Head to Toe Assessment

General survey: Assess gait, mental status, dress, & hygiene. Measure height, weight,
BMI, & vital signs. Inquire/instruct on monthly SBE/STE.

Skin: Examined throughout the assessment for color, edema, lesions, temperature, &
texture; remember to check skin turgor at some point during the assessment.

Head and Face: Inspect the face for overall symmetry; examine scalp & hair; palpate
frontal, temporal, parietal, & occipital bones; palpate occipital, pre and post auricular,
anterior/posterior cervical chain, submandibular, submental, & supraclavicular lymph
nodes; inspect nares, oral cavity & ear canals; perform whisper hearing test, Weber &
Rinne; perform PERRLA, cardinal fields of gaze , peripheral vision, & cover/uncover
test; palpate frontal and maxillary sinuses; test cranial nerves: raise eye brows, frown,
smile with & without teeth, say La, La, La, puff out the cheeks, swallow, check the facial
sensation & assess SCM for strength.

Musculoskeletal exam of upper extremities: Have patient perform ROM of shoulder,

elbow, wrist & finger joints as you note limitations; then assess these same joints for
crepitus, edema, pain, redness, & warmth through passive ROM; assess muscle strength
& dermatomes.

Cardiovascular: Palpate carotid, brachial, radial, femoral, popliteal, posterior tibial, &
dorsalis pedis pulses for strength & equality; assess capillary refill; auscultate the aortic,
pulmonic, tricuspid, & mitral valve areas using the diaphragm of the stethoscope & then
do the reverse with the bell; assess the apical rate for one minute with the diaphragm
while you are at the mitral area.

Lungs: Auscultate eight areas on the front & back of chest, & three areas on the sides
under each axilla.

Abdomen: Inspect, auscultate, & then palpate all four quadrants; note bruit/thrill if found
over aortic area; inquire about BMs, & antidiarrheal or laxative use.

Musculoskeletal exam of lower extremities: Have patient perform ROM of hip, knee,
ankle & toe joints as you note limitations; then assess these same joints for crepitus,
edema, pain, redness, & warmth through passive ROM; straight leg lifts to assess for
herniated disc; assess muscle strength & dermatomes.

Neuro & finish of exam: Have patient stand and put arms out and close eyes to check
for balance, & walk heel to toe; then assess for scoliosis.