Head To Toe Physical Exam

Front 1

Before beginning physical exam?

Back 1

- Greet patient
- Introduce yourself and inform of agenda
- Wash hands
- Ensure patient is appropriately attired and comfortable

Front 2

Step 1

Back 2

Assess General Appearance:
- Habitus
- Posture
- Grooming
- Affect
- Level of consciousness
- Distress
- Psychomotor activity
- Apparent age

Front 3

Step 2 (after General Appearance)

Back 3

Blood Pressure
- Apply cuff
- Determine mmHg at which pulse disappears
- Position patient arm w/ artery at heart level
- Inflate 20-30 mmHg higher
- Tell them you would check other arm

Front 4

Step 3 (after BP)

Back 4

Respiratory Rate
- Observe 30 seconds

Front 5

Step 4 (after RR)

Back 5

Heart Rate
- Have patient extend arms
- Palpate radial pulse for 30 seconds

Front 6

Step 5 (after HR)

Back 6

Inspect skin of hands and nails
- Ask patient to sit on exam table
- Assess gait

Front 7

Step 6 (after inspecting skin of hands and nails)

Back 7

Inspect head size and shape, hair and scalp
- Distribution
- Texture
- Lesions

Front 8

Step 7 (after inspecting head size and shape, hair and scalp)

Back 8

Palpate skull
- Masses
- Depressions
- Tenderness

Front 9

Step 8 (after palpating skull)

Back 9

Observe face for symmetry and test CN V / VII
- Palpate masseter with patient clenching teeth
- Check sensation in 3 branches bilaterally
- Close eyes tight, smile, puff out cheeks

Front 10

Step 9 (after checking CN V / VIII)

Back 10

Inspect eyelids
- Check for ptosis (CN III)

Front 11

Step 10 (after inspecting eyelids / CN III)

Back 11

Inspect conjunctiva, sclera, and cornea

Front 12

Step 11 (after inspecting conjunctiva, sclera, and cornea)

Back 12

Visual Acuity (CN II)
- Use pocket screener

Front 13

Step 12 (after checking visual acuity with pocket screener)

Back 13

Visual fields by confrontation (CN II)
- Check one eye at a time comparing self to patient

Front 14

Step 13 (after checking visual fields by confrontation)

Back 14

Extraocular movements and convergence (CN III, IV, VI)
- Check 6 cardinal directions
- Check convergence

Front 15

Step 14 (after checking extraocular movements and convergence)

Back 15

Pupillary Reactions
- Check for symmetry
- Direct and consensual reaction

Front 16

Step 15 (after checking pupillary reactions)

Back 16

Ophthalmoscope Exam
- Dim lights
- Check red reflex
- Ask patient to look at fixed distant point
- Inspect fundus
- Check both eyes one at a time (R eye looks at R eye and put hand on shoulder)

Front 17

Step 16 (after ophthalmoscope exam)

Back 17

External Ear
- Inspect and palpate tragus

Front 18

Step 17 (after external ear)

Back 18

Ear Canal and Tympanic Membrane
- Use otoscope to check for cerumen
- Identify landmarks
- Look for erythema and effusion

Front 19

Step 18 (after otoscope exam)

Back 19

Auditory Acuity (CN VIII)
- Check with finger rub or whisper

Front 20

Step 19 (after checking auditory acuity w/ finger rub)

Back 20

Weber
- Place vibrating tuning fork on top of head and see if it lateralizes

Front 21

Step 20 (after Weber - tuning fork on top of head)

Back 21

Rinne
- Place vibrating tuning fork on mastoid process to check if air>bone conduction

Front 22

Step 21 (after Rinne - tuning fork on mastoid process)

Back 22

Inspect nose
- Have patient tilt head back (checking neck extension)
- Use otoscope

Front 23

Step 22 (after otoscope exam)

Back 23

Palpate sinuses
- Check frontal and maxillary sinuses for tenderness

Front 24

Step 23 (after palpating sinuses)

Back 24

Inspect mouth
- Lips
- Oral mucosa
- Gums
- Teeth
- Palate with tongue blade and penlight

Front 25

Step 24 (after inspecting mouth)

Back 25

Inspect pharynx (CN IX, X)
- Use tongue blade and penlight to inspect posterior oropharyngeal walls
- Tonsils
- Uvula
- Have patient say ahh to check gag reflex

Front 26

Step 25 (after inspecting pharynx)

Back 26

Inspect tongue (CN XII)
- Have patient protrude tongue and move side to side

Front 27

Step 26 (after inspecting tongue)

Back 27

Feel floor of mouth
- Palpate with a gloved finger for masses or induration

Front 28

Step 27 (after feeling floor of mouth)

Back 28

Test neck flexion and CN XI
- Chin to chest
- Shoulder shrug
- Rotate head against resistance

Front 29

Step 28 (after testing neck flexion and CN XI)

Back 29

Palpate lymph nodes for tenderness and mobility
- Pre- and post auricular
- Occipital
- Tonsillar
- Submandibular
- Submental
- Anterior and posterior cervical
- Supraclavicular

Front 30

Step 29 (after checking lymph nodes)

Back 30

Thyroid and Trachea
- Inspect anterior neck for symmetry and masses
- Move to behind patient
- Place two fingers on both sides of trachea below cricoid cartilage
- Have patient swallow to palpate thyroid gland

Front 31

Step 30 (after thyroid and trachea)

Back 31

Inspect posterior thorax
- Open gown in back
- Symmetry of expansion
- Deformity or skin lesions

Front 32

Step 31 (after inspecting posterior thorax)

Back 32

Tactile Fremitus
- Feel for vibration while patient says 99

Front 33

Step 32 (after tactile fremitus "99")

Back 33

Percussion
- Place left middle finger on patient and strike with right middle finger

Front 34

Step 33 (after percussion)

Back 34

Auscultation
- Listen with stethoscope while patient breathes through mouth
- Check all over back AND on sides

Front 35

Step 34 (after auscultation)

Back 35

Whispered Pectoriloquy
- Auscultate with stethoscope while patient says "99"

Front 36

Step 35 (after whispered pectoriloquy "99")

Back 36

Egophony
- Auscultate with stethoscope while patient says "eee"

Front 37

Step 36 (after egophany "eee")

Back 37

Costovertebral Angle
- Assess for tenderness by tapping with fist bilaterally
- Tie up gown and move to front of patient

Front 38

Step 37 (after tapping at costovertebral angle)

Back 38

Inspect anterior thorax and auscultate
- Listen with stethoscope while patient takes deep breaths

Front 39

Step 38 (after auscultating on anterior thorax)

Back 39

Measure Jugular Venous Pressure
* Place back of exam table at 30 degrees and extend leg support, ask patient to lie on back
- Use penlight to transilluminate
- Use ruler

Front 40

Step 39 (after measuring JVP)

Back 40

Auscultate and palpate carotid arteries
- While patient holds breath

Front 41

Step 40 (after auscultating and palpating carotid arteries)

Back 41

Inspect and palpate point of maximal impulse
* Flatten exam table back so patient is lying supine
- Use right hand to feel PMI

Front 42

Step 41 (after feeling PMI)

Back 42

Auscultate heart
- Use diaphragm
- Aortic, Pulmonic, Tricuspid, and Mitral areas

Front 43

Step 42 (after auscultating heart)

Back 43

Palpate lower extremity pulses and check for edema
- Femoral
- Popliteal
- Posterior tibial (medial ankle)
- Dorsalis pedis

Front 44

Step 43 (after feeling peripheral pulses)

Back 44

Inspect abdomen
- Scars, contour, asymmetry

Front 45

Step 44 (after inspecting abdomen)

Back 45

Auscultate abdomen
- Bowel sounds in all 4 quadrants
- Aortic or renal artery bruits

Front 46

Step 45 (after auscultating abdomen)

Back 46

Percuss abdomen
- All 4 quadrants
- Liver and spleen

Front 47

Step 46 (after percussing abdomen)

Back 47

Palpate abdomen
- Light and deep pressure in all 4 quadrants
- Feel for masses

Front 48

Step 47 (after palpating abdomen in 4 quadrants)

Back 48

Palpate Liver

Front 49

Step 48 (after palpating liver)

Back 49

Palpate spleen

Front 50

Step 49 (after palpating spleen)

Back 50

Palpate abdominal aorta

Front 51

Step 50 (after palpating abdominal aorta)

Back 51

Inspect muscle bulk
* Have patient sit up
- Check for asymmetry or atrophy of arms, hands, legs, temples

Front 52

Step 51 (after inspecting muscle bulk)

Back 52

Check muscle tone
- Upper and lower extremities

Front 53

Step 52 (after checking muscle tone)

Back 53

Test muscle strength
- Shoulder abduction (out to side)
- Forearm flexion and extension at elbow
- Wrist extension
- Finger abduction
- Grip strength
- Finger opposition (touch fingers to thumb)
- Flexion/extension/abduction/adduction of hips
- Extension/flexion of knees
- Dorsi and plantar flexion of ankles

Front 54

Step 53 (after checking muscle strength)

Back 54

Check deep tendon reflexes
- Biceps
- Triceps
- Brachioradialis
- Patellar
- Achilles
- Plantar (Babinski)

Front 55

Step 54 (after checking reflexes)

Back 55

Sensory exam for pain
- Use broken wooden stick and cotton swab

Front 56

Step 55 (after sensory exam for pain)

Back 56

Sensory exam for temperature
- Cold metal reflex hammer handle or tuning fork

Front 57

Step 56 (after sensory exam for temperature)

Back 57

Sensory exam for light touch
- Use cotton wisp or fingers

Front 58

Step 57 (after sensory exam for light touch)

Back 58

Sensory exam for vibration
- Use tuning fork on joints

Front 59

Step 58 (after sensory exam for vibration)

Back 59

Sensory exam for proprioception
- Great toes

Front 60

Step 59 (after sensory exam for proprioception)

Back 60

Test cerebellum by checking coordination
- Rapid alternating hand movement
- Finger to nose
- Heel to shin

Front 61

Step 60 (after testing cerebellum with rapid hand movement, finger to nose, or heel to shin)

Back 61

Check gait
- Observe turning
- Note feet placement for stance
- Arm swing
- Evidence of pain

Front 62

How many general steps? What are they?

Back 62

Five
1. General appearance
2. Blood pressure
3. Respiratory rate
4. Heart rate
5. Inspect skin of hands and nails

Front 63

How many head/face steps? What are they?

Back 63

Three
6. Inspect head size/shape, hair/scalp
7. Palpate skull for masses/depressions
8. Observe face: CN V and CN VII

Front 64

How many eye steps? What are they?

Back 64

Seven
9. Inspect eyelids for ptosis
10. Inspect conjunctiva, sclera, and cornea
11. Visual acuity w/ pocket screener
12. Visual fields by confrontation
13. Extraocular movements and convergence
14. Pupillary reactions
15. Ophthalmoscope exam

Front 65

How many ear steps? What are they?

Back 65

Five
16. Inspect and palpate external ear
17. Use otoscope
18. Auditory acuity w/ finger rub
19. Weber - tuning fork on top of head
20. Rinne - tuning fork on mastoid processes

Front 66

How many nose steps? What are they?

Back 66

Two
21. Inspect nose w/ otoscope
22. Palpate sinuses: frontal and maxillary

Front 67

How many mouth steps? What are they?

Back 67

Four
23. Inspect mouth
24. Inspect pharynx (say ahh)
25. Inspect tongue (side to side)
26. Palpate floor of mouth

Front 68

How many neck steps? What are they?

Back 68

Three
27. Test neck flexion and CN XI
28. Palpate lymph nodes
29. Thyroid and trachea

Front 69

How many back steps? What are they?

Back 69

Seven
30. Inspect posterior thorax
31. Tactile fremitus (feel while saying 99)
32. Percussion
33. Auscultation
34. Whispered pectoriloquy (auscultate while saying 99)
35. Egophony (auscultate while saying "eee")
36. Tap on costovertebral angle

Front 70

How many anterior thorax steps? What are they?

Back 70

One
37. Inspect anterior thorax and auscultate anterior thorax while taking deep breaths

Front 71

How many cardiovascular steps? What are they?

Back 71

Five
38. Table at 30 degrees - measure JVP
39. Table at 30 degrees - palpate and auscultate carotid arteries
40. Lying flat - point of maximal impulse w/ right hand
41. Auscultate heart in 4 areas
42. Palpate lower extremity pulses and check for edema

Front 72

How many abdominal steps? What are they?

Back 72

Six
43. Inspect abdomen
44. Auscultate abdomen
45. Percuss abdomen (including liver and spleen)
46. Palpate abdomen w/ light and deep pressure
47. Palpate liver
48. Palpate spleen
49. Palpate abdominal aorta

Front 73

How many muscle steps? What are they?

Back 73

Four
50. Inspect muscle bulk for asymmetry and atrophy
51. Check muscle tone in upper and lower extremities
52. Test muscle strength
53. Check deep tendon reflexes

Front 74

How many sensory steps? What are they?

Back 74

Five
54. Sensory exam for pain
55. Sensory exam for temperature
56. Sensory exam for light touch
57. Sensory exam for vibration
58. Sensory exam for proprioception

Front 75

How many final steps? What are they?

Back 75

Two
59. Test cerebellum by checking coordination (rapid alternating hand movement, finger to nose, heel to shin)
60. Watch gait