Head to toe Assessment.

Introduce yourself, state what you are there for, identify pt , provide privacy
and perform hand hygiene.
Mental status: Do you know where you are? What year is it?

Pt is clean and well groomed, hair is neat and clean, is dressed appropriately for
setting, season, age and gender. Is awake and alert. Articulation is clear and
understandable.

Skin: Have you had any previous skin disease? Itching, bruising, rash or lessions?
Palpate skin ( check temp with back of hand)

Skin color is even and consistent with genetic background, it feels smooth, firm and
warm to the touch. No evidence of pallor, erythema, cyanosis or edema.

Check for turgor

No tinting

Educate pt about importance of decreased sun exposure and use of sunblock.

Hair: Any recent hair loss?

Hair is evenly distributed, is black, there is some flakiness noted and is free from
infestation.

Nails : Any change on the color of your nails?

Capillary refill is less than 2 secs and there is no clubbing noted.

Abdomen: Have you have any nausea or vomiting recently? Abdominal pain? Difficulty
swallowing? Change in your appetite or weight? Last bowel movement? Have you noticed
any blood in the stool?
Instruct pt to empty bladder before examination and position him/her on bed with hands
on sides.

Inspection Skin surface is smooth and even with homogeneous color and is
symmetric( check with pen light) There are no lesions, scars or striae. The contour
is . ( rounded, flat, protuberant or scaphoid) Umbilicus is midline with no sign of
inflammation or hernia. No piercings. There is no sign of peristalsis or distended
abdomen that could indicate intestinal obstruction.
Auscultate the abdomen with diaphragm beginning in the RLQ at the ileocecal
valve because bowel sounds are normally always present here, then move
clockwise.

Bowel sounds are

normal and present in
all 4 quadrants.
No bruits present
(blowing swishing sound,
blood turbulence.

Listen to vascular sounds by switching to the bell of the stethoscope.

Percuss all 4 quadrants including bladder clockwise. Tympanic predominates

because of air in the intestines. Dullness results from organ percussion or full
bladder.

Go to back of pt and check for costovertebral angle tenderness over the kidneys to
rule out Pyelonephritis.
Palpate for aortic pulsations in the upper abdomen, normally it is about 2.5 to 4
cm. Palpate abdomen (tell pt to breathe slowly) start on RLQ clockwise.
Perform rebound tenderness (Blumberg sign) if pt reports pain or tenderness during
palpation.
Musculoskeletal : Do you have any pain, heat or redness in your joints?
Any
problem in the muscles such as pain or cramping? Any bone pain? Any deformity ? Do you
take any meds?

Inspect I don't see any swelling, redness, deformity.

Ask the patient to stand up and walk. your walking is smooth, centered, no limping or
difficulty
Face Assess trigeminal nerve (Ask the patient open and close the mouth. Ask for any
pain?

There is no tenderness or crepitus noted.

Ask the pt to move the jaw side to side, in and out. To move it forward and laterally
against your resistance and open mouth against resistance.Say cranial nerve 5 intact,
there is no crepitus or tenderness
Neck Inspect
Palpate there is no tenderness, masses Ask pt to move the neck back and forward,
side to side, move the neck one side and put resistance. Assess CN XI there is no muscle
atrophy, tenderness, it fells firm

Shoulder Inspect

Subjective data

Palpate

Ask the patient to move the shoulder and arm (addution , abdution, circumdation,
flex ion and extension of the arm, bend the arm hold the elbow and put resistance.

Ask always for pain

Say there is no crepitus, no tenderness,no masses

Elbow

Inspection

There is no tenderness, redness or bursitis

Wrist

Inspection

Ask the pt to rotate the wrist, extend and flex.

Tunnel test

Phalen test do you feel any burn? : negative test

Phalanges

Inspect, count the fingers

Palpate and extend the fingers

Ask the pt to open and close the fingers, flex and extend, pronation and supination

Say

Ask the pt to lay down on the bed

Hip

Inspect

The joints of the hip feel stable, and symmetrical, with no tenderness or crepitus

Ask the pt to: Move the leg up and down, flexing the leg move it side to side, open
and close leg extended, blend the knee and move it in and out.
Knee

Inspect

The knee are bilateral equal, no tenderness, no redness

Palpate the knee from the sides there is no crepitus, bursitis

Ballottement sign

Ankle

Inspect

Ask the other to inversion, Emerson, dorsiflex, plantarflex , rotate

Says

Toe

Subjective

Inspect

McMurray Test
NEUROLOGICAL
Any coordination problems or weakness?
Tandem walking : have pt walk in a straight line
Romberg: Stand up feet together and arms side , eyes close and maintain position for 20
mins
Rapid alternating movement : flap hands on legs fast upward and downward.

Finger to finger test

Finger to nose test
Light touch test: use a cotton swab to touch pt and have him say when it feels it.
Pain: With a sharp object tell pt to say sharp when it feels it
Vibration: Hit tuning fork with had and place it on a bony prominence , ask pt to say when
vibration stops.
Tactile discrimination:
Stereognosis: Different objects in different hands while eyes closed and have pt identify
it.
Graphestesia: Draw a # on hand and have pt identify it.
Extintion: touch both sides of body at same time and point.
Point location: tounch pt fast and then ask to put finger where I touched you.
Test for plantar reflex. Draw an upside down J on the pt foot( plantar Flextion is normal)
HEENT
Head:

Do you suffer from frequent or severe headaches? Any head injury? Dizziness?Any
abnormalities with your scalp or hair?
Inspect and palpate the skull.
Head appears normocephalic ( is round symmetric skull appropriately related to
body size)
Scalp : there are no masses, tenderness, lesions or flakiness, the hair is evenly
distributed and is free from infestation.
Face:
Inspect for symmetry of eyebrows, nasolabial folds, sides of the mouth and address skin
color.
Eyebrows and nasolabial folds are symmetric.
No involuntary facial movements or abnormal facial structures.
Skin color is consistent with genetic background and has no changes in color
or pigmentation.
Palpate temporal artery
Bilateral temporal artery pulses equal 2+

Test for Range of Motion (ROM) of temporomandibular joint. I will assess CN V (5)
Trigeminal
Palpate temporal and masseter muscle as pt clenches teeth. Muscles are equally strong.
Push jaw down on chin. Do you feel any pain?
Test light touch sensation by using a cotton swap and ask pt to say now when he/she
feels it touching.
Assess CN VII (7) Facial by asking pt to smile, frown, lift eyebrows, show teeth, and puff
cheeks.
EYES
Do you have any problems with your vision? Do you wear glasses? Blurred vision? Eye
pain?
Assess for CN II(2) Optic by performing the Snellen chart. 20 feet away from the chart
Vision is 20/20 (intact)
Assess pupils with penlight twice each eye coming from the side to the center.
PERRLA noted (pupils equal round and reactive to light and accommodation.)
Patient has direct and consensual bilaterally.
Assess CN III (3) Oculomotor, CN IV (4) Trochlear, CN VI (6) Abducen.
Place pen light in front of pts face and move it up, side and down and have pt follow with
eyes. Then check the eyes and state: Conjunctiva pink, moist, no discharge or foreign
bodies.
EARS
Any earache ? Discharge or hearing loss?
Ears are bilaterally equal, no swelling, redness, discharge, lesions or lumps.
Perform Weber test with tuning fork. Air conduction is twice bone conduction.
Assess CN VIII(8) Acoustic
Wispered voice test (test one ear at time) Ask pt to cover one ear and whisper to the
other one 1,2,3 and ask pt to repeat.
NOSE
Nasal discharge? Sinus pain?
Nose is midline to face. Inspect sinus with penlight. Nose mucosa is intact, pink, moist
with no drainage or lesions.No deviated septum. Palpate sinus. Have pt cover one nostril

and inhale through the other one and repeat to check for patency. Nose is patent. Assess
CN I Olfactory by having the pt cover eyes and smell something (coffee, sugar, salt)
THROAT
Inspect lips, teeth, gums, tongue, throat and oral mucosa. Lips look moist and pink, no
cracks or lesions. No sign of bleeding in the gums, or cracked teeth. No sing of throat
redness. Tonsils are present 1+
Assess CN IX (9) Glosopharyngeal and CN X(10) Vagus
Ask pt to swallow and verbalize use of tongue depressor to elicit gag reflex. Oral mucosa
is pink and moist, Uvula is midline and rises up and back.
Assess CN XII (12) Hypoglossal
Ask pt to stick tongue out and move side to side. Then say tight, might , dynamite.
NECK
Any neck pain? Any swelling or lumps? CN XI (10) Spinal
Head is positioned midline, no masses or lumps on the neck.
Asses for movement, move chin to chest, turn head right and left, touch each ear to
shoulder and head backwards.
Have pt to look one side and put hand on de opposite cheek, have pt try to look the other
way by putting pressure on your hand and repeat to the other side. The place hands on pt
shoulders and have him shrug them to put pressure on your hands.( movement feels
equally strong in both sides)
Normal neck movement, no rigidity , limitation or JVD.
Palpate position of the trachea (trachea is midline)
Palpate and auscultate carotid bilaterally.
Auscultate to check for bruit ( with the bell of stethoscope and ask pt to take a deep
breath and hold it)
Move to pt back and palpate the thyroid. Thyroid is not palpable
Assess Lymph nodes

Jugulodigastic

Preauricular

Superficial cervical

Posterior auricular
Occipital
Submental

Deep cervical chain

Submandibular
Supraclavicular