Diana De Guzman HEAD TO TOE QUICK STUDY GUIDE

Neurologic: HA?, Head injury? Dizziness? Vertigo (room spinning)?

Seizures? Tremors? Numbness/tingling? Dysphagia?; Hx of Stroke?, Spinal cord
injury?
Cranial Nerve I (Olfactory): Sense of smell; test the patency of each nostril by
having patient cover 1 nostril at a time and sniff; then use different scent for
each nostril with pts eyes closed & 1 nostril occluded have them sniff. (test on
pt. with head trauma, loss of smell) [ABNORMAL: BIL. DECREASE IN SMELL-
ANOSMIA; UNILATERAL LOSS OF SMELL-NEUROGENIC ANOSMIA; CAUSE: URI;
FRONTAL LOBE LESION]
Cranial Nerve II (Optic): Test visual acuity (defect or absent central vision) &
visual fields (defect in PERIPHERAL VISION, hemianopsia) by confrontation
peripheral vision cover 1 eye & ask pt. to state when sees fingers [ABNORMAL:
VISUAL FIELD LOSS; INCREASING INTRAOCULAR PRESSURE-DECREASE IN
PERIPHERAL VISION; RETINAL DETACHMENT-SHADOW OR DIMINISHED VISION]
Cranial Nerve III (Oculomotor), IV (Trochlear), VI (Abducens):
III: Test corneal light reflex: have pt stare at your nose, then shine light in
between the 2 eyes (stars in eyes, want stars in same area on both eyes)
[ABNORMAL : Ptosis (drooping upper lid) occurs with myasthenia gravis];
PERRLA (Pupil Equal, Round, React to Light & Accomodation): shine light on
pupil one at a time. Come from pts side then shine light on one eye, observe
pupil on eye with light and quickly look at other eye without light for
comparison. Check pupils for size, regularity, equality (want pupil constriction;
Pupillary light reflex is the normal constriction of the pupils when bright light
shines on the retina; When 1 eye is exposed to bright light, a direct light reflex
occurs [constriction of that pupil] as well as a consensual light reflex
[simultaneous constriction of the other pupil]; ABNORMAL: DILATION
Eyes accommodate from far sight to near by looking at something at a distance,
focus on pen light in front of them, & then bring pen light closer to them); want
convergence of eye to a single point; Adaptation of the eye for near vision
6 Cardinal Positions of Gaze: pt. will just follow finger by just moving their eyes
& not their head (extraocular muscle movement: want inward, up & inward, up
& outward, down & outward) [ABNORMAL: FAILURE TO MOVE EYE UP, IN,
DOWN; NYSTAGMUS-back & forth oscillation of eyes].
IV & VI: 6 Cardinal Positions of Gaze: pt. will just follow finger by just moving
their eyes & not their head (IV: want downward, inward eye movements; VI:
want lateral movement of eyeballs) [ABNORMAL: NYSTAGMUS-back & forth
oscillation of eyes]

Cranial Nerve V (Trigeminal): Assess muscles of mastication by Palpating the
temporal and masseter muscles as person clenches teeth [ABNORMAL:
DECREASED STRENGHTH ON ONE OR BOTH SIDES] & try to separate jaws by
pushing down on the chin (normally you cant); Test light touch sensation with
patients eyes closed (forehead, cheek, chin)
Cranial Nerve VII (Facial): Inspect face for expression and symmetry-frown, close
eyes tight, lift eyebrow, show teeth, puff cheeks out and press air out (mouth,
eyes, cheeks)
Cranial Nerve VIII (Vestibulocochlear/Acoustic): Test hearing acuity by normal
conversation heard and whispered voice test while constantly pressing on tragus
& whispering on side where youre not pressing on tragus (document distance
when normal conversation is heard)
Cranial Nerve IX (Glossopharyngel), X (Vagus):
IX: Test for ability to swallow by using tongue blade to elicit gag reflex &
palpating trachea while patient swallow.
X: Testing for sensation of pharynx by asking pt to say ahh when tongue is
depressed down with a tongue blade (want uvula and soft palate to rise in
midline & tonsillar pillars should move medially)
Cranial Nerve XI (Spinal): Examine sternomastoid and trapezius muscles for
equal size. Check equal strength by asking to turn head forcibly against
resistance applied to chin. Then shoulder shrug against resistance, (want equal
strength on both sides)[ABNORMAL: ATROPY; MUSCLE WEAKNESS; PARALYSIS;
STROKE; SURGICAL REMOVAL OF LYMPH NODES]
Cranial Nerve XII (Hypoglossal): Note position of tongue. Ask pt to stick out
tongue (note presence of vibration, tremors; and deviation of tongue, want
deviation to midline) [ABNORMAL: DEVIATION TOWARD PARALYZED SIDE; ask
person to say light, tight, dynamite (note sound of letters L, T, D, N, is clear &
disctinct)

Test sensation by random, light touch on face, arms, hands, legs, feet
Test sensation by dull/sharp touch
Test deep tendon reflexes:
Quadriceps Reflex (Knee Jerk) L2 to L4
Plantar Reflex (Babinski) L4 to S2

Skin Examine skin with corresponding region: Color and pigmentation; Temperature;
Moisture; Texture; Turgor; Lesions
Pulse Strength: 3+ increased, full, bounding; 2+ normal; 1+ weak; 0 absent


2
Heart and Neck Vessels (IPA-Inspect, Palpate, Auscultate): Chest pain?
Dyspnea? SOB? Orthopnea? Cough? Swelling of feet/legs?; Hx of High
cholesterol?, Heart murmur?, Heart disease?; Family Hx of HTN?, Obesity?,
CAD?, Stroke?,
Palpate for capillary refill <3 seconds
Inspect the neck: symmetry, lumps, pulsations
Inspect each side of the neck for a jugular venous pulse, turning head slightly to
the other side
Inspect & palpate (lymph nodes); palpate the carotid pulse (1 at a time)
Palpate the trachea (want midline)
Listen for carotid bruits (using bell, on 3 different sites, on left & right)
Inspect the precordium for any pulsations and/or heave (lift) (& palpate for
thrills/vibrations with base of fingers)
Palpate the apical impulse (for 1 full minute) & note the location (5
th
intercostal
space, midclavicular line)
Auscultate the heart sounds (S1 (apex) and S2 (base)) Z pattern (APETM-Aortic,
Pulmonic, Erbis Point, Tricuspid, Mitral) (A-R 2
nd
intercostals, P-L 2
nd
, E-L 3
rd
, T-L
4
th
, M-L 5
th
& lubb is louder)

Chest, Posterior and Lateral (IPA-Inspect, Palpate, Auscultate): Cough? SOB?
Chest pain with breathing?; Hx of respiratory infections-COPD, Emphysema,
Tuberculosis? Smoke? Environmental cause? Last TB test? Last chest x-ray?
Inspect the posterior chest: configuration (A/P vs transverse dm-A/P should be
less than transverse 2:1; thorax is symmetric, shape: elliptical-egg shaped or
oval), skin characteristics, & symmetry of shoulders & muscles
Palpate: symmetrical chest expansion; using circular motion, inspect for lumps or
tenderness
Palpate length of spinous processes (pt. bend over while you inspect spine)
Auscultate breath sounds: 9 areas - Vesicular over Peripheral lung fields [low,
soft, insp>exp]; bronchovesicular over major bronchi, between spacula
[moderate, insp=exp]; bronchial over trache [insp<exp] - Note adventitious
sounds

Chest, Anterior(IPA-Inspect, Palpate, Auscultate): Cough? SOB? Chest pain with
breathing?; Hx of respiratory infections-COPD, Emphysema, Tuberculosis?
Smoke? Environmental cause?; Last TB test? Last chest x-ray?
Inspect the anterior chest: respirations [rate, rhythm, & depth], skin
Palpate: symmetrical chest expansion; using circular motions palpate for lumps
or tenderness
Auscultate breath sounds: 5 areas; Note adventitious sounds
Abdomen (IAPP-Inspect, Auscultate, Percuss, Palpate): Appetite? Bowel
movement-normal routine, color, consistency, straining? Dysphagia? Food
intolerance? Abdominal pain? Nausea? Vomiting? Use laxatives? Hx of GI
problems? Any abdominal operations? Meds? Alcohol? Diet?
Inspect the abdomen: contour (round, protuberant, scaphoid, flat & inverted or
everted bellybutton), symmetry (quadrants), umbilicus (midline), pulsations
(aortic), skin characteristics (note striae, nevi, scars & use quadrants when noting
location), hair distribution
Auscultate bowel sounds in all quadrants-Present/Active
Percuss abdomen in all quadrants
Light palpation using circular movements in all quadrants

Peripheral Vascular: Upper and Lower Extemities: Leg pain? Cramps? Skin
changes? Swelling in arms/legs? Swollen glands? Meds?
Palpate for capillary refill <3 seconds
Inspect the extremities: symmetry (swelling/atrophy), hair distribution,
varicose/spider veins, skin characteristics
Palpate pulses bilaterally: begin temporal artery (can palpate at same time) to
posterior tibial (inner side of ankle), dorsalis pedis (on top of foot)
Palpate for temperature (starting from face to lower extremities, feeling with
back of hand not the palm) and pretibial edema or lymphedema (push at edema,
note pitting; depress for 5sec. & release)

Musculoskeketal (Grade 0-5): Joints pain, stiffness, swelling, heat, redness,
limitation of movement? Muscles pain (cramps), weakness? Bones pain,
deformity, trauma (fracture)? ADLs?
Test ROM & muscle strength of hands (grip), elbows (flexion & extension), &
shoulders (flexion, extension, hyperextension, internal-hands at the back,
external-hands behind head), abduction & adduction)
Test ROM and muscle strength of hips (laying down-legs straight up & down,
knee flexion-knee to nose, internal & external rotation, abduction & adduction),
ankles (rotation, plantar-toes downward, dorsal-toes to nose), feet (sitting at
edge of bed with bed at lowest setting and feet touching floor-perform inversion
and eversion, knees (stand with patient and perform ROM at same time with
patient)
Person to walk across room, turn, & then return (note gait and swinging of arms)

Muscle Grade: 5-Full ROM; Full resistance; 4-Full ROM; some resistance; 3-Full ROM; no resistance; 2-Full ROM;
eliminated PROM; 1-Slight Contraction; 0-No Contraction
PROM=pt needs help moving, AROM=pt independent moving