Head to Toe Physical Exam

Student preparation

Provides privacy, hand hygiene, AIDET, Cleans stethoscope

General Survey and mental status

Reason for visit, name, age, race, sex, three words, mood, orientation

vitals

pulse, RR, BP, pain, height, weight, three words

head/skull

visually inspects, palpates skull, lifts hair

face

inspect symmetry, palpate for sinus tenderness

eyes

inspect brows and conjuctiva, measure size and shape of pupil, test for reactivity and accommodation, ask about correction

ears

inspect canal, palpate for pain, ask about hearing aids

nose

inspect nose and mucus membrane, assess patency one nare at a time, palpate, assess smell

mouth

inspect lips, mucosa, gums, teeth, tongue, hard and soft palate, ulvula for rise, ask about dental devices

neck

inspect JVD, palpate carotids, auscoltate corotid with bell, palpate tracheal position, ROM x6 w/o and w/ resistence

skin

inspect entire body, asses tugor over sternum

Chest Respiratory

inspect chest wall and AP;L ration, auscolate breath sounds (6 on back, 4 on front, 2 on sides), percuss kidneys

Chest cardiac

palpate 5 areas, palpate PMI, auscolate 5 areas with diaphragm, auscoltate apical pulse for 30 seconds, auscoltate with bell

upper extremities

inspect, palpate temp with back of hands, palpate for firmness, edema, tenderness, ask about bilateral sensation, palpate joints, take bracchial pulses, bicep and tricep reflexes, shoulder ROMx 6, elbow ROM x2

hands

inspect nailbeds, cap refills, take ulnar and radial pulses, wrist ROM x5, finger ROM x3

lower extremities

inspect, palpate with back of hands, palpate for firmness, edema, and tenderness, ask about bilateral sensation, palpate joints, popliteal pulse, ROM x2 with knee, popliteal reflec, achilles reflex

feet

inspect toenails, cap refill, take posterior femoral pulse, take dorsal pedalis pulse, ROM x5 ankle, ROM x1 with toes.

abdomen

jugular distension, inspect at eye level, inspect with head raised, listen to ab quandrants, listen for aortic bruit, palpate costal angle, percuss x4, light palpation x4, deep palpation x4, verbalize palpating ballder and femoral pulses, babinksi reflex

gait

gait, inspect back of legs, assess Romberg, ROM x5 for hips,

spine

forward bend, inspect and palpate spine, ROMx6