Head To Toe Flashcards
inspect face and head for shape
normocephalic
skin color
eyes and eyebrows symmetrical
inspect nose and lips
nose is midline
lips are symmetrical pink and even
check for patency
each nare is patent, no obstructions noted
no sepum deviation
inspect and palpate scalp
hair color
no lesions or infestations
texture
evenly distributed
palpate maxillary and frontal sinus
“any pain or tenderness?”
palpate temporal artery
2+ bilaterally
inspect neck and trachea
trachea is midline
no accessory muscle use
inspect lymph nodes
non palpable
non tender
palpate external ears (pinna, tragus, mastoid process)
no swelling, redness, or tenderness
test pupillary reflexes direct and consensual
cranial nerve II and III intact
UPPER EXTREMETIES
inspect skin and symmetry
palpate temp
inspect and palpate nails
cap reflex- brisk
no clubbing
nail color
palpate radial pulses
2+ bilaterally
THORAX
inspect for JVD @ 30 degrees
no JVD
palpate carotid artery
2+ bilaterally
Auscultate carotid artery for bruit (bell)
no bruit noted bilaterally
listen to trachea for bronchial sounds (diaphragm)
bronchial sounds clear and even bilaterally
inspect anterior thorax, precordium
skin color
symmetry
no lifts or heaves
respirations are unlabored and even
access for tenting
no tenting
Auscultate anterior thorax (vesicular and bronchovesicular)
clear and equal bilaterally
Auscultate posterior thorax (vesicular and bronchovesicular)
clear and equal bilaterally
auscultate 5 heart sounds and identify location
S1 and S2 sounds heard
Apical pulse rate and rhythm
78 bpm and regular
Auscultate heart sounds with bell
@ mitral area– turn pt on left side
no extra heart sounds
no S3 and S4 heard
ABDOMEN
inspect contour and symmetry
contour is flat
no peristalsis
visible abdominal aortic pulsations
2 horizontal scars noted superior to umbilicus, they are well healed, no redness or swelling
Auscultate bowel sounds starting in RLQ (diaphragm)
bowel sounds present and active in all four quadrants
Auscultate for vascular sounds (aorta, renal, and iliac)(bell)
No bruits
percuss- zigzag pattern
tympany
lightly palpate
“any pain or tenderness?”
abdominal wall is relax
no pain or tenderness noted
LOWER EXTREMITIES
