HEAD TO TOE ASSESSMENT

 
Interview while conducting Head to Toe exam.
GENERAL APPEARANCE HEART

1.      Age, race, sex, Ht. Wt., hygiene, grooming
nutritional status, build, VS.
2.      LOC & orientation X 4 (person, place, time,
situation).
3.      Speech, understanding, memory, facial
expression, mood, affect.
1.      Inspect for pulsations & palpate at PMI.
2.      Auscultate apical-radial, & apical-carotid
(amplitude, rhythm, rate).
3.      Auscultate at A, P, T, M.
4.      Identify S1, S2.

4.      Obvious physical deformities and 5.      Listen for murmurs.

involuntary movements.
6.      Listen for S3, S4 gallups.
5.      General Mobility – posture, stability, gait &
assistive devices (CN 11).  
HEENT ABDOMEN

1.      Inspect face; head. 1.      Inspect color, contour, pulsations.

2.      Inspect EENT external structures. 2.      Auscultate bowel & aortic sounds.

3.      Check 6 cardinal fields (CN 2, 3, 4, 6). 3.      Percuss 4 quadrants (tympany).

4.      Inspect conjunctiva, sclera, 4.      Lightly palpate 1cm. Over 4 quadrants.

5.      PERRLA.  
UPPER EXTREMITIES
6.      Hearing (CN 8).
1.      Assess skin, hair, nails.
7.      Inspect teeth, gums, tongue, palate, uvula.
Palpate masseters with clenched teeth (CN 2.      Assess ROM and strength.
5, 7).
3.      Assess handgrips.
8.      Check tonsil fossa: Say “ah” (CN 9, 10),
swallow reflex intact. 4.      Palpate & assess radial pulses (rate,
rhythm, & force), cap. Refill.
9.      Pt. Protrudes tongue (CN 12).
NECK LOWER EXTREMITIES
1.      Inspect carotids & jugulars. 1.      Assess skin, ROM and strength.

2.      Palpate carotids (separately). 2.      Palpate & assess posterior tibial, and
dorsalis pedis pulses.
3.      Auscultate carotids for bruits.
3.      Assess Homan’s sign.
4.      Palpate cervical lymph nodes.
4.      Check for edema.
5.      Note trachea midline.
5.      Assess babinski reflex.
6.      Shrug shoulders (CN 11).
6.      Inspect toes & cap. Refill.
7.      Assess ROM neck.
7.      Check skin sensation (evaluate based on
8.      Assess skin turgor upper chest. dermatome levels).
CHEST (Lungs) GU

1.      Inspect post., lat. & ant. Chest. 1.      Last BM’s, color, amt.

2.      Percuss side to side (resonance). 2.      Urine color, clarity, etc.

3.      Auscultate for adventitious sounds (upper

lobes, lower lobes).
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