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Posted: October 31st, 2023
COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
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SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
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Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
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Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
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Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
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Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
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Comprehensive Assessment SH Transcript, Sub, Obj & Documentation
Transcript
Hello, my name is . I will be conducting an interview and later perform a physical exam. Hey.
What is your name? Tina Jones
Your date of birth? February 17th.
How old are you? I’m 28.
What brought you into the clinic today? I came in because I’m required to have a recent physical exam for the health insurance at my new
job.
Do you have any current health problem? I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both
of those are under control. I’m taking good care of my health these days.
What is your new job? I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more
experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–
I’m really excited!
That is great. Empathize
Thanks.
When was your last physical exam? Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came
in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
What did your gynecologist say?
She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it
seems to be helping things.
How often do you take birth control? I take it every morning, with breakfast.
What is the name of the birth control pill you took? They’re called Yaz.
Has your menstrual cycle improved since taking Yaz? Now that I’m on the pill I’m getting my period every month.
That is great. I am glad you are having your period every month. Empathize
Thanks.
How long have you had asthma. I’ve had asthma a long time. . . since I was really little.
What age were you diagnosed with asthma? My doctor told me when I was pretty little… I think I was about two and a half? I used
to have a lot of trouble with asthma attacks back then.
______________________
Comprehensive Physical Assessment: A Head-to-Toe Examination
A comprehensive physical assessment, also known as a head-to-toe examination, is an important part of primary care. By gathering both subjective and objective health data, providers can identify any existing medical conditions, monitor chronic illnesses, screen for new issues, and ensure patients are up-to-date on preventive care. This paper will outline the components of a thorough physical exam based on the case of a 28-year-old female patient.
Subjective Data
The subjective portion involves collecting the patient's chief complaint, history of present illness, past medical and surgical histories, medications, allergies, social history, and a review of systems. In this case, the chief complaint was a required physical for new health insurance. Her history was notable for well-controlled asthma and diabetes diagnosed in childhood. She took metformin and oral contraceptive Yaz daily. No significant family history or allergies were reported.
Objective Exam
Vital signs provide an initial assessment of physiological status. The patient's temperature, pulse, respirations, and blood pressure were all within normal limits (1). A general exam found her to be well-nourished and in no distress. Head, eye, ear, nose, and throat exam revealed no abnormalities. The neck was supple without lymphadenopathy. Lung auscultation was clear bilaterally. Cardiac exam found a regular rate and rhythm without murmurs. Abdomen was soft, non-tender, with no organomegaly. Extremities had no edema, clubbing, or cyanosis, and strength and sensation were intact on neurological exam. Skin appeared normal.
Comprehensive exams allow providers to monitor chronic conditions and screen for complications or new issues. For example, diabetes patients should be assessed for signs of neuropathy, nephropathy, or retinopathy (2). Asthma patients may develop wheezing or decreased breath sounds on exam (3). Thyroid, heart, and lung exams help identify underlying causes of metabolic disorders. Well-woman visits incorporate breast and pelvic exams to screen for cancers and infections (4).
Documentation of exam findings provides a baseline for future comparison and demonstrates thorough evaluation. It supports medical decision making and justifies billing (5). Standardized templates like the one used here ensure consistency and comprehensiveness. Subjective and objective data together form the basis for clinical assessment and plan of care.
In conclusion, head-to-toe physical assessments are a core component of primary care practice. They provide an opportunity to address preventive health, manage chronic conditions, identify new problems early, and document the encounter. With regular exams, providers can monitor patients’ health over time, encourage healthy behaviors, and intervene promptly if issues arise.
References
Vital signs. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 40. Available from: https://www.ncbi.nlm.nih.gov/books/NBK351/
Complications of diabetes. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, editors. Williams Textbook of Endocrinology. 13th edition. Philadelphia: Elsevier; 2016. Chapter 34.
Asthma diagnosis and management. American Lung Association. Updated July 2022. https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/diagnosis-and-management
Well-woman visits. Women's Preventive Services Initiative. https://www.womenspreventivehealth.org/recommendations/well-woman-visits
Documentation in the medical record. American Medical Association. https://www.ama-assn.org/practice-management/documentation-medical-records
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