Head to Chest Assessment

Question 1

General Survey:

LOC, orientation

Allergies, pain

Facial expression, speech

Hygiene

Answer 1

Alert and oriented to person, place, time, and situation

No allergies and denies pain

Appears relaxed and appropriate to the situation
Speech: Clear and understandable

Clean no odors

Question 2

Skin/Nails:

Color, lesions

Temperature, moisture

turgor

Capillary refill, shape

Answer 2

Pink, no lesions.

Warm and dry

Good

<2-3 seconds bilateral. No clubbing

Question 3

Head/Face:

Symmetry

Hair

Answer 3

Symmetric

Even, thick texture, clean, no lesions

Question 4

Eyes:

Eyelids, conjunctiva, sclera, cornea, iris

PERRLA

Answer 4

No ptosis and symmetric; Pink and clear; China white; Clear
No cloudiness; hazel
PERRLA

Question 5

Ears:

Auricle, tragus

Whisper test

Answer 5

Pink, equal size, no lesions/lumps
Tragus is firm, no pain/tenderness

Able to correctly identify 2 syllable word bilateral

Question 6

Nose & Sinuses:

Symmetry

Patency

Deformities/inflammation

Answer 6

Nares patent bilateral

Symmetric

With deformities/inflammation

Question 7

Mouth & Throat:

Lips

Teeth

Buccal mucosa, gums

Tongue

Hard Palate

Soft palate/uvula

Answer 7

Lips: Pink, moist, no cracking, crusting or lesions.

Teeth: White, straight, evenly spaced, free of debris/decay

BM/G: pink, smooth, moist, no lesions. Gums: tight margins.

Tongue: Smooth, pink, protrudes midline, no tics, tremors or fasciculations.

HP: White with irregular ridges

SP/U: Pink, smooth and rises midline when patient says “ahhh”

Question 8

Chest (Posterior):

Thoracic cage configuration

Expansion

Breath sounds

Answer 8

AP

Question 9

Chest (Anterior):

Respirations/accessory muscle use

apical impulse

Breath sounds

heart sounds, apical pulse

Answer 9

Regular and unlabored. No use of accessory muscles.

Clear vesicular, no adventitious sounds bilateral