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Physical Head to toe

Pysical assessment

General Survey Observe for Appear stated age, level of consciousness, skin color, posture, position, personal hygiene, mobility, Physical deformities, Mood, signs of distress
Vital signs Height, weight, oral temperatue, radial pulse: rate, rhythm, quality, equality, Respiration: Rate, rhythm, depth, Blood pressure
Head and Face (face) Inspect: color, pigmentation, and lesions.Palpate: moisture, temperature, texture, mobility, and turgor
Head and face (hair) Inspect: quantity and distributionpalpate: texture
Head and Face ( Scalp) Inspect: Scaliness, lumps, nevi, lesionsPalpate: general size, contour noting deformities, depressions, lumps, or tenderness
Head and Face ( Face) Inspect: Facial expressions, symmmetry, involuntary movements, edema, and masses
Head and face (TMJ) Palpate TMJ ( temporomandibular joint) for tenderness,Test for limited ROM, crepitation.
Eyes Measure Visiaul Acuity by snellen or reading print.
Eyes Inspect: position, and alignment
Eyelids Inspect: position, edema, color, lesions, condition, and direction of eyelashes.
Scleras and palebral conjunctiva of lower lids Inspect: color, nodules, and swelling
Eyes ( corneas and lens) inspect: opacities
Test range of extraocular movements 6 cardinal direction
Eyes ( Pupil) Inspect: size, shape, equality
Test direct and consensual light reaction Direct: flash light in one eye and check the pupil responce of the eye,Consensual: flash light in one eye and check the opposite eye for reaction.
Test for accommodation have pt look at an object at a distance and then look at your finger in front of them.
Test for convergence move the finger closer to the pt and see how eyes react
Test peripheral vision by confrontation do the bunny ears moving fingers around pts ears, then over head around face, and bottom of head.
test to determine corneal light reflex use pen light ( to see the reflection of the light on the pupils)
Ears (auricles and tragus) Inspect: deformities, lumps, and skin lesionsPalpate: tenderness
Ears ( mastoid process) Palpate: separately for tenderness
Ear ( external canal) Inspect: discharge, foreign bodies, redness, or swelling ( use otoscope)
Ear ( tympanic membrane) Inspect: color and contour ( use otoscope)
Auditory Acuity Perform whisper test
Nose (external nose) Inspect: deformity and asymmetry
Test patency of nares oclude one nare and have pt breath and in. then oclude the other nare and have pt breath in
Nose ( mucosa) Inspect: color, swelling, exudate, bleeding, moisture. (use otoscope)
Nose (septum) inspect: inflammation, abnormalities, perforation, deviation (use otoscope)
Nose ( maxillary/ frontal) Palpate: sinuses for tenderness
Mouth (lips) Inspect: color, moisture, ulcers, lumps, cracking, scaliness
Mouth ( oral mucosa) Inspect: color, ulcers, white patches, or nodules
Mouth ( gums) Inspect: color, swelling, or ulcerations (use pen light and tongue blade)
Mouth (teeth) Inspect: presence, discoloration, misshapen, abnormal position, or looseness ( use tongue blade and pen light)
Mouth (Tongue) Inspect: color, texture, nodules, or ulcerations ( all 4 sections) ( use tongue blade and pen light)
Mouth ( hard palate) Inspect: Color and architecture (use pen light and tongue blade)
Mouth (soft palate, uvula, tonsils, posterior pharyngeal wall) Inspect: exudate, swelling, ulcerations, induration, or tenderness ( use penlight and tongue blade)
Mouth (uvula) Inspect: position and movement ( if it raises medline) ( use penlight and tongue blade)
Test cranial nerve VII Motor- frown, smile, puff out cheeks, show teeth
Neck Inspect: symmetry, massess, or scarring
Neck (thyroid) Inspect: thryoid enlargement using penlight
Neck (trachea) Inspect: alignment (have pt swallow)
Neck ( lymphnodes) Palpate: for enlargement, tenderness (palpate and name all 10) 1)preauricular,2)postauricular,3)occipital,4)tonsillar,5)submandibular,6)submental,7)superficial cervical,8)deep cervical chain,9)posterior cervical,10)supraclavicular
Neck observe: pain and crepitation Perform ROM: flexion, extension, lateral bending, rotation
Test muscle strength of neck turning head against resistance
upper extremities Inspect: overall symmetry
Upper Extremities Inspect: skin color, lesions, hair distribution, edema
Upper extremities Palpate: temperature, turgor, mobility
Upper extremities (nails) Inspect: color, shape, lesions
Upper Extremities (nails) Palpate: capillary refill ( at least two fingers on each hand)
Upper Extremities (shoulder) Inspect: swelling, deformity, muscle atrophy, or abominal postion
Upper Extremities (shoulder) Palpate: for pain
Upper extremities ( ROM Shoulder) Perform ROM: flexion, extension, internal rotation, abduction, adduction, external rotation. Observe for pain, crepitation
Upper extremities ( Shoulder) Test muscle strength shrug against resistance
Upper extremities ( elbows) inspect: nodules, and swellingPalpate: tenderness, swelling, or thickening
Upper Extremities ( elbows) ROM Perform ROM: flexion, extension, internal rotation, abduction, adduction, external rotation.Observe: pain, crepitationTest muscle strength: flexion, extension against resistance
Upper extremities (hands/ wrists) Inspect: swelling, redness, nodules, deformities, and muscular atrophy
Upper extremities (wrists) Palpate: swelling, bogginess, or tenderness
Upper extremities ( interphalangeal joints/ metacarpophalangeal joints) Palpate: swelling, bogginess, or tenderness
Upper extremities (fingers) perform ROM: flexion, extension, abduction, adduction, oppositionObserve: pain & crepitation
Upper Extremities (hands) test hand for grip strength
Upper Extremities ( wrist) Test ROM: flexion, extension, ulnar and radial deviationobserve for pain & crepitationTest muscle strength: flexion agains resistance
Posterior Thorax Inspect: symmetry, countour, skeletal deformities
Posterior thorax ( skin) Inspect: color, lesions, scarsPalpate: temperature, moisture
Posterior thorax auscultate breath soundsIdentify: bronchovesicular & vesicular sounds normally heard
Posterior thorax percuss for CVA tenderness
Breast and Axillae (central/ pectoral nodes) palpate: enlargement and tenderness
Breast and Axillae Inspect: w/ arms and hands at side; above head; pressed against hips to elicit pectoral contractionObserve: size, symmetry, dimpling, edema, prominent venous pattern, scars, lesions, skin color, and thickening
Breast and axillae ( areola/nipple) Inspect: size, shape, direction, bleeding, discharge, lesions
Breast and axillaept lies down Inspect axillae: lesionspalpate breast: in supine position for tissue consistancy, masses, tenderness
Breast and axillae (nipples/areola)pt lies down Palpate: masses and discharge
Anterior Thorax Inspect: symmetry, contour, skeletal deformities, Respiratory rate,and rhythm
Anterior thorax (skin) Inspect: color, lesions, scarsPalpate: temperature, moisture auscultate breath sounds (identify bronchovesicular, bronchial, tracheal, vesicular sounds are normally heard)
Heart (coratid) Palpate: rate, rhythm, equality. Palpate one side at a timeand well below the upper border of the thyroid cartilage.
Heart (apical) auscultate: rate, rhythm, listem for 1 full minuteand state rate.
Heart ( valve closure s1 and s2) auscultate: aortic, pulmonic, ticuspid, & mitral valve.identify : where is S1 and S2 are heard loudest
Abdomen (skin) Inspect: color, scars, striae, dilated veins, rashes, lesions
Abdomen ( umbilicus) Inspect: contour, location, signs for inflammation, hernia
Abdomen Inspect: contour, symmetry, masses, peristalsis, pulsations ( look from side as well)Auscultate: all 4 quadrants for frequency and character of bowel sounds (state would listen for at least 2min. over abdomen before stating absent)
Abdomen percuss: all four quadrants for tympany and dullnessperform light palpation in all four quadrants for tendernes, masses, and guarding
Abdomen ( inguinal) palpate: lymph nodes: tenderness, enlargement
abdmone ( femoral pulses) palpate: rhythm, quality, equality
Lower extremities Inspect: overall symmetry
Lower Extremities (skin) Inpsect: color, lesions, hair distribution, edemaPalpate: tugor, temperature, texture, edema
Lower extremities ( nails) inspect nails for color condition
Lower extremities ( hips) inspect: swelling, enlargemnet, deformitypalpate: pain, tenderness, nodules, swelling, deformityTest ROM: flexion, extension, abduciton, adduction, internal rotation, external rotation, observe:pain and crepitation
Lower extremities (knees) Inspect: swelling, enlargement, deformitypalpate: pain tenderness, nodules, swelling, deformityTest ROM: flexion, extensionobsereve: pain, crepitationTest muscle strength of knees: flexion and extension against resistance
Lower Extremities (feet/ankles) Inspect: swelling, enlargement, deformityPalpate: pain, tenderness, nodules, swelling, deformityTest ROM: dorsiflexion, plantar flexion, inversion, eversion, and flexion of toesObserve: pain & crepitation
Lower Extremities (feet/ ankles) Test muscle strength of ankles: dorsiflexion, and plantorflexion against resistance
Lower extremities (popliteal pulses) palpate: rhythm, quality, equality
lower extremities (posterior tibial pulse) palpate: rate, Rhythm, equality
lower extremities (dorsalis pedis pulse) Palpare: rate, rhythm, equality
Lower extremities ( superficial reflex) plantar (babinski)
Lower Extremities ( deep tendon reflex) Biceps, triceps, brachioradials, patellar, achilles
Spine Inspect: abnormal curvature (from back and side)
Spine Test ROM: flexion, extension, lateral bending, rotation,observe: pain and crepitation
spine (spinous process) Palpate: tenderness, paravertebral muscles for tenderness and spasms
Created by: jessg445