Head-to-toe Assessement

Question 1

14 systems involved in the ROS

Answer 1

1. Constitutional
2. Eyes
3. ENT
4. Cardio
5. Resp
6. GI
7. GU
8. Musculo
9. Integumentary
10. neurological
11. Psych
12. Hematologic/lymphatic
13. Endocrine
14. allergic/immunologic

Question 2

Eye Qs

Answer 2

Any changes in vision, eye pain, wear glasses/contacts

last eye doc apt

Question 3

ENT Qs

Answer 3

Ears: any eat pain, or discharge, ringing in ears or dizziness

Nose: any congestion, runny nose or sinus pain

Throat: any sore throat, voice changes, mouth soures
last dental apt

Question 4

Cardio Qs

Answer 4

Any chest pain/tightness, SOB with activity or lying down, any hear palpitations/racing heart, high blood pressure or High chol

Question 5

Resp Qs

Answer 5

Any SOB, cough, wheezing or painful breathing

Question 6

GI Qs

Answer 6

any n/v/d, constipation, abdominal pain, last BM

Heart burn or indigestion

Question 7

GU Qs

Answer 7

Male: any changes in urinary frequency, decreased force of stream, difficult achieving or maintaining erection

Question 8

Musculoskeletal Qs

Answer 8

Any join pain or muscle pain, stiffness, weakness, or back pain

Question 9

Neurological Qs

Answer 9

any headache, numbness or tingles anywhere , fainting, trouble memory, seizure

Question 10

Integumentary Qs

Answer 10

Any changes to hair skin or nails, like hair loss, or brittleness, any changes to any moles, any new moles or rashes/ lumps

Question 11

Endocrine Qs

Answer 11

any heat or cold intolerances, unexpected wt gain or loss, or increased thirst or hunger

Question 12

Psychiatric Qs

Answer 12

depression, anxiety, stress, feelings of hoplessness

Question 13

hematological/Lymphatic Qs

Answer 13

Any swollen or painful lymph nodes, any abnormal bleeding or bruises anywhere, anemia

Question 14

Allergic/immunological

Answer 14

any eczema, medication or environmental allergies, psoriasis or rheumatoid arthritis

Question 15

Constitutional Qs

Answer 15

any fever, chills or weight loss or weight gain

Question 16

Components of a Health History

Answer 16

1. Major adult illness
2. allergies with reaction
3. Hospitalizations/surgeries/ER visits/injuries
4. Health Maintenance/immunizations
5. Psychiatric/mental health symptoms or conditions

Question 17

Components of Family and Social History

Answer 17

Family history of diseases/illness, deaths 
family relationships divorces
Marital status
sexual history
living houses
occupation
what do you like to do for fun
good support system at home
any alcohol, tobacco or drug use
diet, exercise, sleep practice
stress levels
like to travel

Question 18

Components of an HEENT Exam

Answer 18

1. Inspect
   - skin, hair nails
2. Palpates
   - head scalp face and hair
   - sinus
   - skin hair nails
   - TMJ
   - lymph nodes
   - lips/tongue/teeth, gums
   - trachea
   - thyroid glad
3. auscultate
   - thyroid
4. Exams
   - CN 1-12
   - tansilluminatioin of sinus
   - Optho exam
   - snellen chart
   - otoscope
   - potency of nostrils
   - PERRLA

Question 19

Components of Heart/Lung exam

Answer 19

1. Inspect (anterior/posterior)
   - RJVP
2. Auscultate (anterior/posterior)
   - heart 5 sites bell/diaphragm
   - Lungs diaphragm
   - carotid
3. Palpate
   - CVA
   - thoracic expasioin
   - tactile fremitis
   - pulses
   - PMI