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a Head to toe Medical Assessment

It is an assessment done at a patient’s admission and is used to determine the hemodynamic context and the patient’s status. The assessment includes checks of all body systems, and findings will show the doctor or nurse the patient’s overall condition. However, unusual findings will assist healthcare professionals in taking necessary action to solve that effect on the patient’s body system. Therefore, physical examination includes collecting objective data using techniques of palpation, inspection, auscultations, and percussion. (Giddens and Wilson 2013). Therefore, this paper entails the physical assessment I would perform on the patient who visited the health care center, the assessment process, and the findings collected from the patient.

There is safety consideration that I will take into account regarding the policy of the health center (hospital), these are: I will perform on my hand’s hygiene, check the room to contact precaution, I introduce myself to the patient. I confirm the patient’s identity by observing his ID. Then, I explain the process to the patient. I organize myself for assessment, and I use appropriate questioning and listening skills, I assure the patient’s dignity, and privacy is secret. I will apply all the principles of safety and asepsis, check for vital signs, and finally. I will completely focus on assessment. In the delineate system of the healthcare organization, the assessment will be limited to the organization’s policy. Therefore I will follow all the regulation and the policy of the organization when interacting with the patient.

In case there is no equipment to perform my assessment, I will use the available method for that illness that will help me get results. For example, I will palpate the body of the patient to see if the patient feels my touch. Also, body temperature can be estimated by touching the patient. Although I may not get an exact temperature measurement, I will discover if the patient’s temperature is high by touching him. Other symptoms of the illness are observable, such as shivering when the patient feels cold. Therefore in case, there is no possible equipment I will use the observable method to assess the patient to get the detail of his or her condition or status.

The following is some of the assessment done of the patient and a record of the abnormal and normal findings based on my assessment. Therefore, the normal findings of the patient’s condition are as follows. The patient’s general appearance is observed if the patient can move, is clean, or has other unusual behavior. These are symptoms that can be inspected by observation. In a normal appearance, the patient should be clean, he is not experiencing anxiety, and he is mobile. Therefore, some of the actual assessments that I did on the patient are as follows:

The assessment was on the patient’s head to identify if there was any problem with his head or other components of the head.

The normal finding on the skull was round with prominences in the occipital and frontal areas. There was no tenderness noted by palpation. The client was lighter in color than the complexion. It looks like moisture. A scar was noted due to a cut injury. The client’s scalp was free from nits, dandruff, and lice. Noted no lesion and no masses or tenderness was experienced on palpation. The client’s hair was observed to be brown. There was no evidence of alopecia because the hair was evenly distributed on the whole scalp. Their hair was thin and smooth.

The sensory function of the trigeminal is that I request the client to close her eyes, then I run a cotton wisp over her forehead and jaw and check on both sides of her face, asking her if she feels it and at what particular point she feels it. I then checked for corneal reflexes using a cotton wisp. The normal response to all that should be blinking.

The normal finding of the client’s face is round, and the face is symmetrical. There was no involuntary muscle movement. The client can move facial muscles at her will. She has intact cranial nerves.

The abnormal finding on the patient is the unusual thing the patient experiences on his or her body. This experience can be observable like swelling part of the body, or the patient feels pain on some part of the body. In this situation, I will examine the cause of the problem by asking the patient some questions, such as when the problem started. How are you feeling? Did you take some drugs when the problem began? This conversation will assist me in identifying the status of the patient’s illness. After the useful conversation, I will assess the illness in the laboratory by examining the sample from the patient body in a laboratory. Tests in the laboratory will show the main cause of the problem, and I will analyze the treatment measures to take so that the patient is healed.

The age of the patient is a very important consideration when dealing with the patient. Some of the diseases are common to people at a certain age. According to the assessment people from the age of thirty-five years are likely to experience cancer in their body. Therefore, a proper assessment of the patient at this age is needed to know their status. For proper assessment of the patient’s health problem, health screening is one of the better methods to diagnose the health of the patient by blood testing. Health screening will assist me in identifying some of the abnormalities the patient is experiencing in his or her body. Therefore, it provides essential information for diagnosis, treatment, and preventive measures that should be taken for the disease. Frequent health screening for healthy persons assists in detecting some developing illnesses at an early stage, which makes the treatment of the illness more effective than when the disease is discovered at a later stage. For example, when I assess an individual with cancer at its starting stage, it can be treated, and the person becomes healed when discovering cancer at its later stage where it has developed more harm in the body. It may be treated, but its effect remains in the body.

It is essential for an individual to analyze his or her life to know where the problem in his or her life is. To reduce risk in the body, the patient should change his or her lifestyle. In some cases, some of the illness is developed by our lifestyle and the diet we normally use every day. For example, excess use of red meat can lead to illness. Therefore, it’s important that the patient changes to a proper diet so that his body remains healthy. The other method to reduce the risk of the disease is by immunization. Immunization is the process in which the individual is immune or made resistant to the influence of certain diseases by providing a vaccine. Therefore, the vaccine stimulates the body’s immune system to defend the individual against disease. Therefore I advise the patient I assess to take the vaccine if they did not take so that his body will be defended from subsequent infection. Immunization is the proper way and tool to eliminate and protect life-threatening infections in the human body.

There are many normal findings when I assess the patient, but the letter stage becomes abnormal for the exam of the patient who experiences shivering in the morning. It may be a normal finding because of the cold hours of the day. However, during the daytime when the solar radiation is hot, the individual may still experience shivering. This shows an abnormal finding of the individual. Therefore, a medical check of the patient is important to know the cause of the problem. At this moment, a blood test is essential to diagnose the cause of the shivering. This is done in the laboratory using medical tools and substances. The result of the assessment in the laboratory will be used to treat the patient by providing proper treatment methods.

Every disease has different symptoms that make it uniquely identified in the medical field. The symptoms are general to all diseases but appear in different ways. For example, shivering is an abnormal finding that may be caused by different illnesses. In my assessment, the patient experienced shivering because of the malaria illness. After the blood test, the patient was identified to be suffering from malaria. However, another disease has the same symptoms as asthma, yellow fever, and others. Therefore it’s important to assess the disease correctly before treating it. Otherwise, the patient may be treated with the wrong disease.

The Plan to Care

This is the strategy developed and followed by the medical profession in caring for patients. It has a well-defined flow of activities from when the patient enters the health center to when he or she leaves. Therefore, the plan I use in this assessment is as follows:

Patient assessment: At this point, essential details of the patient are taken. Also, the patient illustrates his problem to the nurse or doctor. The assessment is based on the following abilities: emotional, physical, functional, age relation, psychosocial, and cognitive. This will give the correct condition of the patient and resemble the symptoms that the patient observes in his body.

Medical test: This is the second step, where the patient’s sample is taken to the laboratory to be examined. This test will provide a result regarding the cause of the disease and the extent of the illness. Therefore, medical tests give full identification of the disease.

Treatment: After the disease is identified, proper treatment begins on the patient. The doctor instructs the patient on drugs to take for his healing

The intervention process between the doctor and the patient is documented in the healthcare record for future reference

The age of the patient is considered in the promotion of his health because it gives the doctor the correct dose the patient is required to take for that illness. A difference in age varies the number of drugs the patient should take.

Pharmacology treatment of the patient is important as it deals with identifying the illness in the patient and treating it using the correct drugs that will heal the illness on the body of the patient.


KM, F. (1999). Does the physical examination have a future? Canadian Medical Association Journal.

Krogsbøll, L. T., & Jørgensen, K. (2012). General health checks in the adults for reducing morbidity and mortality from the disease.

McAlister FA, S. S. (2000). High marks for the physical exam. Canadian Medical Association Journal.

Vera, M. (2012). Ultimate Guide to Head-to-Toe Physical Assessment. Fundamentals of Nursing.



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