Head to Toe Assessment Guide

A comprehensive set of vocabulary-style flashcards covering vital signs, head-to-toe exam components, cranial nerves, and musculoskeletal assessments as described in the notes.

Vital Signs

Five core measurements: temperature, pulse, respiration, blood pressure, and pain score.

Pain Score

Numeric rating of a patient’s pain intensity used with vital signs.

HEENOT

Head, Eyes, Ears, Nose, Oral cavity/Throat – the sequence of the head-to-toe exam.

Integumentary Exam

Inspection/palpation of skin on chest, back, arms, and legs for color, temperature, lesions, turgor, and deformities.

Lymph Nodes (locations)

Nodes inspected/palpated: occipital, pre/post-auricular, tonsillar, submandibular, submental, anterior/posterior cervical, supraclavicular.

Head Assessment

Examination of head position, skull size/shape/symmetry, hair texture/pattern, infestations, and tenderness.

Eyes Assessment

Inspection of surrounding structures and features such as eyebrows, orbits, edema, tremors, eyelids, and eyelash conditions.

Eyelids Conditions

Assess for tremors, entropion, ectropion, and styes/crusting.

Conjunctiva

Lower conjunctivae color and texture assessment.

Cornea Clarity

Evaluation of the cornea for clarity/opacity.

Ears Assessment

Inspect/palpate size, shape, symmetry, color, nodules, tenderness, and discharge in the auditory canal.

Nose Deviation/Tenderness

Inspect for nasal deviation and palpate bridge/soft tissue for tenderness or masses.

Oral Cavity/Teeth

Inspect lips, buccal mucosa, gums for color/edema/lesions; note wear, notches, caries, loose/missing teeth.

Oropharynx/Tonsils

Inspect color/texture/exudate of oropharynx and tonsils.

Cranial Nerves (I–XII)

Assessment of all 12 cranial nerves with the described tests and defer specific tests as noted.

Patellar Reflexes

Knee reflexes graded 0–4 to assess deep tendon reflexes.

Romberg Sign

Balance test: feet together, eyes closed, observe for sway.

Gait Observation

Observe walking symmetry and rhythm for coordination and balance.

PERRLA

Pupils Equal, Round, Reactive to Light and Accommodation.

EOMs

Extraocular Movements tests to assess eye movement in various directions.

CN V – Trigeminal

Tests light touch on forehead/cheeks/jaw and teeth clench.

CN VII – Facial

Assess facial movements: raise eyebrows, close eyes, smile, frown, puff cheeks.

CN VIII – Acoustic

Whispered words or finger rub test to assess hearing.

CN IX – Glossopharyngeal

Evaluate swallow; testing taste deferred; gag reflex deferred.

CN X – Vagus

Assess speaking/hoarseness; pt phonates 'Ahh'.

CN XI – Accessory

Shoulder shrug and turning head against resistance.

CN XII – Hypoglossal

Tongue protrusion and movement in all directions.

Musculoskeletal ROM/Strength

Assess cervical, upper and lower extremity ROM and strength per rubric.

Back Alignment

Observe lordosis, kyphosis, and scoliosis in the spine.