General Head-to-Toe Physical Assessment

Overview & History

Liam O'Connor (DOB: 14/08/1965, Medicare: 2849 18293 1) presents at 09:30 on 15/10/2023 for a routine physical assessment and review of newly diagnosed essential HTN. He reports mild intermittent occipital headaches over the past two weeks, typically occurring in the morning, which resolve with paracetamol (Panadol®) 1,000 mg PO PRN. His past medical history includes hyperlipidaemia and a lap appendicectomy in 2010; current regular medications are atorvastatin (Lipitor®) 20 mg PO daily and perindopril (Coversyl®) 5 mg PO daily (commenced 01/10/2023). He appears alert, comfortable, and in NAD, with initial vitals showing BP 138/84 mmHg, HR 72 bpm, RR 14 breaths/min, and T 36.8 °C.

Hair, Skin & Nails

Skin is warm, dry, and intact with normal turgor and no rashes, bruising, or pressure injuries. A well-healed 3 cm surgical scar is noted in the RLQ. Hair is evenly distributed with a clean scalp, and nails are smooth and pink without clubbing or cyanosis.

Head & Neck

The head is normocephalic and atraumatic with symmetrical facial movement and no tenderness on palpation. The neck is supple with full ROM, no cervical lymphadenopathy, and no thyromegaly or JVD.

Eyes & Vision

Eyes are aligned with conjunctivae clear and sclerae anicteric, with no discharge noted. Pupils are 3 mm, equal, round, and reactive to light and accommodation (PERRLA), and visual fields are full by confrontation. Visual acuity is 6/6 bilaterally with corrective reading glasses.

Ears

External auditory canals are clear with minimal cerumen and no tenderness on tragal palpation. Tympanic membranes are pearly grey and intact with normal landmarks bilaterally, and gross hearing is intact to whispered voice.

Nose & Sinus

Nasal mucosa is pink and moist with a midline septum and patent nares bilaterally, without discharge or epistaxis. No tenderness is elicited on palpation of the frontal and maxillary sinuses.

Mouth & Throat

Lips and oral mucosa are pink and moist with good dentition and no gingival inflammation or ulcerations. The tongue and uvula are midline, tonsils are grade 1 without exudate, and swallowing is intact without discomfort.

Thoracic – Cardiovascular, Respiratory, Breasts, Lymph

Heart sounds are dual (S1, S2) with a regular rhythm and no murmurs, gallops, or rubs; radial and pedal pulses are 2+ bilaterally with brisk capillary refill < 2 seconds. Chest expansion is symmetrical with RR 14 breaths/min, and lungs are clear to auscultation bilaterally without wheezes or crackles. Chest wall is symmetrical without gynaecomastia, masses, or skin changes, and no axillary or supraclavicular lymphadenopathy is palpable.

Abdomen

Abdomen is soft, non-distended, and non-tender without guarding, rebound, or palpable masses. Normoactive bowel sounds are present in all four quadrants, and no hepatosplenomegaly or hernias are detected.

Genitourinary

The patient reports normal urinary frequency and flow without dysuria, haematuria, nocturia, or incontinence. External genitalia examination was not clinically indicated and was deferred.

Rectum

Perianal skin is intact without lesions, fissures, or external haemorrhoids. A DRE was performed, revealing normal sphincter tone, a smooth, non-tender prostate without nodularity, and no palpable rectal masses or gross blood.

Extremities and Musculoskeletal System

Upper and lower extremities are symmetrical without peripheral oedema, cyanosis, or joint effusions. Full active and passive ROM is maintained across all major joints without crepitus or tenderness, muscle strength is 5/5 throughout, and gait is steady and normal.

Neurological

The patient is alert and oriented to person, place, and time (GCS 15). Cranial nerves II–XII are intact, deep tendon reflexes are 2+ and symmetrical, sensation to light touch is intact distally, and cerebellar coordination (finger-to-nose) is normal without tremor.