Head to Toe Assessment

Question 1

General Survey (3)

Answer 1

1. Introduces self to patient
2. Appearance
3. Hygiene

Question 2

SKIN (10)

Answer 2

1. Skin color
2. Skin temperature
3. Skin Turgor
   4• Moisture Palpate
   5• Bony prominences (elbows, sacrum, heels)
   6• Suspicious lesions or bruising
   7• Oral mucous membrane Inspect only
   8• Palpebral conjunctiva
   9• Sclera
   10• Lips

Question 3

FACE (4)

Answer 3

1. Features
2. Facial movement
   • CN 7 Facial
3. Sensation
   • CN 5 Trigiminal
4. Temporal Masseter Muscle Strength
   • CN 5 Trigiminal

Question 4

EYES (7)

Answer 4

1. Visual acuity (Snellen) (Right, Left, Both)
•	CN 2 Optic
2. Visual fields by confrontation This is peripheral vision not EOM’s
•	CN 2 Optic
3. Pupils
4•	Size, shape, equality 
5•	Direct reaction to light 
6•	Consensual reaction 
7•	Accommodation 
	CN 3 Occularmotor

Question 5

EARS (1)

Answer 5

1. Whisper test

CN 8 vestibuocochlear

Question 6

NECK (4)

Answer 6

1. Trachea
2. Phonation, swallowing, tongue movement and strength
   • CN 12 hypoglossal
3. Sternocleidomastoid resistance
   • CN 11 Spinal accessory
4. Shoulder shrug resistance
   • CN 11 Spinal accessory

Question 7

LUNGS Anterior, posterior & lateral surfaces (6)

Answer 7

1. Rate (Count for 30 secs. & multiply)
2. Rhythm
3. Depth
4. Thoracic expansion
5. Auscultation of anterior breath sounds Classification & ratio
   • Bronchial
   • Bronchovesicular
   • Vesicular
   • Adventitious.
   • Technique
6. Auscultation of posterior breath sounds
   • Bronchovesicular
   • Vesicular
   • Adventitious
   • Technique

Question 8

HEART (7)

Answer 8

1. Jugular vein distention

2•	Palpates location and verbalizes auscultatory points			
•	Aortic  			
•	Pulmonic  			
•	Erbs  			
•	Tricuspid  			
•	Mitral 			

3. Auscultation supine with diaphragm of stethoscope
4. Auscultation supine with bell of stethoscope
   • Aortic
   • Pulmonic
   • Erbs
   • Tricuspid
   • Mitral
5. Auscultation left lateral with bell of stethoscope
   • Tricuspid
   • Mitral
6. Auscultation sitting, leaning forward with diaphragm
   • Aortic
   • Pulmonic

7• Apical pulse (Auscultate for 1 minute at mitral point)

Question 9

PERIPHERAL VASCULAR (3)

Answer 9

1. Pulses (Palpate for 15 secs. & multiply) rate, rhythm, grade, symmetry	
•	Carotid 			
•	Radial 			
•	Brachial 			
•	Femoral 			
•	Pedal 			

2. Fingernails & Toenails	
•	Capillary refill 			
3. Edema 	
•	Periorbital			
•	Hand			
•	Arm			
•	Pedal			
•	Ankle			
•	Leg			
•	Sacral

Question 10

ABDOMEN (6)

Answer 10

1. Shape & symmetry
2. Vascular pattern
3. Aortic pulsation
4. Peristalsis
5. Bowel sounds (Listen for 1 min in the R lower quad)
6. Palpation

Question 11

MUSCULOSKELETAL (4)

Answer 11

1. Muscle mass arms & legs
2. Muscle strength
   • Shoulders
   • Upper arms
   • Lower arms
   • Hips
   • Upper legs
   • Lower legs
3. Joints
   • Shoulders
   • Elbows
   • Wrists
   • Hips
   • Knees
   • Ankles
4. Range of motion
   • Neck
   • Shoulders
   • Elbows
   • Wrists
   • Fingers
   • Knee
   • Ankles
   • Hips
   • Spine

Question 12

NEUROLOGICAL (13)

Answer 12

1. Level of consciousness (Glasgow Coma Scale)
   • Eyes open Spontaneous (4), to speech (3), to pain (2), none (1)
   • Best verbal response Oriented x’s 3 (5), confused (4), inappropriate words (3), inappropriate sounds (2), none (1)
   • Best motor response Obeys commands (6), localizes pain (5), withdraws- pain (4), flexion-decorticate (3),extension-decerebrate (2), none (1)
2. Recent memory
3. Remote memory
4. Thought process
5. Mood, feelings, expression
6. Speech
7. Gait
8. Tandem walk
9. Romberg
10. Coordination- rapid alternating movements
11. Coordination - finger to nose
12. Sensation
    • Sharp, dull, light touch hands/feet
13. Reflexes
    • Patellar
    Babinsky/plantar response