HEAD-TO-TOE ASSESSMENT

General Survey:  B.J. is male, awake, oriented to person, place, time and calm. Patient is
cooperative and respond to questions appropriately. Facial features are symmetric and
establishes eye contact when conversing with others. . Dress is appropriate for weather and
occasion. Patient is clean and groomed. Gait is coordinated with arms swinging at sides. With
the following V/S: BP=120/80 mmHg, PR= 75 bpm, RR-18 cpm, T= 35.5 C/ axilla. Pt. is 5’5 in
o

height and weight is 57kg.

  

SKIN: The skin is light brown, smooth and warm to touch. No redness and swelling noted. The
skin of patient is moist to dry. Skin is mobile with elasticity and returns to origin quickly. Recoil is
immediate.

SCALP & HAIR: Scalp is clean and dry. Hair is color black, firm and elastic.

NAILS: Upper and lower extremities have transparent nail beds and nails are firmly attached to
their nail beds. Finger nails are clean, short and pinkish.CRT is immediate in upper extremities
and lower extremities. No clubbing noted.

HEAD & FACE: Head is hard and smooth without lesions. Head is symmetric, erect, round, in
midline and appropriately related to body size. No abnormal movements noted. Temporal artery
is not tender, no swelling and redness. Mouth opens and closes fully. Swollen face and lips
noted with no lymphadenopathy.

EYES & VISION: Eyeballs are symmetrically aligned in sockets without protruding or sinking.
The upper lid is between upper margin of iris and upper margin of pupil, lower lid margins rests
on the lower border of the iris. Upper and lower lids meet completely when closed. Sclera is
clear. The lower and upper palpebral conjunctivae are clear and free of swelling or lesions. The
lens are free of opacities. Both pupils are round and reacts to light and accommodation.
Reflection of light on the corneas is in exact same spot on both eyes. Uncovered eye remains
fixed straight ahead and covered eye is remain fixed straight ahead after being uncovered. Eye
movement is smooth and symmetric throughout all six directions. The ct. can read the
nameplate and has 20/20 vision without eyeglasses. The patient was able to identify the
numbers in four visual fields.

EARS: The ears are equal in size bilaterally about 5cm and attached. Ears are smooth with no
lesions, color is consistent with facial color. Auricle, tragus and mastoid process are not tender. 

NOSE & SINUSES: Color is the same with the rest of the face, nasal structure is smooth,
symmetric and not tender. Ct. is able to sniff through each nostril while other was occluded. No
tenderness and crepitus was noted upon palpation on the frontal and maxillary sinuses

MOUTH & PHARYNX: Lips are moist and swollen. There are 30 white to yellow teeth, no dental
carries, the two lower third molars of client was extracted. The buccal mucosa is pinkish in color
and free from lesions. Tongue is pink, moist and a moderate size with papillae present and no
lesions. The ventral surface is smooth, shiny, pink with visible veins and no lesions noted. The
uvula hangs freely in midline, no redness or exudate is noted. The tonsils are pink, symmetric
and +1. Throat is pink without exudate or lesions. The gag reflex is intact.
NECK: The neck is symmetric, with head centered and without bulging masses. Thyroid
cartilage and cricoid cartilage move upward symmetrically as ct. swallows. Neck movement is
smooth with 45-degree flexion, 50-degree extension, 40-degree lateral abduction, and 70-
degree rotation. No welling and enlargement in preauricular, tonsillar, submandibular,
submental, supraclavicular, deep chain, superficial & posterior cervical nodes.

CHEST, LUNGS & Heart: Nasal flaring was not observed. Nailbeds are pink and in 160-degree
angle with the skin. Ct. does not use accessory muscles to assist breathing in sitting position.
Respirations are relaxed, effortless, quiet and in regular rhythm of 18 cpm. Equal chest
expansion and clear breath sounds was noted. Distinct S1 and S2 with no murmurs.

PERIPHERAL VASCULATURE: Arms are bilaterally symmetric. Skin is warm to touch

bilaterally. Radial pulses in both left and right was 77bpm and bilaterally strong (2+). Artery
walls are elastic. Legs are identical in size and shape.

ABDOMEN: Flat abdomen with no masses . Negative in murphy`s and psoas sign. Tenderness
on RUQ and hypogastric area was noted.

BACK & EXTREMITIES:.Grade 1 edema of both ankles was noted .Patient’s gait is steady,
opposite arms swings. , Spine, shoulders, elbows, hands, fingers, hips, knees and feet are in full
ROM against gravity, full resistance. Overall muscle strength is 5/5.

Muscle strength:             Scale:

5 – Full ROM against gravity, full resistance
5/5 5/5 4 – Full ROM against gravity, some resistance
3 – Full ROM with gravity
_________  2 – Full ROM with gravity eliminated (passive
motion)
5/5 5/5 1 – Slight Reaction
0 – No Reaction
 

Allen test: Radial and ulnar arteries in both hands are patent. Pink coloration returns to palms
within 3 seconds.

NEUROLOGIC ASSESSMENT

MENTAL STATUS/CEREBRAL FUNCTION: The patient is alert and awake during physical
exam. The patient can talk clearly and understands every question. The patient is oriented well
in time, person and place.
MOTOR/CEREBELLAR FUNCTION: Patient touches each finger to thumb rapidly. He was able
to touch nose with smooth, accurate movements & without hesitation with eyes closed. No
fasciculations, tics and tremors noted.

SENSORY FUNCTION: Patient correctly identifies light touch sensation, able to differentiate
between dull and sharp. He correctly identified the area touched, distinguish between 8 and 0
number written on his palm and the key (object) with eyes closed.

CRANIAL NERVE TESTING

CN I (olfactory): Patient correctly identified the scent of cologne presented to each nostril.

CN II (optic): The patient has 20/20 vision OD & OS, was able to read nameplate at 2ft without
difficulty, without eyeglasses. Visual field degrees: Inferior: 70 , Superior: 50 , Temporal: 90 ,
o o o

Nasal: 60 .
o

CN III, IV & VI (oculomotor, trochlear & abducens): Eyelids meets completely when eyes
closes. Eye moves bilaterally in all directions and pupils constrict simultaneously.

CN V (trigeminal): Temporal and masseter muscles contract bilaterally. Ct. correctly identified
light touch sensation, differentiates between dull and sharp. Eye blinks bilaterally.

CN VII (facial): Patient smiles, wrinkles forehead, frowns, puffs out cheeks, shows teeth, purses
lips, raises eyebrows and closes eyes against resistance and movements are symmetric.

CN VIII (vestibulocochlear): Patient can hear the tick of the watch. Rinne and Weber test was
not performed since client doesn't have hearing loss. 

CN IX & X (glossopharyngeal & vagus): Uvula and soft palate rises bilaterally and
symmetrically. Gag reflex was intact, swallows without difficulty. No hoarseness noted.

CN XI (spinal accessory):  There was strong contraction of sternocleidomastoid muscle on the

side opposite the turned face. Symmetric and strong contraction of trapezius muscles.

CN XII (hypoglossal): Tongue movement was symmetric, smooth and bilateral strength is
apparent.