Head-To-Toe-Assessment

Front 1

General Inspection when patient is greeted

Back 1

Body constitution, manner of sitting,relaxed,alacrity,eyes expression,skin color,facial expression,gait, nutritional status, respiratory distress, dress,posture

Front 2

Measurements

Back 2

Height, weight, Assess vision Snellen Chart, vital signs (temperature, respirations, O2 SATs, B/P both arms, HR

Front 3

Patient Instructions

Back 3

Empty bladder, remove clothing leaving bra and underpants

Front 4

HEAD AND FACE

Back 4

INSPECT:
Skin, symmetry of eyes & ears, configuration of skull.
PALPATE:
Scalp & hair for quality, texture and distribution.
Facial bones.
Patient to open & close mouth palpate mandible joints
Sinuses if tender translluminate
INSPECT:
Clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick tongue out , puff cheeks (CN V & VII)
Test light sensation to of forehead, cheeks, chin (CNV)

Front 5

EYES --EXTERNAL

Back 5

INSPECT:
Eyelids, eyelashes, palpebral folds, alignment of eyebrows, sclerae, conjuctivae
PALPATE:
Lacrimal apparatus
Near Vision screening--Rosenbaum chart (CN II)

Front 6

EYE FUNCTION

Back 6

Test pupillary response to light & accommodation.
Perform cover & uncovertest & light reflex.
Test extraoccular eye movements (CN III, IV, VI).
Assess visual fields (CN II).
Test corneal reflexes (CN V).

Front 7

OPHTHALMOSCOPIC EXAM

Back 7

Test red reflex.
Inspect lens, disc, cup margins, vessels, retinal surface, vetreous humor

Front 8

EARS

Back 8

INSPECT;
Alignment, placement, surface, characteristics

PALPATE:
Auricle

Assess hearing with whisper test (CN VIII)

Front 9

OTOSCOPE

TUNING FORK (assess bone &
air conduction

Back 9

INSPECT:
Canals, tympanic membranes for landmarks, deformities, inflamation

Front 10

NOSE (If some aberration then test
sense of smell or taste)

Back 10

Nose structure, position of septum, patency of each nostril

INSPECT:
Mucosa, septum, turbinates with nasal speculum.

Front 11

MOUTH & PHARYNX

Back 11

INSPECT:
Lips, buccal mucosa, gums, soft & hard pallate, floor of mouth for color & surface characteristics.
Oropharynx, uvula, tonsils, posterior pharynx, mouth odor.
Teeth for color, number, surface characteristics.
Tongue for color, characteristics,symmetry, movement (CN XIII).
Gag and ah reflex (CN IX, X).

Front 12

NECK

Back 12

INSPECT:
Symmetry, smoothness & thyroid.
Jugular Venous Distention
Active & Passive ROM
Test strength of shoulder shrug (CN XI)

PALPATE:
Carotid Pulses one @ a time
Tracheal position
Thyroid
Lymph nodes-preauricular,postauricular, occipital,tonsillar,submental,submandibular,superficial cervical chain,posterior cervical, deep cervical, supracavicular

AUSCULTATE:
Carotid arteries & thyroid

Front 13

UPPER EXTREMETIES

Back 13

INSPTECT:
Skin, nails, hands, arms, shoulders.
Muscle Mass, muscular strength
Musculoskeletal deformities, joint ROM, fingers, wrists, elbows, shoulders.
ASSESS:
Pulses-radial, brachial, epitochlear nodes.

Front 14

PATIENT SEATED BACK EXPOSED

Back 14

INSPECT:
Skin, thoracic configuration, symmetry of shoulders, musculoskeletal development
INSPECT & PALPATE SCAPULAE & SPINE
PALPATE & PERCUSS Costovertebral angle.

Front 15

LUNGS

Back 15

INSPECT:
Respirations-excursion, depth, rhythm, pattern
PALPATE:
Expansion & tactile fremitus.
Scapular & subscapular nodes

PERCUSS:
Posterior chest & lateral walls systematically for resonance, for diaphragmatic excursion

AUSCULTATE systematically for breath sounds(egophony,bronchophony,whispered pectoriloquy)
Characteristics & adventitious sounds.