Important things to know for HEAD TO TOE ASSESSMENT

Provocation/Palliation

When did the pain start? What makes it better or worse?

Quality/Quantity

What does it feel like and is it sharp or dull?

Region and Radiation

Can you point to the pain? And does it radiate anywhere else?

Severity

on a scale of 0-10 0 being least pain and 10 being worse pain what do you rate your pain?

Timing

Is there a certain time of day when the pain feels better or worse? 

Understanding

How does the pain affect your activities of daily living?

CN I: Olfactory

Test smell, eye closed, different scent each nostril

CN II: Optic

Test Visual acuity using the snellen test and test peripheral vision with the confrontation test (cover the same eye say when u see fingers)

CN III: Occulomotor

PERRLA (w/ pen light) & cardinal field test

CN IV: Trochlear

Cardinal field test

CN V: Trigeminal

Clench jaw, test facial sensation with cotton ball 

CN VI: Abducens

Test Cardinal Fields

CN VII: Facial

Test by closing eyes, smiling, frowning, puff cheeks

CN VIII: Acoustic

Cover one ear at a time. In one ear whisper letters, in the other ear whisper numbers. 

CN IX: Glossopharyngeal 

Test Gag reflex, Say “ahhh” 

CN X: Vagus

Test swallowing by placing a hand on the throat, assess the coarseness and tone of voice. 

CN XI: Spinal Accessory nerve

Shrug the shoulder and cervical rotate to resistance 

CN XII: Hypoglossal

stick out tongue & say light, tight, dynamite 

Gait Testing

Walk normal, heel to toe, tippy toe, and heel walk

Rapid Alternating test

Patty cake quickly on thighs

Romberg test

Get parallel to patient have them close eyes test for swaying

Heel to shin

Have patient rub heel on shin from top to bottom on both sides

Pain

Tell patient to tell you if they feel pain or dull on one side

Light touch

Ask patient to tell you when they feel cotton ball on one side

Extinction

Tell Pt to tell you when they feel two points or one point on one side

Graphesthesia

close eyes tell patient to determine number written on palm

Stereognosis

Close eyes have patient determine two different objects in each hand.

Kinesthesia

Close eyes, tell patient to say up or down when they feel finger go in that direction

Vibration

With tuning fork ring it have it go on two bony prominences and have the patient tell you when they feel it.

Bicep Reflex

Hit in between antecubital fossa with mallet and on top of thumb arm straight should illicit flexion

Tricep reflex

Hit near the olecranon with the arm bent at 90 angle should illicit extension of the arm.

Brachioradialis Reflex

A hit near the wrist over the thumb should elicit a forearm/wrist flexion

Quadricep reflex or Patellar reflex

A hit in the middle of the knee with mallet should produce knee flexion. 

Achilles reflex

a hit to the achilles tendon should ellicit plantar flexion

Plantar reflex

A swipe from down to top on foot should elicit dorsiflexion

Temp normals for vitals

96.4-99.1 degrees F

SPO2 normal Range for vitals

97-100%

Blood Pressure Normal Range for vitals

120/80

Radial Heart Rate Normal Range for vitals

60-100 BPM 

Respiratory rate normal range for vitals

12-20

Carotid first inspect

Inspecting for Distention 

Carotid palpate

For any palpable thrills

Carotid auscultation with bell 

Have the patient breathe in, then exhale and hold their breath for a couple of seconds listen for bruit. 

Inspect anterior and posterior chest

Both for symmetric expansion bilaterally.

Palpate precordium

Open hand palpate across chest for any heave or thrill

Palpate for symmetric expansion

Put your hands on patient’s back thumb to thumb feel for symmetric expansion. 

Auscultate for lung sounds

10 in front and 16 in back listening for any adventitous sounds

S1 best heard at 

Apex (Mitral 5th ICS, MCL) 

S2 best heard at

Pulmonic (LSB 2nd ICS), otherwise known as base. 

inspect from above and side for abdomen 

Looking for contour (rounded, flat, rotund), Umbilical symmetry, and color

During Abdomen test ask PT for pain

Tell Patient this area would be palpated last!

If bowel sound was absent what to do?

Listen for 5 min before declaring absence.

when measuring calf size

List areas of common pressure injuries, which are the elbows, heels, shoulders, and coccyx.

Assess pulses

Brachial, Radial, Popliteal, Femoral, Posterior tibial, Dorsalis pedis.