HEAD-TO-TOE ASSESSMENT GUIDE

Assessment Tests Materials Needed Procedure Normal Findings

1. General Survey 1. – 1. Check level of consciousness and attachments 1. Alert and oriented
2. Blood Pressure 2. Stethoscope, of patient 2. 120/80
3. Pulse Rate Sphygmomanometer 2. Check BP 3. 60-100 bpm
4. Respiratory Rate 3. – 3. Check PR 4. 12-20 cpm
5. Temperature 4. – 4. Check RR 5. 36.5 – 37.5 degrees Celcius
General 6. O2 Sat 5. 2 Alcohol Swabs, 5. Check temperature using axillary thermometer 6. ??
Appearance 7. Height Thermometer 6. ?? 7. varies
8. Weight 6. ?? 7. Measure height 8. varies
9. IBW 7. Tape Measure 8. Measure weight 9. varies
10. BMI and 8. Weighing Scale 9. Male: 50 kg + 2.3 kg for each inch over 5 ft 10. varies
Interpretation 9. – Female: 45.5 kg + 2.3 kg for each inch over 5 ft.
10. – 10. Calculate BMI
1. Color and 1. – 1. Inspect 1. Evenly colored skin tones without
Pigmentation 2. – 2. Use palmar surface of hand to check under skin unusual discolorations
2. Moisture 3. – folds and unexposed areas 2. Moist to dry depending on area
3. Temperature 4. – 3. Use dorsal surface of hand 3. Warm temperature
4. Texture 5. – 4. Use palmar surface of 3 middle fingers 4. Skin is smooth and even
5. Thickness 6. – 5. Use index finger and thumb 5. Skin is normally thin but callused
Skin
6. Mobility and 7. – 6. Ask client to lie down. Use 2 fingers to pinch 6. Skin is mobile, with elasticity and
Turgor skin over clavicle returns to original shape quickly.
7. Edema 7. Use thumbs to press down on skin of feet, Recoil is immediate
ankles, or pretibial area 7. Skin rebounds and does not
remain indented when pressure is
released
1. Color 1. – 1. Inspect 1. Natural or chemically colored hair
2. Distribution 2. – 2. Inspect hair on scalp, body, axillae, and pubic 2. Varying amounts of terminal and
3. Condition 3. Gloves hair fine vellus hair
Scalp and Hair
3. At 1 inch intervals, separate hair from scalp and 3. Scalp is clean and dry. Sparse
inspect and palpate for cleanliness, dryness or dandruff may be visible. Hair is
oiliness, parasites, and lesions smooth and firm, somewhat elastic
1. Color 1. – 1. Inspect nail color and markings 1. Pink tones, some longitudinal
2. Shape 2. – 2. Inspect ridging
3. Condition 3. – 3. Inspect nail grooming and cleanliness 2. 160-degree angle between nail
base and skin
Nails
3. Clean and manicured

1. Configuration and 1. – 1. Inspect for size, shape and configuration 1. Head is symmetric, round, erect,
Symmetry 2. Gloves 2. Palpate head and in midline, appropriately
Head and Face 2. Consistency 3. – 3. Inspect face related to body size
3. Facial Symmetry 4. – 4. Inspect face

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 4. Involuntary 5. – 5. Place index fingers over front of each ear as 2. Head is hard and smooth, without
Movements client opens mouth. Check for swelling. lesions
5. TMJ tenderness 3. Face is symmetric with round, oval,
elongated, or square appearance
4. No involuntary movements
5. No swelling or tenderness. Mouth
opens and closes (3-6 cm) and side
to side (1-2 cm)
1. Eyeballs 1. – 1. Inspect position and alignment of eyeballs in 1. Symmetrically aligned in sockets
2. Eyebrows 2. – socket without protruding or sinking
3. Eyelids: 3. – 2. Inspect eyebrows 2. Even
4. Bulbar Conjunctiva 4. – 3. Inspect eyelids, noting width and position of 3. Upper lid margin between upper
and Sclera 5. Gloves, cotton tip palpebral fissure, ability to close eyelids, any margin of iris and pupil. Lower lid
5. Palpebral applicator redness, swelling, discharge, or lesions margin rests on lower border of
Conjunctivae 6. Gloves 4. Client’s head is straight while looking side to iris. No white sclera seen above or
6. Lacrimal Apparatus 7. Penlight side, then up toward the ceiling. Observe below iris. Palpebral fissures
7. Cornea and Lens 8. – clarity, color, and texture horizontal
8. Iris 9. Gauge 5. Use thumbs to pull down skin below eye to 4. Bulbar conjunctive is clear, moist,
9. Pupils 10. Penlight expose palpebral conjunctiva as client looks up. and smooth. Sclera is white
10. Corneal Light 11. Opaque card Use cotton tip applicator to evert upper eyelid 5. Palpebral conjunctiva is free of
Reflex 12. Penlight while client looks down. swelling, foreign bodies, or
11. Cover Test 13. ?? 6. Inspect for tenderness of redness. Put on trauma. Pink and moist
12. Cardinal Gaze 14. Visual Acuity gloves and use 1 finger to palpate nasolacrimal 6. No tenderness, swelling, or
13. Color Vision - Distant: Snellen or duct just inside lower orbital rim drainage
14. Visual Acuity E chart 7. Shine light from side of each eye for an oblique 7. Cornea is transparent. Lens is free
- Distant Vision - Near: Snellen card view of opacities
- Near Vision 8. Inspect shape and size of iris 8. Iris is round, flat, or evenly colored
Eyes and Vision - Peripheral Vision 9. Inspect size and shape of pupil. Measure pupils 9. Pupil is round with regular border.
against gauge Equal in size (3-5mm)
10. Hold penlight 12 inches from client’s face and 10. Reflection of light on corneas in
shine light toward bridge of nose while client same exact spot, indicating parallel
stares straight ahead alignment
11. Client stares straight ahead and focuses on 11. Uncovered and covered eye
distant object. Cover one of client’s eye with remains fixed all throughout
card and observe uncovered eye’s movement. 12. Smooth and symmetric eye
Remove card and observe previously covered movement
eye’s movement. Repeat on the other eye’ 13. ??
12. Client focuses on penlight 12 inches away from 14. Distant: 20/20
face. Move penlight through 6 cardinal Near: 14/14
positions in a clockwise direction and observe Peripheral Vision: Can guess all
eye movements numbers correctly
13. ??
14. Distant: Position client 20 ft from Snellen chart
and ask to read each line until she cannot
decipher
Near: Cover one eye as client reads letters from
top to bottom. Repeat

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 Peripheral Vision: Have client focus on distant
object. Ask “Do you see my whole face?” In
each quadrant, hold up a number using your
hand and have client guess what number it is
1. Symmetry 1. – 1. Inspect size, shape, and position of ear 1. Ears are equal in size bilaterally (4-
2. Auricle Position 2. – 2. Inspect position of auricle 10 cm)
3. External Ear 3. – 3. Inspect lobule. Observe for lesions, 2. Auricle aligns with corner of each
4. External Canal 4. Penlight discolorations, and discharge. Palpate auricle eye and within 10-degree angle of
5. Whisper Test 5. – and mastoid process. Ask if pain is felt when vertical position
6. Watch Tick Test 6. Watch touched 3. Earlobes may be free, attached
7. Weber Test 7. Tuning fork 4. Pull ear up and back, shine light into ear canal soldered. Skin is smooth, with no
8. Rinne Test 8. Tuning fork 5. Rub tragus of each ear to determine better lesions lumps, or nodules. Color
hearing ear, which will be tested first. 2 ft away consistent with facial color.
from client, whisper a 2-syllable word and have Darwin’s tubercle may be present.
Ears and Hearing client repeat word back. If incorrect, repeat No discharge. Auricle, tragus, and
word once more. mastoid process not tender
6. 5 inches away from client’s ear, have client 4. Small amount of yellow, orange,
identify when they can hear ticking of watch red, brown, gray, or black
7. Strike tuning fork and place it at center of head. cerumen, that is soft, moist dry,
Ask if client can hear in one or both ears flaky, or even hard
8. Strike tuning fork and place on base of mastoid 5. 3/6 words correct
process. Once sound is no longer heard, place 6. Can hear ticking
tuning fork in front of external auditory canal 7. Vibrations hear easily in both ears.
and have client identify when no sound is heard No lateralization
anymore 8. AC>BC
1. External Portion 1. – 1. Inspect nasal color, shape, consistency, and 1. Color is same as rest of face. Nasal
2. Patency 2. – tenderness structure is smooth and
3. Internal Portion 3. Penlight 2. Occlude one nostril at a time and ask client to symmetric. No tenderness
4. Sinuses 4. – sniff of exhale 2. Client able to sniff or exhale while
3. With client’s neck slightly extended, shine light nostril is occluded
Nose and Sinuses into nostril. View nasal mucosa, nasal septum, 3. Nasal mucosa is dark pink, moist,
inferior and middle turbinates, nasal passage and free of exudate. Nasal septum
4. Using thumbs, palpate frontal and maxillary is intact and free of ulcers or
sinuses. Percuss sinuses using finger pads perforations. Turbinates are dark
pink, moist, and free of lesions
4. No tenderness. No crepitus
1. Lips 1. – 1. Inspect lip color and consistency 1. Smooth and moist without lesions
2. Teeth and Gums 2. Gloves 2. Count number of teeth, color, condition. Check or swelling
3. Buccal Mucosa 3. Penlight, tongue for any repairs. Ask client to bite down. Retract 2. 32 pearly whitish teeth with
4. Tongue depressor client’s lips and cheeks to check gums for color smooth surfaces and edges. May
5. Palate 4. – and consistency have appliances. Jaw is aligned.
Mouth and
6. Breath Odor 5. Penlight 3. Retract lips and cheeks to check color and Color and consistency of tissues
Pharynx
7. Uvula 6. – consistency along cheeks and gums are even
8. Tonsils 7. Tongue depressor, 4. Inspect for color, moisture, size, texture, 3. Tissue is smooth and moist
9. Oropharynx penlight fasciculations, and midline protrusion. Palpate without lesions
10. Gag reflex 8. Tongue depressor any lesions for induration. Assess ventral 4. Tongue is pink, moist, moderate
size with papillae. No lesions.
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 9. Tongue depressor, surface of tongue, frenulum, and area under Ventral surface is smooth, shiny,
penlight tongue. Observe sides of tongue pink with visible veins and no
10. Tongue depressor 5. Ask client to open mouth, and shine light on lesions. On sides, no lesions,
roof of client’s mouth. Observe color and ulcers, or nodules present
integrity 5. Hard palate is pale or whitish with
6. Inspect without client knowing firm, transverse rugae. Soft palate
7. Apply tongue depressor halfway on tongue and is pinkish, movable, spongy and
shine light into client’s open mouth. Have client smooth
say “ah” 6. No unusual odor
8. Inspect tonsil color, size, and presence of 7. Uvula is fleshy, solid structure that
exudate or lesions. Grade tonsils hangs freely in midline. Uvula and
9. Keep tongue depressor in place, shine light on soft palate elevate symmetrically
back of throat. Observe color of throat, note 8. Tonsils present or absent. Pink and
any exudate or lesions. symmetric. Grade of 1+. No
10. Move tongue depressor towards throat. Warn exudate, swelling, or lesions
patient before doing so 9. Throat is pink, without exudate or
lesions
10. Client gags
1. Symmetry 1. Penlight 1. Observe neck’s position, symmetry, lumps or 1. Neck is symmetric, with head
2. ROM 2. – masses. Shine light on masses to check for centered and without bulging
3. Trachea 3. – swelling. masses
4. Thyroid Gland 4. – 2. Ask client to turn head to the right and to the 2. Flexion: 45 degrees
5. Lymph Nodes 5. – left, touch each ear to the shoulder, touch chin Extension: 55 degrees
to chest, and lift chin to ceiling Lateral Abduction: 40 degrees
3. Place finger in sternal notch. Place thumb on Rotation: 70 degrees
each side of trachea and palpate each tracheal 3. Trachea is midline
Neck
ring. 4. Landmarks are midline
4. Palpate hyoid bone, thyroid cartilage, cricoid 5. No enlargement or tenderness
cartilage
5. Palpate the following lymph nodes:
preauricular, posterior auricular, occipital,
tonsillar, submental, submandibular, superficial
cervical, deep cervical chain, posterior cervical,
supraclavicular

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 1. Shape and 1. – 1. Have client disrobe and sit with arms hanging 1. Round and pendulous. One breast
Symmetry 2. – freely larger than the other
2. Nipples 3. – 2. Note size and direction, dryness, lesions, 2. Nearly equal bilaterally in size and
3. Masses 4. Gloves, slide bleeding, or discharge in same location on each breast.
4. Discharges 5. – 3. Ask client to raise arms overhead, then press Nipples are everted, inverted or
5. Lymph Nodes her hands against her hips, then press her flat
hands together, then to lean forward from the 3. Breast rise symmetrically with no
waist. sign of dimpling or retraction. No
Breasts Palpate breast in circular, wedge, or vertical masses, dimpling, or retraction
strip pattern. 4. No discharge
4. If discharge occurs, place on slide and sent to 5. No palpable nodes
lab
5. Palpate the following 7 nodes: brachial, central,
anterior axillary, posterior axillary,
supraclavicular, infraclavicular, epitrochlear

1. Configuration 1. – 1. Client sits with arms at sides. Stand behind 1. Symmetric and nonprotruding
2. Retractions and 2. – client and observe position of scapulae, and scapulae. Shoulders and scapulae
Bulging 3. – shape and configuration of chest wall are at equal horizontal positions.
3. Depth, Rhythm 4. – 2. Watch client breathe and note use of muscles 1:2 ratio of anteroposterior to
and Quality of 5. – 3. Note client’s posture and ability to breather transverse diameter
Respiration 6. – comfortably 2. Client does not use accessory
4. Tenderness and 7. – 4. Use fingers to palpate for tenderness, warmth, muscles to assist breathing
Sensation 8. – pain, or other sensations 3. Sitting up and relaxed, breathing
5. Crepitus 9. – 5. Use fingers to palpate for crackling sensation easily with arms at sides or lap
6. Fremitus 10. Diaphragm of 6. Use ulnar edge or ball of one hand to asses for 4. No tenderness, pain, or unusual
7. Chest Expansion stethoscope vibrations. Ask client to say “99” for each area sensations. Temperature equal
8. Percussion 11. Diaphragm of 7. Place hands on posterior chest wall at T9-T10 bilaterally
9. Diaphragmatic stethoscope while pressing a small skin fold. As client takes 5. No palpable crepitus
Excursion 12. Diaphragm of a deep breath, observe movement of thumbs 6. Symmetric and Identifiable
10. Breath Sounds stethoscope 8. Using fingers, percuss the following areas: fremitus
Chest and Lungs
11. Adventitious apices of scapulae, tops of shoulders, 7. 5-10 cm upon deep breath
Sounds intercostal spaces, lateral and bases aspects of 8. Resonance over lung tissue.
12. Voice Sounds lungs Flatness over scapula
- Egophony 9. Exhale, hold breath, percuss T7 until tone 9. Excursion is equal bilaterally and
- Bronchophony changes from resonance to dullness. Mark. measure 3-5 cm. Higher on right
- Whispered Inhale, hold breath, percuss downward until side due to position of liver. 7-8 cm
Pectoriloquy resonance to dullness. Mark, then measure in well-conditioned clients
distance 10. Bronchial, Bronchovesicular, and
10. Deep breath in and out per area of auscultation vesicular breath sounds
11. Note while auscultating for breath sounds 11. No adventitious sounds
12. Egophony: Ask client to repeat the letter “E” 12. Egophony: soft and muffled, “E”
while you listen over chest wall distinguishable
Bronchophony: Ask client to repeat the phrase Bronchophony: soft, muffled, and
“99” while you listen over chest wall indistinct
Whispered pectoriloquy: Ask client to whisper

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 and repeat “1,2,3” while you auscultate chest Whispered pectoriloquy: faint and
wall muffled

1. Heaves and Apical 1. – 1. Have client in supine position with head at 30- 1. Apical impulse may or may not be
Impulse 2. – 45 degrees, stand on client’s right side and look visible at left MCL, 4th/5th ICS.
2. Abnormal 3. Diaphragm of for apical impulse. Note for any pulsations Apical impulse size of 1-2cm
Pulsations stethoscope (heaves) other than apical pulsation. 2. No pulsations are palpated.
3. Apical Pulse 4. Diaphragm of 2. Use palmar surface to palpate apex, left sternal 3. 60-100 bpm with regular rhythm.
- Rate stethoscope border, and base RRR varies by age
- Rhythm 5. Diaphragm and bell 3. Assess heart rate and rhythm at apical point 4. S1 and S2 can be identified
- Pulse Deficit of stethoscope 4. Identify “lub” and “dubb” 5. No extra sounds
4. S1 Sounds and S2 6. Diaphragm of 5. Use diaphragm first, then bell to auscultate 6. No murmurs
Sounds stethoscope over entire heart area 7. Jugular vein not distended,
5. Extra Heart Sounds 7. Tangential lighting 6. Listen for swishing sound across entire heart bulging, or protruding at 45
6. Murmurs 8. Bell of stethoscope area degrees or greater
7. Jugular Vein 9. – 7. Position client in a supine position with head at 8. No bruits
Distention and 10. – 30, 45, 60, and 90 degrees. Have client’s head 9. Arms are bilaterally symmetric. No
Jugular Venous 11. – turned slightly away from the side being edema
Pressure 12. – evaluated. Use tangential lighting to observe 10. <2s
8. Bruits 13. – distention, protrusion, or bulging 11. Pink coloration returns within 3-5 s
Heart and
9. Arm/ Leg Edema 14. – 8. Check for bruits on carotid artery 12. Veins are flat and barely seen
Peripheral
10. Nail Bed and CRT 9. Observe arm size and venous pattern; also look under surface of skin
Vasculature
- Upper Extremities for edema 13. No pain upon dorsiflexion
R and L 10. Compress nail bed until it blanches, then 14. Strong pulses: temporal, carotid,
- Lower Extremities release pressure and calculate time it takes for radial, brachial, femoral, dorsalis
R and L color to return pedis, posterior tibialis
11. Allen Test R and L 11. Have client close fist as you occlude both radial May not be detectable: ulnar
12. Varicosities and ulnar arteries, then let client release fist
13. Homan’s Sign R and watch as hand turns pale. Release pressure
and L on ulnar artery. Repeat, but release pressure
14. Peripheral Pulses on radial artery instead
- Rate and Strength 12. Ask client to stand and inspect for superficial
of R and L: vein thrombophlebitis and palpate to check for
Temporal, Carotid, tenderness. Note redness or discoloration
Brachial, Radial, 13. Ask client to be in supine position and to flex
Ulnar, Femoral, their knee. With one hand, support the leg
Popliteal, Posterior from underneath the knee, and with the other
Tibialis, Dorsalis hand on the lifted foot. Dorsiflex client’s foot
Pedis 14. Palpate for peripheral pulses
1. Contour & Girth 1. Tape measure 1. Have client in supine position and sit on client’s 1. Abdomen is flat, rounded, or
2. Symmetry 2. – side. Look at abdomen at level slightly higher scaphoid
3. Striae 3. – than the abdomen. Inspect area between lower 2. Abdomen is symmetric
Abdomen 4. Umbilicus 4. – ribs and pubic bone. Measure abdominal girth 3. New striae are pink or bluish. Old
5. Aortic Pulsations 5. – 2. Client in supine position stria are silvery white and linear
6. Peristaltic Waves 6. – 3. Inspect for stretch marks 4. Skin surrounding umbilicus is
7. Bowel Sounds 4. Note color of umbilicus, location, and contour similar to abdominal skin,
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8. Vascular sounds 7. Diaphragm of 5. Palpate abdomen for pulsations umbilicus is midline at lateral line,
and Friction Rubs stethoscope 6. Observe for waves and contour is recessed (inverted)
9. Percussion Tone 8. Bell of stethoscope; 7. Warm diaphragm and place on abdomen, or protruding <5.cm and is round/
10. Liver Span Diaphragm of applying light pressure if no tenderness. Begin conical
11. Liver Palpation stethoscope in RLQ and proceed clockwise, covering all 5. Slight pulsation of abdominal
12. Spleen 9. – quadrants (1 min per quadrant = 4-5 min total). aorta, which is visible in
13. Masses Palpated 10. Marker Note intensity, pitch, and frequency epigastrium, extends full length in
14. Kidneys 11. – 8. Listen for bruits using bell over abdominal aorta thin people
15. Urinary Bladder* 12. – and renal, iliac, and femoral arteries. Listen for 6. Not usually see, but sometimes in
16. Shifting Dullness* 13. – friction rub using diaphragm over right and left thin people
17. Fluid Wave Test* 14. – lower rib cage 7. 5-30 soft clicks per minute
18. Rebound 15. – 9. Percuss lightly and systematically over all 8. No bruits. No friction rub over liver
Tenderness* 16. – quadrants and spleen
19. Psoas Sign 17. – 10. To assess lower border, percuss upward at RLQ 9. Generalized tympany over
20. Obturator Sign 18. – MCL and note change from tympany to abdomen. Dullness over liver and
19. – dullness. Mark. Ask client to take deep breath spleen
20. – and hold, then repeat procedure. 10. 6-12 cm
To assess upper border, percuss upper right 11. Usually not palpable
chest at MCL going downward, noting change 12. Seldom palpable
from lung resonance to liver dullness. Mark. 13. No masses, possible tenderness
Measure distance between two marks upon deep palpation
11. Have client in prone position and stay on 14. No tenderness. Dull thud. Usually
client’s right side. Place left hand underneath not palpable
right side (11th and 12th rib), and place right 15. Empty bladder is neither palpable
hand lateral to right costal margin, with nor tender
fingertips pointing towards head. Ask client to 16. Borders between tympany and
inhale, and begin to palpate dullness remain relatively constant
12. At client’s right side, place left arm under throughout position changes
posterior lower ribs at client’s left side and pull 17. No fluid wave transmitted
up gently. Place right hand at left costal margin 18. No rebound tenderness
with fingers pointing toward heard. Ask client 19. No abdominal pain
to inhale and begin palpation 20. No abdominal pain
13. Deeply palpate abdomen and check for masses.
Note location, size, shape, consistency,
demarcation, pulsatility, tenderness and
mobility
14. Blunt percussion of kidneys at costovertebral
angles as client sits upright. In prone position,
palpate kidneys by using left hand to support
right posterior flank with left hand and placing
right hand in RUQ just below costal margin at
MCL
15. In supine position, palpate at symphysis pubis
and move upward to estimate bladder borders
16. Have client in supine position and percuss
flanks from the bed upward toward the
umbilicus. Note change from dullness to

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 tympany. Move client to side lying position and
percuss abdomen from the bed upward. Mark
level where dullness changes to tympany.
17. In supine position. Have assistant place ulnar
side of hand and lateral side of arm firmly on
midline of abdomen. Place palmar surface of
one hand on one side of client’s abdomen. Use
other hand to tap the opposite side of
abdominal wall.
18. Palpate abdomen deeply at 90 degrees halfway
between umbilicus and anterior iliac crest.
Suddenly release pressure. Watch client’s facial
expression
19. Ask client to lie on left side and hyperextend
client’s right leg
20. In supine position, support client’s right knee
and ankle. Flex hip and knee, rotate the leg
internally and externally
1. Perianal Area 1. Gloves, lubricating 1. As client bears down, spread client’s buttock 1. Hairless, moist, tightly closed. Skin
2. Sacrococcygeal jelly and inspect anal opening and surrounding area around anus is coarser and darkly
Area 2. Gloves, lubricating for lumps, ulcers, lesions, rashes, redness, pigmented. Surrounding areas free
3. Anus jelly fissures, or thickening of epithelium of abnormalities
4. Rectum 3. Gloves, lubricating 2. Inspect area for swelling, redness, dimpling or 2. Smooth, free of redness and hair
jelly hair 3. Sphincter relaxes and allows finger
4. Gloves, lubricating 3. Inform client before inserting gloved lubricated to enter anus. Client can close
jelly index finger into anus. Place pad of finger on sphincter on command. Anus is
Rectum anal opening and apply slight pressure to relax smooth, non-tender, free of
sphincter. Finger pad facing down as finger nodules and hardness.
enters anus. Ask client to tighten external 4. Mucosa is soft, smooth, non-
sphincter, note tone. Rotate finger to examine tender, and free of nodules
muscular anal ring for tenderness, nodules,
hardness.
4. Insert finger further into rectum as far as
possible. Turn hand clockwise then
counterclockwise
1. Penis 1. Gloves 1. Sit on stool while client stands in front facing 1. Base and pubic hair are free of
- Base and Pubic 2. Gloves you. Ask client to raise drape. excoriation, erythema and
Hair 3. Gloves - Note for pubic hair growth pattern and any infestation. Skin of shaft is
- Shaft 4. Gloves, lubricating excoriation, erythema, or infestation wrinkled and hairless, free of
- Foreskin and jelly - Observe shaft for rashes, lesions, or lumps. rashes, lesions or lumps. In non-
Male Genitalia Glans Palpate any abnormalities erect state, shaft is flaccid, soft,
and Prostate - Urethral Opening - Inspect foreskin or color, location, and and non-tender. Foreskin is intact
and Discharge integrity. Observe glans’ size, shape, and and uniform in color with penis.
2. Scrotum lesions or redness. If client is not circumcised, Glans size varies, and surface is
- Size, Shape, and ask him to retract foreskin. smooth, free of lesions and
Position - Note location of urinary meatus. Palpate for redness. If uncircumcised, foreskin
- Scrotal Skin retracts easily, may have smegma.

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 - Testicles and urethral discharge using index finger and Urinary meatus is slit-like and at
Nearby Structures thumb center of glans, free of discharge
- Masses 2. Ask client to hold penis out of the way. 2. Left scrotal sac hangs lower than
3. Inguinal Area - Observe for swelling, lumps, or bulges right side. Scrotal skin is thin and
- Hernia - Observe scrotal skin color, integrity, and rugated, slightly darker than penis,
- Lymph Nodes lesions or rashes by spreading out scrotal folds with no lesions or rashes. Testes is
4. Prostate - Using thumb and 2 fingers, palpate scrotal smooth, firm, rubbery, mobile,
contents such as testes, epididymis, spermatic free, and tender to pressure.
cord and vas deferens. Note any swelling, Epididymis is non-tender, smooth,
tenderness, or nodules and softer than testes. Spermatic
- Perform trans-illumination if masses were cord and vas deferens are uniform
palpated on both sides. Cord is smooth,
3. Use right finger to press upward into triangular- non-tender, and rope-like
shaped, slit-like opening of external inguinal 3. Bulging or masses are not
ring. Once inside, ask client to cough, and feel palpated. No enlargement or
for any bulges. Repeat on other side. Note for tenderness of nodes.
any nodes 4. Prostate is non-tender and
4. As client bears down, insert lubricated index rubbery, has 2 lateral lobes divided
finger into rectum and using finger pad to by median sulcus. Lobes are
palpate anterior surface of rectum smooth, 2.5 cm long, heart-shaped
1. External Genitalia 1. Gloves 1. In lithotomy position 1. Pubic hair distributed in an
- Mons Pubis 2. Gloves - Mons pubis: note distribution of hair, inverted triangle with no signs of
- Inguinal Lymph infestation, lesions infestation. No enlargement or
Nodes - Check for lymph nodes swelling of lymph nodes. Labia
- Labia Majora and - Observe labia majora and perineum for majora are equal in size and free of
Perineum lesions, swelling, and excoriation lesions, swelling, and excoriation.
- Labia Minora, - Use gloved hand to separate labia majora and Perineum is smooth. Labia minora
Clitoris, and inspect for lesion, excoriation, swelling, or is symmetric, dark pink, and moist,
Female Genitalia Vaginal Opening discharge Clitoris is a small mound of erectile
- Urethra - Palpate Bartholin’s glands by pinching inferior tissue, varying in size. Vaginal
- Bartholin’s portion of posterior labia majora to anterior opening is positioned below
Glands portion. Repeat on opposite side urethral meatus. Urethra is small
2. Internal Genitalia 2. Insert gloved index finger into vagina and slit-like. Bartholin’s glands are
- Vaginal Mucosa - Note if lining is thinning or feels dry. Ask client soft, non-tender, and drainage free
- Cervix is squeeze around finger 2. Client should be able to squeeze
- Observe cervical color, size and position around finger. Surface of cervix is
smooth, pink, and even
1. Gait 1. – 1. Ask client to walk around room 1. Evenly distributed weight, able to
2. Stature/ Posture & 2. – 2. Have client stand with feet together, noting stand on heels and toes, toes point
Symmetry 3. – alignment of head, trunk, pelvis, and straight ahead, equal on both
3. ROM 4. – extremities. Observe posture while sitting sides, posture erect, movements
Back and
* Spine 5. – 3. * Cervical: ask patient to flex, hyperextend, coordinated and rhythmic, arms
Extremities
- Cervical 6. – laterally bend, and rotate neck swinging in opposition, stride
(Musculoskeletal)
- Thoracic and 7. – Lumbar: Ask client to touch toes and observe length appropriate
Lumbar 8. – symmetry of shoulders, scapula and hips 2. Posture is erect and comfortable
* Upper * Shoulder & Arms: Ask client to put arms at for age
Extremities sides. Ask to move the arms forward, then 3. No pain upon movement

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 - Shoulders & Arms backward with elbows straight. Then have 4. No palpable crepitus
- Elbows client bring hands overhead, elbows straight, 5. No fasciculations
- Wrists following by moving hands in front of the body 6. No body deformities
- Hands and past midline with elbows straight (abduction 7. Can resist
Fingers and adduction). In continuous motion, have 8. Phalen and Tinel: No tingling,
* Lower client brings hands together behind the head numbness, burning, or pain
Extremities with elbows flexed (external rotation) and Laseque: no pain in leg or back
- Hips behind the back (internal rotation) Bulge: no bulge of fluid appears on
- Knees * Elbows: flexion, extension, pronation, the medial side of the knee
- Ankles and Feet supination Ballottement: no movement of
4. Crepitus * Wrists: flexion, extension patella noted, no pain
5. Fasciculations * Hands and Fingers: abduction, adduction, McMurray: no pain or clicking
6. Bony Deformities flexion, hyperextension, thumb away from
7. Muscle Strength fingers, thumb touching base of small finger
8. Special Tests * Hips: Hip flexion with knee straight, hip
- Phalen’s Test flexion with knee flexed, abduction, adduction,
- Tinel’s Test external rotation, internal rotation,
- Lasèque Test hyperextension
- “Bulge” Knee * Knees: flexion, extension, hyperextension,
Test* walk normally
- “Ballottement” * Ankles and Feet: dorsiflexion, plantar flexion,
Knee Test eversion, inversion, abduction, adduction; toes:
- McMurray’s Test flexion, extension
4. Observe for any crackling sensation
5. Observe for shaking of any body part
6. Note any bony deformities
7. Apply force and make client resist when testing
ROM
8. Phalen: Ask client to place back of hands
against each other while flexing wrists 90
degrees with fingers pointed downward and
wrist dangling. Hold for 1 min
Tinel: Use finger to percuss lightly over median
nerve on the inner aspect of writs
Laseque: leg raised until pain is felt, lower same
leg 5%-10%, dorsiflex foot with straight leg
Bulge: In supine position, use ball of hand to
firmly stroke medial side of knee upward 3-4
times to displace accumulated fluid. Then press
on the lateral side of the knee and look for a
bulge on the medial side of the knee
Ballottement: In supine position, press non-
dominant thumb and index finger on each side
of patella. With dominant fingers, push patella
down on the femur and feel for fluid or a click
McMurray: In supine position, flex one knee
and hip, then place thumb and index finger of

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 one hand on either side of knee. Use other
hand to hold heel of foot up. Rotate lower leg
and foot laterally, slowly extend knee. Ask if
pain is felt
1. Mental Status/ 1. Pencil, paper, pen 1. Mental Status/ Cerebral Function 1. * Alert and oriented
Cerebral Function 2. ?? * Level of Consciousness: Ask client for name, * score of 15
- Level of 3. cotton wisp, paper address, and phone number, identify where * cooperative and purposeful in
Consciousness clip, test tubes with you are, the day, and time of day interactions, affect is appropriate
- GCS hot and cold water, * GCS: for clients who have experienced a for situation
- Mood and Affect tuning fork, EKG traumatic brain injury * Dress, Hygiene, Grooming: dress
- Dress, Hygiene, calibers, coin, * Mood and Affect: observe behavior and affect is appropriate for occasion and
and Grooming 4. scented object, * Dress, Hygiene, Grooming: observe weather. Client is clean and
- Facial Expressions Snellen chart, * Facial Expressions: observe eye contact groomed appropriately for
- Speech & newspaper, safety * Speech & Vocabulary: note tone, clarity, and occasion
Vocabulary pin, paper clip, pace * Facial Expressions: maintains eye
- Thought cotton wisp, tuning * Thought Processes: observe for clarity, contact
Processes fork, tongue content, and perceptions expressed; “Tell me * Speech & Vocabulary: clear,
- Attention depressor, cup of more about what you just said” or “Tell me moderate tone and pace, culturally
- Remote Memory water what your understanding is of the current appropriate
* Recent Memory 5. reflex hammer situation or your health” * Thought Processes: expresses
- Fund of 6. reflex hammer * Attention: “Please pick up the pencil with full, free-flowing thoughts
Information 7. – your left hand, place it in your right hand, then * Attention: listens and follows
- Abstract hand it to me” directions without difficulty
Reasoning & * Remote: “When did you get your first job?” or * Remote Memory: recalls past
Similarities “When is your birthday?” events
Neurological - Judgement * Recent: “What did you eat today?” “What is * Recent Memory: recalls events
- Visual Perceptual the weather today?” without difficulty
and Constructional * Fund of Information: Ask client to repeat 4 * Fund of Information: can recall
Ability unrelated, non-rhyming words, and have client words after 5, 10, 30 min
2. Motor/ Cerebellar repeat is after 5, 10, and 30 min * Abstract Reasoning &
Function * Abstract Reasoning & Similarities: Ask client Similarities: explains similarities
- Rapid Alternating to compare objects, ask client to explain a and differences, and proverbs
Movements proverb correctly
- Finger-Thumb * Judgement: “What do you do if you have * Judgement: sound and rational
Test pain?” answers
- Finger-Nose Test * Visual Perceptual and Constructional Ability: * Visual Perceptual and
- Heel-to-Shin Test Ask client to draw the face of a clock or copy Constructional Ability: draws face
- Button-Unbutton simple figures of clock or can copy simple figures
Shirt 2. Motor/ Cerebellar Function 2. Motor/ Cerebellar Function
- Tandem Walk - Rapid Alternating Movements - Rapid Alternating Movements
- Romberg Test * Finger-Thumb Test: Ask client to sit down, ask * Finger-Thumb Test: Can touch
- Involuntary to touch finger to thumb and to increase speed rapidly
Movements as client progresses. Repeat on other side * Heel-to-Shin Test: can run each
3. Sensory Function * Heel-to-Shin Test: In supine position, ask heel smoothly down each shin
- Light Touch client to slide heel of right foot down the left * Button-Unbutton Shirt: can
Sensation shin, Repeat on other side button and unbutton in short span
- Discrimination * Button-Unbutton Shirt: ask client to button of time

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 bet. Sharp/ Dull and unbutton shirt * Tandem Walk: 10s >
Sensations * Tandem Walk: Let client sit, stand, walk away * Romberg Test: Stands erect with
- Temperature from then towards chair, and sit again minimal swaying
Sensation * Romberg Test: Ask client to stand erect with * Involuntary Movements: none
- Vibratory hands at side and feet together. Then ask client 3. Sensory Function
Sensation to close eyes and stay in same position for 20s * Light Touch Sensation &
- Two-Point * Involuntary Movements: Observe Discrimination bet. Sharp/ Dull
Discrimination fasciculations, tics, or tremors Sensations: can differentiate
- Stereognosis 3. Sensory Function between light, dull, and sharp
- Graphesthesia * Light Touch Sensation: Ask client to close eyes sensation
- Kinesthesia and report when stimuli can be felt. Apply * Temperature Sensation: can
4. Cranial Nerve stimulus using cotton wisp all over body differentiate hot from cold
Testing * Discrimination bet. Sharp/ Dull Sensations: * Vibratory Sensation: can
- CN I (Olfactory) Apply paper clip, the safety pin on client’s skin correctly identify sensation
- CN II (Optic) * Temperature Sensation: Apply hot or cold * Two-Point Discrimination:
- CN III, IV, and VI test tubes to skin and ask what temperature is - fingertips: 2-5mm
(Oculomotor, felt - forearm: 40 mm
Trochlear, * Vibratory Sensation: Strike tuning fork and - dorsal hands: 20-30 mm
Abducens) place base on distal radius, forefinger tip, - back: 40 mm
- CN V (Trigeminal) medial malleolus, and tip of great toe. Repeat - thighs: 70 mm
- CN VII (Facial) on other side * Stereognosis: can identify objects
- CN VIII * Two-Point Discrimination: Ask client to * Graphesthesia: can identify
(Vestibulocochlear) identify number of points (1 or 2) felt when number
- CN IX and X touched with EKG calibers and measure * Kinesthesia: can identify
(Glossopharyngeal distance between 2 points when client can no direction of movements
and Vagus) longer distinguish 2 points as separate 4. Cranial Nerve Testing
- CN XI (Spinal * Stereognosis: Have client close eyes, and give * CN I (Olfactory): correctly
Accessory) a coin. Let client identify object. Repeat with identifies scent present in each
- CN XII another object nostril
(Hypoglossal) * Graphesthesia: Have client look away. Use * CN II (Optic): 20/20, 14/14, full
5. Deep Tendon blunt object to write a number on palm of visual fields
Reflexes client’s hand. Have client identify number * CN III, IV, and VI (Oculomotor,
- Biceps R and L written. Repeat on other hand Trochlear, Abducens): eyelid
- Patellar R and L * Kinesthesia: Ask client to close both eyes. covers about 2 mm of iris. Eyes
- Triceps R and L Move client’s finger or toe up or down. Have move in smooth, coordinated
- Achilles R and L client tell what direction it was moved. Repeat motion in all directions. Bilateral
- Brachioradiallis R on other side illuminated pupils constrict
and L 4. Cranial Nerve Testing: Have client sit in a simultaneously. Pupil opposite the
6. Superficial Reflexes comfortable position at eye level one illuminated constricts
- Abdominal * CN I (Olfactory): Ask client to clear nose to simultaneously
- Cremasteric remove any mucus, then close eyes, occlude * CN V (Trigeminal): Temporal and
- Plantar one nostril, and identify a scented objected. masseter muscles contract. Client
7. Pathologic Reflexes Repeat for other nostril correctly identifies stimulus
- Brudzinki’s Sign * CN II (Optic): Use Snellen chart to assess * CN VII (Facial): Movements are
- Kernig’s Sign vision in each eye, ask client to read newspaper symmetric
paragraph, assess visual fields * CN VIII (Vestibulocochlear): client
* CN III, IV, and VI (Oculomotor, Trochlear, can hear whispered words. AC > BC

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 Abducens): Inspect margins of eyelids of each
eye. Assess cardinal fields. Assess pupillary
response to light and accommodation in both
eyes
* CN V (Trigeminal): Ask client to clench teeth
while palpating temporal and masseter
muscles. Tell client you are going to touch
forehead, cheeks, and chin with sharp or dull
sensation, to close eyes and identify when
stimulus is felt. Repeat test for light touch of
cotton wisp
* CN VII (Facial): Ask client to smile, frown and
wrinkled forehead, show teeth, puff out
cheeks, purse lips, raise eyebrows, close eyes
tightly against resistance
* CN VIII (Vestibulocochlear): Weber and Rinne
test
* CN IX and X (Glossopharyngeal and Vagus):
Use tongue depressor and ask client to say
“ah”, check gag reflex, check ability to swallow
* CN XI (Spinal Accessory): Ask client to shrug
shoulders against resistance. Ask client to turn
head against resistance, first to the right then
to the left
* CN XII (Hypoglossal): Ask client to protrude
tongue, move it to each side against resistance
of a tongue depressor. Then put back in mouth
5. Deep Tendon Reflexes: Have client sitting
* Biceps R and L: Ask client to partially bend
arm at elbow with palm up. Place thumb over
biceps tendon and strike thumb with pointed
side of hammer. Repeat on other side
* Patellar R and L: Ask client to let both legs
hang freelt off the side of exam table. Use flat
side of reflex, tap patellar tendon located
below patella. Repeat on other side
* Triceps R and L: Ask client to hang arm freely
(“limp”) while you support it with non-
dominant hand. With elbow flexed, use flat side
of reflex hammer to tap tendon above
olecranon process. Repeat on other side
* Achilles R and L: With client’s leg hanging
freely, dorsiflex foot. Tap Achilles tendon with
flat side of reflex hammer
* Brachioradiallis R and L: Ask client to flex
elbow with palm down and hand resting on
abdomen or lap. Use flat side of hammer to tap
* CN IX and X (Glossopharyngeal
and Vagus): Uvula and soft palate
rise bilaterally and symmetrically,
gag reflex intact, client swallows
without difficulty
* CN XI (Spinal Accessory): strong
contraction of trapezius and
sternocleidomastoid muscles
* CN XII (Hypoglossal): smooth and
symmetric tongue movement and
bilateral strength
5. Deep Tendon Reflexes
* Biceps R and L: elbow flexion and
bicep contraction
* Patellar R and L: knee extends,
quadriceps muscle contracts
* Triceps R and L: elbow extends,
tricep contracts
* Achilles R and L: Plantar flexion
of foot
* Brachioradiallis R and L: flexion
and supination of forearm
6. Superficial Reflexes
* Abdominal: abdominal muscles
contract, umbilicus deviates
toward side being stimulated
* Cremasteric: Scrotum elevates
on stimulated side
* Plantar: flexion of toes
7. Pathologic Reflexes
* Brudzinki’s Sign: hips and knees
remain relaxed and motionless
* Kernig’s Sign: no pain is felts
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 tendon at radius at 2 inches above wrist.
Repeat on other side
6. Superficial Reflexes
* Abdominal: Stroke abdomen lightly on each
side, above and below umbilicus
* Cremasteric: In male clients, stroke inner
aspect of upper thigh
* Plantar: Using end of reflex hammer or
tongue blade, stroke lateral aspect of sole from
heel to ball of foot, curving medially across the
ball. Repeat on other side
7. Pathologic Reflexes: Client in supine position,
use your hands to flex client’s neck forward
until chin touches chest if possible
* Brudzinki’s Sign: watch hips and knees in
reaction to maneuver
* Kernig’s Sign: flex client’s leg at both the hip
and the knee, then straighten knee

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