Name
Western Governors University
D222 Comprehensive Health Assessment
Prof. Name
Date
What is your name?
At the beginning of the assessment, the patient clearly stated her full name, appropriately confirming her identity as part of standard patient verification procedures.
What is your date of birth?
The patient accurately reported her date of birth and demonstrated an understanding of her age and its relevance to her overall health status.
Where are you currently located?
The patient correctly identified her present location, indicating intact spatial awareness and orientation to place.
What is today’s date?
The patient correctly verbalized the current date, reflecting normal cognitive function and appropriate temporal orientation.
Do you have any medical conditions or are you currently taking any medications?
The patient denied having any diagnosed medical conditions and reported that she is not currently taking prescription, over-the-counter, or herbal medications.
Do you understand why you are here today?
The patient confirmed that she understood the purpose of the visit, stating that she was present for a routine physical examination and general health evaluation.
Observation
Throughout the interaction, the patient remained alert and fully oriented to person, place, time, and situation (A&O ×4), indicating normal mental status and cognitive functioning.
How has your appetite been recently?
The patient reported a stable appetite with no recent increases or decreases.
Do you feel you are eating well?
She stated that she consumes regular, balanced meals throughout the day and does not experience difficulty with eating or digestion.
The patient was observed sitting upright with relaxed posture and no apparent physical limitations. Facial expressions were appropriate and congruent with conversation. Speech was clear, fluent, and coherent, and no hearing impairment was noted. Personal hygiene and grooming were excellent, and clothing was clean and suitable for the clinical environment.
| Measurement | Result / Observation |
|---|---|
| Height and Weight | To be recorded |
| Radial Pulse (bpm) | Counted over 30 seconds |
| Respiratory Rate | To be recorded |
| Blood Pressure (Arm) | To be recorded |
| Pain Level | Assessed and documented as indicated |
| Parameter | Observation |
|---|---|
| Color / Pigmentation | Even tone; no discoloration |
| Temperature | Warm to touch |
| Moisture | Normal hydration |
| Texture | Smooth and intact |
| Turgor | Elastic with no tenting |
Palpation of the scalp, skull, and hair revealed no tenderness, lesions, or structural abnormalities. Cranial nerve function was assessed by instructing the patient to protrude her tongue. The tongue remained midline without deviation, indicating intact motor control and normal cranial nerve function.
| Structure | Assessment Findings |
|---|---|
| Eyes | Clear sclera and cornea; normal eyelids; pupils equal, round, reactive to light and accommodation (PERRLA); extraocular movements intact |
| Ears | External ears intact; no discharge, pain, tinnitus, vertigo, or hearing loss reported |
| Nose | Symmetrical nasal structure; patent nares; no discharge |
| Mouth and Throat | Oral mucosa moist and pink; gums healthy; teeth intact; tongue midline; uvula centered and mobile |
| Neck | Trachea midline; full range of motion; carotid pulses equal bilaterally; no lymphadenopathy or thyroid enlargement |
The thorax was symmetrical with normal spinal alignment. Chest expansion was equal bilaterally. Tactile fremitus was assessed using the phrase “99” and revealed no abnormal vibrations, tenderness, or crepitus. Auscultation across six posterior lung fields demonstrated clear breath sounds bilaterally. No costovertebral angle tenderness was present.
Do you experience any shortness of breath?
The patient denied dyspnea, wheezing, or breathing difficulty.
| Parameter | Observation |
|---|---|
| Apical Pulse | Palpable at the 5th intercostal space, midclavicular line |
| Heart Rate | Counted for 60 seconds; within normal limits |
| Heart Sounds | Clear S1 and S2; no murmurs, rubs, or extra sounds |
Do you have any chest pain or discomfort?
The patient denied chest pain, pressure, or palpitations.
The patient demonstrated full range of motion with symmetrical muscle strength. Radial and brachial pulses were strong and equal bilaterally (+2 to +3). Capillary refill of the fingers was less than three seconds, indicating adequate peripheral perfusion.
| Area | Findings |
|---|---|
| Jugular Veins | No distention; visible approximately 1 cm above sternal angle |
| Abdomen | Flat and symmetrical; umbilicus midline |
| Bowel Sounds | Active in all four quadrants |
| Percussion | Tympanic sounds throughout |
| Palpation | Abdomen soft, non-tender, no guarding or masses |
Both lower extremities were symmetrical with normal skin temperature and hair distribution. No edema, cyanosis, or discoloration was observed. Capillary refill of the toenails was less than three seconds. Peripheral pulses (femoral, popliteal, posterior tibial, and dorsalis pedis) were palpable, strong, and equal bilaterally. The patient exhibited full range of motion in the hips, knees, and ankles.
| Test | Findings |
|---|---|
| Deep Tendon Reflexes | Normal (+2) bilaterally |
| Sensory Testing | Appropriate response to sharp and dull stimuli |
| Spine and Coordination | Full spinal range of motion; steady gait; able to perform heel-to-toe walking, tiptoe walking, and knee bends |
Are you experiencing any pain or discomfort during these movements?
The patient denied pain, weakness, or balance issues during all neuromuscular assessments.
Two primary health promotion strategies were discussed to support long-term wellness.
The patient reported consuming approximately six to eight cups of coffee daily. Education was provided on the potential cardiovascular and hydration effects of excessive caffeine intake. A gradual reduction plan was recommended, along with increasing daily water intake to approximately 64–120 ounces to promote optimal hydration and physiologic balance.
The patient acknowledged a predominantly sedentary lifestyle. A gradual exercise plan was encouraged, beginning with walking 2,000–5,000 steps per day. Regular physical activity was emphasized to improve circulation, support digestion, enhance cardiovascular health, and reduce the risk of chronic conditions such as venous insufficiency and thrombosis.
All patient questions were addressed thoroughly. The patient verbalized understanding of the recommendations and expressed willingness to implement the suggested lifestyle changes. The assessment concluded with positive reinforcement of her active engagement in her health care.
Bickley, L. S. (2020). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Jarvis, C. (2019). Physical examination and health assessment (8th ed.). Elsevier.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). Elsevier.
