally (BL).

    • No bruits detected.

  • Trachea

    • Midline position noted.

  • Lymph Nodes

    • No palpable post auricular, submaxillary, submental, posterior cervical, or supraclavicular lymph nodes present.

  • Cranial Nerve 11 (CN11) Intact Bilaterally

    • Confirmed through shoulder shrug test.

Ears, Nose, and Throat (ENT) Examination

  • Ears

    • Symmetrical appearance.

    • No pain or tenderness observed in:

      • Auricle

      • Tragus

      • Helix

    • No signs of erythema or drainage detected.

  • Nose

    • Midline position.

    • No scars, polyps, or crusting present.

    • No deviated septum noted.

    • Nares are patent (open).

  • Lips

    • Moist, no dryness or cracks observed.

  • Buccal Mucosa

    • Pink and moist appearance.

  • Teeth

    • No cracks, missing teeth, or dental caries observed.

  • Cranial Nerve 9 (CN9) Intact

    • Determined by uvula and soft palate rising midline when the patient says "Ahh".

  • Cranial Nerve 10 (CN10) Intact Bilaterally

    • Confirmed by eliciting gag reflex.

  • Cranial Nerve 12 (CN12) Intact

    • Evidence through tongue protrusion midline.

  • Eyes

    • Symmetrical appearance, conjunctiva pink and moist, sclera white.

    • PERRLA Intact

      • Pupils constrict briskly from 3mm to 2mm.

  • Cranial Nerve 3 (CN3) and Cranial Nerve 4 (CN4) Intact

    • Assessed through six cardinal positions of gaze test.

    • No nystagmus noted.

Cardiovascular Examination

  • Heart Sounds

    • S.S₂ (second heart sound) audible.

  • Heart Rate

    • Regular; 80 beats per minute (BPM).

  • Rhythm

    • Regular.

  • Murmurs

    • None auscultated.

Respiratory Examination

  • Breathing

    • Effortless breathing observed.

  • Respiratory Rate

    • Even and unlabored; 15 breaths per minute (BPM).

  • Chest Shape

    • Elliptical shape noted.

    • Anterior/Posterior diameter noted to be less than lateral diameter.

  • Muscle Tone

    • Anterior and posterior muscle tone symmetrical.

  • Skin Assessment

    • Congruent with ethnicity; no scars, lesions, or tattoos present.

  • Spine

    • Spinous process midline; patient denies tenderness.

  • Lung Sounds

    • Clear to auscultation.

    • No adventitious sounds noted.

  • Landmarks for Auscultation:

    • Anterior: Supraclavicular to 4th rib (4-4)

    • Lateral: Axilla to 6th or 7th rib (2)

    • Posterior: C7 to T10 (8-9 lovers)

General Survey Note

  • Date: 02/07/2026 0800

  • State of Consciousness

    • Awake, alert, and oriented x3 (to person, place, time).

  • Appearance

    • Appears stated age; average body build.

    • Skin color consistent with ethnic background; no signs of acute distress present.

    • Patient is well-nourished, sitting erect with good posture; ambulating without assistive device.

    • Maintains good eye contact throughout the examination.

    • Mood congruent with affect; clothing appropriate for the climate.

Orders

  • Examinations and Assessments:

    • Inspect

    • Palpate

    • Auscultate

    • Percuss (not performed by LPN)

  • Abdominal Examination Procedures:

    • Inspect

    • Auscultate

    • Palpate

    • Percuss (not performed by LPN)

The head and neck examination reveals that cranial nerve 7 (CN7) is intact bilaterally, inferred through facial expression assessment. The head is normocephalic and symmetric, with both head shape and symmetry observed to be normal. There is no jugular vein distention (JVD) present, and carotid pulses are strong and equal bilaterally (BL) with a rating of +2. No bruits were detected. The trachea is positioned midline, and lymph nodes are assessed with no palpable post-auricular, submaxillary, submental, posterior cervical, or supraclavicular nodes present. Cranial nerve 11 (CN11) is also intact bilaterally, confirmed through the shoulder shrug test.

In the ears, nose, and throat (ENT) examination, the ears show a symmetrical appearance with no pain or tenderness observed in the auricle, tragus, or helix. Additionally, there are no signs of erythema or drainage detected. The nose is positioned midline with no scars, polyps, or crusting present, and there is no deviated septum noted; the nares are patent. The lips are moist with no dryness or cracks, and the buccal mucosa appears pink and moist. The teeth are intact with no cracks, missing teeth, or dental caries noted. Cranial nerve 9 (CN9) is intact, determined by the uvula and soft palate rising midline when the patient says "Ahh," while cranial nerve 10 (CN10) is intact bilaterally, confirmed by eliciting the gag reflex. Cranial nerve 12 (CN12) appears intact, evidenced by the tongue protruding midline. The eyes exhibit a symmetrical appearance, with the conjunctiva pink and moist and the sclera white. The pupils react briskly to light, constricting from 3mm to 2mm, indicating that the PERRLA is intact. Both cranial nerve 3 (CN3) and cranial nerve 4 (CN4) are intact, assessed through the six cardinal positions of gaze test, with no nystagmus noted.

The cardiovascular examination shows heart sounds with the second heart sound (S2) audible. The heart rate is regular at 80 beats per minute (BPM) with a regular rhythm, and no murmurs are auscultated. During the respiratory examination, effortless breathing is observed with a respiratory rate of 15 breaths per minute (BPM). The chest shape noted is elliptical, with the anterior/posterior diameter being less than the lateral diameter. Muscle tone is symmetrical in the anterior and posterior sides, and the skin assessment is congruent with the patient's ethnicity, showing no scars, lesions, or tattoos. The spine appears straight, with the spinous process midline, and the patient denies tenderness. Lung sounds are clear upon auscultation, with no adventitious sounds detected. The landmarks for auscultation include anteriorly from the supraclavicular area to the fourth rib, laterally from the axilla to the sixth or seventh rib, and posteriorly from C7 to T10.

In the general survey note dated 02/07/2026 at 0800, the patient is awake, alert, and oriented to person, place, and time. The patient appears to be of stated age with an average body build, and their skin color is consistent with their ethnic background, showing no signs of acute distress. They are well-nourished, sitting erect with good posture, ambulating without any assistive devices and maintaining good eye contact throughout the examination. The mood is congruent with their affect, and the clothing is appropriate for the climate.

Orders for examinations and assessments include inspecting, palpating, auscultating, and percussing, though percussion is not performed by the LPN. The abdominal examination procedures consist of inspecting, auscultating, palpating, and percussing, with percussion also not performed by LPN.