Every system, general survey to mental status, sits in one layout, with technique and finding throughout, scales named, two abnormal findings measured and deferred parts listed. Searches like "mn 552 unit 9 assignment example", "mn552 unit 9 sample" and "mn552 unit 9 example" land here.
Comprehensive Physical Examination Documentation: New-Patient Visit for a 52-Year-Old Bus Mechanic
[Student Name]
Purdue University Global
MN552: Advanced Health Assessment
Unit 9 Assignment
[Instructor Name]
[Date]
Composite patient written as a model document. No real patient, employer or clinician is described.
Visit Context
Composite 52-year-old man seen on September 15, 2026, for a new-patient visit to establish primary care after moving to the area. He has worked for 24 years as a mechanic in a city bus maintenance garage. He reports no current symptoms and requested a complete examination because he has not had one in about six years. He takes no daily medications, drinks two to three beers on weekends and quit smoking at 40 after about 15 pack-years. The history is recorded separately; this document covers the physical examination only, performed with a chaperone offered and declined. All portions of the examination were completed in a single visit of about 40 minutes, with the patient seated for the head, neck, chest and heart, and supine for the heart, abdomen and lower extremities.
Conventions Used in This Record
Findings in each system follow the order inspection, palpation, percussion and auscultation where each technique applies; in the abdomen, auscultation precedes palpation and percussion so that bowel sounds are heard before the abdomen is touched. Pulses are graded 0 to 4, where 2 is normal. Deep tendon reflexes are graded 0 to 4+, where 2+ is normal. Muscle strength is graded 0 to 5, where 5 is full strength against resistance (Bickley et al., 2021). Right and left are named for every paired structure. Normal findings are written as what was seen, felt or heard, and the word normal is not used as a finding.
General Survey and Vital Signs
General survey: Well-developed, heavyset man who appears his stated age, seated comfortably, alert and cooperative. Clothing clean, grease under the fingernails consistent with his work. Speech clear and fluent, affect bright and appropriate. Gait steady with a normal base and arm swing.
Vital signs: Blood pressure 138/86 mm Hg right arm and 134/84 mm Hg left arm, seated, after 5 minutes of rest, adult large cuff. Pulse 76 per minute and regular, counted at the right radial artery for 30 seconds. Respiratory rate 14 breaths per minute, unlabored. Temperature 36.7 C by the oral route. Pulse oximetry 97 percent breathing room air. Measured height 178 cm and weight 102 kg, giving a body mass index of 32.2 kg/m2.
Skin, Head, Eyes, Ears, Nose and Throat
Skin: Warm and dry, color even. No rashes, no jaundice, no spider angiomas on the chest or upper back, no palmar erythema. Several small seborrheic keratoses on the back, the largest 6 mm, uniformly brown and stuck-on in appearance. Nails without clubbing. Head: Normocephalic, scalp without lesions, hair of normal distribution. Eyes: Visual acuity 20/20 right and 20/25 left without correction on a Snellen chart at 20 feet. Sclerae white and anicteric bilaterally. Pupils 3 mm, equal, round and reactive to light bilaterally. Extraocular movements full. Ophthalmoscopy, undilated: red reflex seen in each eye; disc margins sharp with a cup-to-disc ratio of about 0.3 bilaterally; no hemorrhages or exudates seen. Ears: External canals clear bilaterally. Tympanic membranes gray and translucent with visible landmarks bilaterally. Whispered words repeated correctly at arm's length on each side. Nose: Septum midline, mucosa pink, no discharge. Throat and mouth: Mucosa moist and pink. Upper and lower dentition present with two crowns. Tonsils not enlarged. Uvula rises symmetrically.
Neck and Lymph Nodes
Neck: Trachea midline. Full range of motion. No jugular venous distension at 45 degrees. Right thyroid lobe: a 2 cm firm, smooth, nontender nodule, palpated from behind, that rises with the gland on swallowing; left lobe not enlarged and without nodules. No thyroid bruit on auscultation. Carotid pulses 2 bilaterally, no bruits.
Lymph nodes: No palpable preauricular, posterior auricular, occipital, submandibular, submental, anterior cervical, posterior cervical or supraclavicular nodes bilaterally. No palpable axillary, epitrochlear or inguinal nodes bilaterally.
Chest, Lungs, Heart and Peripheral Vascular
Chest and lungs: Chest symmetric with equal expansion. Tactile fremitus equal bilaterally. Resonant to percussion throughout. Vesicular breath sounds throughout both lung fields, with no crackles, wheezes or rubs.
Heart: Point of maximal impulse at the fifth intercostal space, midclavicular line, about 2 cm in diameter. No heaves or thrills. Regular rate and rhythm. S1 and S2 heard clearly at the aortic, pulmonic, Erb's point, tricuspid and mitral areas, with no S3, no S4 and no murmurs, rubs or gallops at any of the five areas, with the patient seated and supine.
Peripheral vascular: Pulses graded 2 and equal on both sides at the radial, brachial, femoral, popliteal, posterior tibial and dorsalis pedis sites. No edema of the lower extremities. Capillary refill under 2 seconds in the fingers and toes bilaterally. No varicosities.
Abdomen
Inspection: Rounded, symmetric, no scars, no visible pulsations. Auscultation: Bowel sounds present in all four quadrants; no bruits over the aorta or renal arteries. Percussion: Tympanic over most of the abdomen. Percussed liver span in the right midclavicular line measures 14 cm. Spleen: no dullness at the lowest left intercostal space in the anterior axillary line. Palpation: Soft, nontender, no guarding. On deep inspiration the liver edge is felt 2 cm below the right costal margin in the midclavicular line; the edge is smooth and nontender. Percussed span is recorded rather than estimated from the palpable edge, since the edge alone does not establish liver size (Naylor, 1994). Spleen not palpable. No masses. No costovertebral angle tenderness bilaterally.
Musculoskeletal, Neurological and Mental Status
Musculoskeletal: Active range of motion full and painless at every joint tested on both sides: cervical spine, shoulder, elbow, wrist, finger, hip, knee and ankle. No joint swelling, warmth or deformity. Mild calluses on both palms. Spine without tenderness to palpation; straight leg raise negative bilaterally.
Neurological: Cranial nerves II through XII intact as tested: visual fields full to confrontation, facial sensation and movement symmetric, hearing as above, palate and tongue midline. Strength 5 in the upper and lower extremities bilaterally. Deep tendon reflexes 2+ and equal side to side at the brachioradialis, biceps, triceps, knee and ankle; plantar responses flexor bilaterally. Sensation intact to light touch and to 10-g monofilament at the feet bilaterally, vibration sense intact at the great toes. Finger-to-nose and heel-to-shin testing accurate bilaterally. Romberg test negative.
Mental status: Alert and oriented to person, place, time and situation. Attention intact; recalls three of three words at 5 minutes. Mood described as "pretty good," affect congruent. Thought process linear (Ball et al., 2023).
Deferred Portions and Summary of Abnormal Findings
Deferred: Genitourinary and rectal examinations were deferred at this visit at the patient's request and will be offered at his follow-up appointment, where colorectal screening status will also be reviewed.
Abnormal findings: (1) 2 cm firm, smooth, nontender nodule in the right thyroid lobe that rises with swallowing, described under Neck. (2) Percussed liver span of 14 cm in the right midclavicular line, and a smooth, nontender edge felt 2 cm under the right costal margin when he breathes in deeply, described under Abdomen.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Naylor, C. D. (1994). The rational clinical examination: Physical examination of the liver. JAMA, 271(23), 1859-1865. https://doi.org/10.1001/jama.1994.03510470063036
How this MN552 Unit 9 example is structured
Consistency is the organizing principle. Every system follows the same internal sequence, the four classic techniques in their usual order where each applies, so a reader moving between sections never relearns the pattern. Scales are named once at first use: pulses on 0 to 4, reflexes on 0 to 4+, strength on 0 to 5. Laterality appears whenever a structure is paired. Normal findings are written as observations rather than as the word normal; the lungs are resonant throughout with vesicular breath sounds and no added sounds, instead of lungs clear. The two abnormal findings are measured, located by landmark and described by consistency and tenderness, with nothing inferred about cause. Deferred portions are listed rather than silently omitted. A closing list of abnormal findings, two items long, points back to the sections where each one is described in full.
Get an MN552 Unit 9 example written to your instructions
Send your MN552 Unit 9 prompt with its required format, whether SOAP, a system template or your program's own, and the rubric. The first full-body record is on us, prepared to your instructions and delivered in 24-48h, with every normal described as an observation and every abnormal finding measured and located. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
MN552 Unit 9 questions, answered
What length suits a full head to toe write-up?
Long enough that every system has a written finding, which usually runs several pages. Length itself is not graded; completeness and consistency are. The sample fits fourteen systems in about five pages by writing each normal finding once, precisely, rather than listing every structure examined with the same word beside it.
Is it acceptable to defer parts of the exam?
Yes, when the reason is stated. Sensitive examinations, parts outside the visit's scope, or anything the patient declines can be deferred. What costs credit is a system that simply disappears from the record. The sample gives every deferred portion a brief stated reason, so a reader knows the omission was deliberate.
Should the record end with a diagnosis or plan?
Not unless your prompt asks. A documentation assignment typically ends with a list of abnormal findings pointing back to where each is described. Diagnoses and plans belong to later work, often the final unit, and adding them here shifts attention away from the record, which is what this unit grades.