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HEAD-TO-TOE PHYSICAL EXAMINATION
STEP
General appearance:
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Level of Consciousness (LOC):(alertness & Orientation)
Observe the appearance (personal hygiene & posture), Behavior (facial expression & speech)
Cognitive functions orientation memory
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Inspect & palpate the head and scalp and movements of head, face
Assess the Hair for cleanliness, presence of lice and dandruff ,hair color and texture
Palpate the head and scalp, temporal, and carotid artery
Test the ROM of the Temporomandibular Joint (TMJ)
Inspect nose for shape, patency, size, symmetry
Palpate sinuses
Assess cranial nerve I (Olfactory)
Inspect lips, buccal mucosa, gums, tongue and teeth.
Inspect throat and assess cranial nerve IX (Glossopharyngeal)
Assess cranial nerve X (Vagus)
Assess cranial nerve XII (Hypoglossal)
Assess cranial nerve V (Trigeminal)
Assess cranial nerve VII (Facial)
Eyes: Inspect External and Internal, Visual Fields, Extra Ocular Muscles- pupils: size, reaction
to light and accommodation.
Assess cranial nerve II (Optic), Testing Central Visual Acuity using Snellen chart within 6 meters
distance.
Assess cranial nerves III, IV, and VI (Oculomotor, Trochlear & Abducens)
Assess Accommodation Test, Six Cardinal Fields of Gaze Tests
Inspection & Palpation of External Ear
Note the size & shape, redness, lesion, lumps or discharge
Palpate pinna and mastoid process for tenderness
Otoscopic Examination (tympanic membrane)
Hearing Acuity: Test cranial nerves vestibulocochlear nerve (Cranial Nerve VIII) by whisper
test
Perform Weber Test & Rinne test
Palpate lymph nodes ( preauricular, posterior auricular, occipital, submandibular, submental, and
cervical)
Perform ROM of cervical spine and muscle strength
Inspect the thyroid gland for symmetry/enlargement
Palpate the thyroid gland for nodules, tenderness/enlargement
Skin assessment:
Inspect for cleanliness, skin tone ( color & pigmentation ) & Superficial arteries and veins
Palpate skin temperature, texture, elasticity (Turgor & Mobility)
Assess Nails for even, pink undertone, capillary refill & perform Schamroth technique to assess
clubbing
Perform ROM of shoulder, wrists and hands and elbows, and muscle strength
Head and neck region:
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Cardio vascular assessment
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Palpate the carotid arteries and determined the rhythm
Identify the common sites for auscultation (i.e., Aortic, Pulmonic, Erb’s, Mitral point).
Comment
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Palpate for peripheral pulses ( radial, brachial, dorsalis pedis, posterior tibial)
Assess for Edema ( pitting/Non pitting)
Respiratory Assessment
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Inspect Anterior Thorax & posterior thorax for shape and configuration and Quality of Respiration
Palpate for Lung Expansion and Tactile fremitus
Percuss for resonance and hyper resonance and flat sound
Auscultate the trachea &breath sounds
Abdominal Assessment
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Abdomen: inspect for shape, size and symmetry, and location of umbilicus
Auscultate Bowel Sounds in one full minute
Percuss for Tympany/Dullness
Palpate for Tenderness/Mass
Musculoskeletal & Neuro Assessment
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Assess ROM of Spine, Hip, Knee, Ankle and Foot
Assess cranial nerve XI (Accessory Spinal)
Assess for muscle strength of shoulder, wrist and hands and knee
Assess Reflexes (Biceps, triceps, patellar , Achilles and plantar (babinski)
Summary of abnormal findings