Head to Toe Flashcards
General Survey
Introduces self to client
notes dress and hygiene
orientation
mood/affect
speaks to washing hands
Skin
Notes generalized color, texture, temperature, moisture and variations
Notes one lesion and describes color, size, shape, location, tenderness, consistency, discharge/drainage using appropriate terminology
Scalp and hair
Notes amount, distribution, texture, condition, color of hair and tenderness and color of scalp
Head
Notes facial movement-smile, frown, puff out cheeks
Notes sensation-sharp or dull
Examines temporomandibular joint
Notes temporal masseter muscle strength
Neck
Notes symmetry and position of trachea
Sternocleidomastoid resistance
Shoulder shrug resistance
Thyroid: isthmus and lobes
Lymph nodes
Preauricular
Posterior auricular
Occipital
Tonsillar
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical
Supra clavicular
Eyes
Visual fields by confrontation
Extraocular muscle function
Corneal light reflection
Eyebrows/Eyelashes
Eyelids: palpebral fissure and closure resistance
Pupils: PERRLA , size
red reflex
Puncta, conjunctiva
Retinal background
Retinal vessels
Optic disc
Ears
Weber and Rinne tests
Hearing acuity (whisper)
External features(position, auricle)
Internal features( note canal, membrane, color & integrity light reflex, umbo, handle of malleus and short process)
Nose
External: Appearance, note bridge, dorsum, tip and symmetry and patency of nares
Internal structures: mucous membrane, septum, discharge
Sinuses: frontal and maxillary for tenderness
Mouth
Internal: note buccal mucosa, gums, teeth,
Tongue: dorsum, ventral, movement and strength
Throat
Hard and soft palate, uvula
Tonsils or fossa
Pharynx, swallowing and gag reflex (verbalize gag)
Lungs and Posterior Thorax
Tenderness and masses
Tactile fremitus
Chest expansion
Percussion: tone and technique
Diaphragmatic excursions (one side only)
Costovertebral angle tenderness
Auscultation: breath sounds, technique, note adventitious breath sounds
Heart
Pulsations
Point of maximum impulse
Thrills/Heaves
Auscultatory points
Supine with diaphragm (aortic, pulmonic, tricuspid, mitral) verbalize names and landmarks
Supine with bell (aortic, pulmonic, tricuspid, mitral)
Apical pulse for 1 min. (verbalize)
Left lateral with bell (tricuspid, mitral)
Sitting leaning forward with diaphragm (aortic, pulmonic)
Peripheral vascular
Note clubbing of fingernails
Distribution of hair on lower extremities
Temperature of extremities (to each other and trunk)
Capillary Refill time
Skin turgor
Edema: upper and lower extremities
Peripheral Pulses: note rate, rhythm, symmetry and grade of the following
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Abdomen
Vascularity and strae
Umbilicus- note for hernia
Note for contour and symmetry and movement
Bowel Sounds (verbalize that you listen for one min in each) RLQ, LLQ, LUQ RUQ)
Percussion: general, liver span, spleen, bladder,
Light Palpation
Deep Palpation: general
Deep palpation: liver, spleen, kidneys
