Head To Toe Assessment Example (Sample)

Seeing an example of a completed document, like an assessment tool, can be the best way to learn how to complete the form correctly. In this Head To Toe assessment example, Mark Julian Andrews, a 45-year-old male construction worker, complained of shortness of breath and chest pain. After examining the patient from head to toe, the doctor determined that everything was normal: the heart rate was regular, the breath sounds from the lungs were audible, and the peripheral pulses were strong and evenly distributed. Additionally, the patient had no edema in the lower extremities and showed normal reflexes and mental status. Although mild erythema was observed in the pharynx, there were no signs of infection or abnormalities in the genitalia, and the urine test was normal. Based on the results, the healthcare professional may conclude that Mark is in overall good health. However, since the patient presented with chest pain and shortness of breath, the healthcare professional may recommend further tests or referrals to a specialist to determine the cause of the symptoms and provide appropriate treatment.

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