Head to Toe Assessment Flashcards
Initial Approach and History Taking
- Obtain age, gender, race DOB
-Describe Chief Complain
-Complete HPI (OLDCARTS)
-Include Associated Signs and Sx
Past Medical History
General Health- Include last dates/findings of exams
Chronic Illness when-what, how treated
Psych- diagnosis, treatment, hospitalizations
Infectious diseases (TB, HIV, Hepatitis, etc)
Allergies and reactions
Medications (Verbalize medication name, purpose, dose, and timing)
Surgery- year, type, complications, anesthesia
Injuries and previous hospitalizations
Immunizations (childhood + flu, covid )
GYN history (LMP, menses pattern/ characteristics), gravida/para or menopause
Male and female- Sexual history, partners, sexual practices, past history of STI, protection, pregnancy plans
Male TSE, Educate about GYN appropriate exams (Women who are 30 to 65 have three options for testing. They can have a Pap test and an HPV test (co-testing) every 5 years. They can have a Pap test alone every 3 years. Or they can have HPV testing alone every 5 years.
Breast Health both genders (annual Mammogram for woman over 40)
Family History
Grandparents, parents, siblings, children- Health Status, age and cause of death
HEENT- macular degeneration, Hearing impairment
CVD- Heart attack, congenital defects
Neurological- Alzheimer, Parkinsons
Pulmonary- Asthma, COPD
GI- Acid reflux, IBS
GU- Cystitis, Kidney Stones
Endocrine- Hypothyroidism, Diabetes
MSK- Arthritis, Degenerative Disk disease
Obesity
Cancer (cervical cancer, Lung Cancer)
Bleeding Disorders - Hemophilia, Von Willebrand disease
Mental/emotional- Depression, Anxiety
Genetic Disorders- Down Syndrome, Turner Syndrome
Substance Abuse
Allergies
Social History
Place of Birth
Race/Nationality/ Ethnicity
Marital Status/Significant other
Occupation
Military history
Social and economic status- Living arrangements
Habits- diet, hydration, nutritional status, exercise, laxative use, caffeine use
Tobacco, Alcohol, and Drug use
Emotional/ stress/ Sleep
Hobbies/Leisures activities, alternative health care practices
Violence and safety
Review of Systems
Constitutional- overall health, fever, chills, weight loss, fatigue
Eyes- changes vision, blurred vision, double vision, tunnel vision, floaters and last eye exam
ENT/mouth- changes/difficulty in hearing, ear pain or discharge, difficulty smelling, runny nose, sore throat, problem swallowing, difficulty eating/chewing food, sores or lesions in the mouth, and last dental exam
Cardiovascular- chest pain, abnormal heartbeat, skipped beats, fluttering, shortness of breath with or without exertion
Respiratory- difficulty breathing cough
GI- Daily bowel movements (Quantity and quality), diarrhea or constipation, blood in the stool
GU- Difficult urination, discharge, or pain
M/S- painful joints or muscles, problems with range of motion
Skin/Breast- changes in the skin, dryness, rashes, lesions, or nodules
Neurologic-Dizziness, blurred vision, unsteady gait, unilateral weakness, peripheral neuropathy SX,, seizures
Psych- depression, anxiety, bipolar, schizophrenia, sleep
Endocrine- hot or cold, sweaty, hair, weight loss or gain
Hem/Lymph- bruising easily prolonged bleeding, taking a long time to heal, getting sick easily
Allergic/immunologic- Allergy to any foods or environmental substances
General Survey
General Appearance, Physical Appearance/ state of health, ease of breathing, nutritional status, posture, hygiene, odors mobility, attentiveness/attitude, LOC, A&Ox3 affect and mood, signs of distress or illness
Obtain Height and weight, and BMI
Asses Vital Signs (BP, P, R, T
Exam of Skin, Hair, and Nails
Inspect for skin moisture/dryness, rashes, facial swelling/ asymmetry, pallor/cyanosis/jaundice, erythema
Inspect Skin, hair, and nails for appearance, turgor, mobility, temperature, edema, lesions, clubbing, color and texture pigmentation, hair distribution, joint swelling
Inspect for scars, vascular and purpuric lesions, suspicious tumors, and nevi. ABCDE method of evaluation (Asymetry, irregular borders, Color, Diameter, Evolving.
Changes in skin, hair such as macule, papule pustule (etc)
Head And Neck Exam
Inspect Facial Expression, Symmetry, and Edema
Head: Palpate shape, appearance, Hair/scalp, appearance, texture, hair loss, lesions
Palpate: Temporal artery, TMJ, frontal and maxillary sinuses
Assess for CN V(Trigeminal) motor and sensory function (sharp and dull, clench your teeth)
Assess cranial nerve VII function (Close your eyes, Don’t let me open them, frow, smile, puff cheeks, pucker your lips)
Eyes exam
Inspect the eyelids, sclera, Conjunctiva, cornea, iris, lens, and pupils
Assess PERRLA, Assess CN II (Visual Acuity)
Assess extraocular movements - Six cardinal fields of gaze (CN III, VI, VI), Nystagmus
Ophthalmoscopic exam- Red reflex, retina, vessels, optic disc, disc-to-cup ratio, fovea, and macula
Ears exam
Complete External exam for appearance and tenderness
Assess ear canal for obstruction
Assess Hearing (CN VIII)- Whisper Test, Rhine and Weber
Otoscopic exam- examine ear canal, inspect TM for appearance and normal structures, color and cone of light
Nose Exam:
Inspect External appearance, test for Patency
inspect nasal mucosa and turbinates for appearance/drainage
Assesss CN I function (Smell coffee and Cinamon)
Mouth / Throat Exam
Inspect lips, teeth, gums, tongue, buccal mucosa, soft and hard palate, anterior and posterior pillars
Inspect and grade tonsils
Assess CN IX, X, XII function
Neck Exam
Assess for symmetry, enlargement
Palpate/ Name lymnodes pre/posterior auricular, occipital, tonsilar, submandibular, submental, anterior/posterior cervical, supraclavicular
Inspect/palpate trachea for deviation
Examine the thyroid
Assess CN XI function (Shoulder shrug against resistance, Turn head against resistance)
Observe for JVD
Initial exam of Thorax and lungs
Inspect the skin for appearance, lesions, rashes, and chest wall deformities such as pectus excavatum/carinatum
Inspect for symmetry of thorax, respiratory rate/effort, abnormal breath sounds
Notes the approximate a/P ratio of the chest (Looking for barrel Chest)
Palpate the sternum for tenderness
Exam of Posterior Thorax
Palpate intercostal and back spine for pain, tenderness, or other abnormalities
Assess for respiratory excursion/expansion
Palpate for tactile fremitus
percuss posterior fields
Assess for Diaphragmatic excursion
Auscultate lung fields- minimum of eight areas
