Family history:

The patients stated that they have no family health history.

Head to toe assessment:

1. Head Head is appropriate in the size of the patient’s body, face

is symmetrical and facial expressions is symmetrical, no
drooping of the face on one side.
2. Eyes Able to distinguish colors, the eyes and eyelids are
symmetrical, no swelling or redness around the eyelids,
sclera is white in color, palpebral conjunctiva appears
pink, pupils are equally round and clear, reactive to light
and accommodation; the patient could look
upwards/below/to the left/to the right/diagonally
3. Ears Able to understand and hear spoken language correctly,
no presence of discharge, redness, cerumen, swelling
and foreign bodies, no any tenderness in pinna and
targus during palpation, the tympanic membrane
normally reflects the otoscope’s light.
4. Nose and sinuses Color is the same as the rest of the face, no flaring noted,
able to distinguish the scent of alcohol; the nasal structure
is smooth and symmetric; the client reports no tenderness.
Frontal and maxillary sinuses are no tender to palpation,
and crepitus is evident
5. Mouth Lips are pink in color, complete set of adult teeth and free
from cavities, color of the mucous membranes and gums
are pink and shiny and tongue is moist and pink, tonsils
are not inflamed, uvula is located midline.
6. Neck No deformities, asymmetry, masses, tracheal deviation,
no palpable lymph nodes; thyroid is located midline
below the thyroid cartilage and is normally not visible, no
enlargement noted, trachea is located midline and no
lesions, lumps or enlarged lymph nodes
7. Chest Shape of the chest is side to side symmetrical ,no
crackles, no wheeze, no stridor,
8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI
at 50 ICS LMCL, no murmur noted, no visible pulsations in
the precordium, palpable apical pulse.
9. Breast/Chest Skin color is similar with the rest of the body; nipple is dark
 colored, no discharges. Superior aspect of the breast is
bounded by the clavicle; Breasts that are evenly shaped
without visible distortion or swelling, no redness, soreness,
rash or swelling noted.
10. Abdomen No scars, striae, vascular changes or protrusions noted;
with gurgling bowel sounds heard during auscultation in
all the quadrants and tympanic sound over air-filled
stomach/intestinal sections; muffled sounds over fluid-
filled or solid organs during percussion; no direct
tenderness or rebound tenderness upon palpation,
11. Genitals Patient verbalized that he had been inserted with a
catheter when he was in the OR. No complaints of dysuria
or urinary retention or incontinence post operatively.
12. Musculoskeletal Muscle strength at the right side is 5/5 and also the rest of
extremities are 5/5.
No visible tremors noted; no complaints of pain.
13. Integumentary Color of the nails is pink, clean and wally trimmed;
assessed hair well distributed, no lesions or infestations
noted, no masses or indentations during palpation.

This portion presents assessments performed as seen in the example below. You can do
FOCUS assessment especially on the affected area (eg. CHF  focus on Cardiac
Assessment) and focus on abnormal findings.
1. Head Normocephalic, hair well distributed, oiliness and flaking
noted no areas of pain or tenderness during palpation.
2. Eyes Able to distinguish colors, with astigmatism, verbalized
difficulty to identify objects 6 feet away, wears corrective
lenses, sclera is anicteric, pupils are equally round,
reactive to light and accommodation, EOM is intact, able
to follow penlight with gaze, no detectable oscillations,
mucous membranes are moist and light pink.
3. Ears Able to understand and hear spoken language correctly,
with minimal cerumen build – up in the ear canal, sliver
and intact tympanic membrane.
4. Nose and sinuses Nose is patent, septum is located midline, no flaring
noted, able to distinguish the scent of alcohol and
perfume, and no episodes of epistaxis during the shift,
and sinuses are not tender on palpation.
5. Mouth Complete set of adult teeth, pearly white in color, and no
mal aligned tooth, had braces for 1 year and a half year.
No dental caries noted. Oral mucosa is moist and pinkish,
 no lesions noted, tonsils are not inflamed, Grade 1
bilaterally present, uvula is located midline.
6. Neck ROM intact, able to change direction of head slowly but
with without complaints of pain, carotid pulse are
bilaterally symmetrical, full and strong pulses, 2+, jugular
vein is not distended, superficial cervical lymph nodes are
palpable but non tender. Thyroid is located midline, no
enlargement noted, trachea is located midline.
7. Chest Shape of the chest is elliptical, asymmetrical chest wall
expansion noted, with respiratory excursion best
appreciated on the left side of the thorax, decreased
tactile fremitus in the right lung area, decreased breath
sounds in the right, no crackles, no wheeze, no stridor,
production of hollow drum like sounds in percussion of the
right side and resonant sound appreciated on the left.
Patient with an Axillary thoracotomy, dressing intact and
dry, chest tube draining to a bloody discharge 300 cc in
amount. With limited movement on the right shoulder.
Patient verbalized, “mahina daw ung lungs ko,
spontaneous rupture of the bleb, kaya may
pneumothorax ako” “Masakit tlaga ung sugat, parang
8/10 din, pati ata sa loob masakit talaga, ditto lang
naman sya sa may incision, parang may tumutusok kaya
binigyan nila ako ng analgesic, ngayon, ayos ng konte
pero may pain pa din at 6 na cguro ung scale nya out of
10”. Patient is observed to guard area and grimaces
when a painful stimulus is felt. Diaphoresis noted, hands
are cool to touch. Maintains the supine position with head
of bed elevated to a moderate high back rest.
8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI
at 50 ICS LMCL, no murmur noted, no visible pulsations in
the precordium, palpable apical pulse.
9. Breast/Chest Skin color is similar with the rest of the body, nipple is dark
colored, no discharges.
10. Abdomen Flat, with normoactive bowels sounds heard in all the
quadrants, soft, no direct tenderness or rebound
tenderness upon palpation, tympanic, no organomegaly.
11. Genitals Patient verbalized that he had been inserted with a
catheter when he was in the OR. No complaints of dysuria
or urinary retention or incontinence post operatively.
12. Musculoskeletal Muscle strength at the right side is 4/5 while the rest of
extremities are 5/5.
No visible tremors noted no complaints of pain.
13. Integumentary Skin…