Head to Toe Script

General Survey, Orientation, & Cognitive Assessment

• Assessment Procedure: Ask $4$ orientation questions.
• Clinical Findings & Verbalization:
  • Patient is alert and oriented $\times 4$.
  • Overall appearance and behavior are appropriate.
  • Cognitive function is fully intact.
  • Remote memory is intact.
  • Patient actively follows simple commands.

Integumentary System & Extremities Assessment

• Assessment Procedure:
  • Inspect skin first, followed by direct palpation.
  • Test skin turgor for elasticity.
  • Evaluate capillary refill time on nail beds bilaterally.
• Clinical Findings & Verbalization:
  • Skin is warm, dry, and intact throughout.
  • Skin color and pigmentation are appropriate for ethnicity.
  • No redness, lesions, edema, or skin breakdown identified.
  • Skin turgor is brisk with no tenting ($< 2\,\text{seconds}$).
  • Extremities demonstrate symmetry with equal venous patterns.
  • Capillary refill on nails is $< 3\,\text{seconds}$ bilaterally.
  • No nail clubbing or spooning noted.

Head, Face, & Sensory Organs Assessment

• Head Assessment:
  • Visual and tactile examination shows no lumps, lesions, redness, or swelling.
  • Size and shape are normocephalic.
  • Hair is evenly distributed; hair texture and color are appropriate for ethnicity.
  • Skin pigmentation is uniform across the scalp and head.
  • Patient hygiene is clean and appropriate.
  • Hand hygiene performed.
• Face & Sinuses Assessment:
  • Includes examination of maxillary and frontal sinuses.
  • Face is symmetrical with no skin breakdown.
  • Skin pigmentation is warm and appropriate for ethnicity.
  • No pain or lumps noted upon palpation; frontal and maxillary sinuses are non-tender.
• Eye Assessment:
  • Eyebrows and eyelashes are evenly distributed.
  • Eyes are symmetrical without any ptosis or drooping.
  • Sclera is white, conjunctiva is pink, cornea is clear, and iris is flat and round.
• Nose Assessment:
  • Nose is symmetrical with no skin breakdown.
  • Absence of drainage, lesions, lumps, or tenderness.
  • Nasal septum is midline; nasal passages are patent bilaterally.
• Mouth Assessment:
  • Lips are symmetrical without cracks.
  • Mucous membranes and tongue are moist and pink.
  • Absence of lumps, lesions, redness, drainage, or swelling.
  • Teeth are intact and healthy.
  • Uvula is midline.
• Ear Assessment:
  • Ears are symmetrical; size and shape are normal.
  • External structures are soft and non-tender.
  • No lumps, lesions, redness, swelling, or drainage noted.

Comprehensive Cranial Nerve Examination

• Cranial Nerve I (Olfactory):
  • Procedure: Alcohol smell test.
  • Verbalization: Cranial nerve $1$ olfactory is intact.
• Cranial Nerve II (Optic):
  • Procedure: Read name on badge.
  • Verbalization: Cranial nerve $2$ optic is intact.
• Cranial Nerves III (Oculomotor), IV (Trochlear), & VI (Abducens):
  • Procedure: Shine light at bridge of nose, bring light in from each side, measure eyeball/pupil size, and assess the $6$ cardinal fields of gaze.
  • Verbalization: Smooth ocular movements observed with no nystagmus.
  • Pupils are Equal, Round, Reactive to Light and Accommodation (PERRLA), measuring $3\,\text{mm}$.
  • Corneal light reflex is present and symmetrical bilaterally.
  • Cranial nerves $3$ oculomotor, $4$ trochlear, and $6$ abducens are intact.
• Cranial Nerve V (Trigeminal):
  • Procedure: Assess light/hard and soft sensation on face, legs, and arms; palpate jaw muscles.
  • Verbalization: Jaw strength is intact with no clicking or crepitus. Sensation is equal bilaterally. Cranial nerve $5$ trigeminal is intact.
• Cranial Nerve VII (Facial):
  • Procedure: Evaluate facial expressions.
  • Verbalization: Cranial nerve $7$ facial is intact.
• Cranial Nerve VIII (Vestibulocochlear):
  • Procedure: Perform whisper test.
  • Verbalization: Cranial nerve $8$ vestibulo-cochlear is intact.
• Cranial Nerves IX (Glossopharyngeal), X (Vagus), & XII (Hypoglossal):
  • Procedure: Have patient say "Ahhh", swallow, stick out tongue and move it side to side, and say "Right Tight Dynamite".
  • Verbalization: Uvula is midline, soft palate rises symmetrically, swallowing is intact, and speech is clear. Cranial nerves $9$ glossopharyngeal, $10$ vagus, and $12$ hypoglossal nerves are intact.
• Cranial Nerve XI (Spinal Accessory):
  • Procedure: Have patient shrug shoulders against hand resistance; push face against hand resistance on each side.
  • Verbalization: Cranial nerve $11$ spinal accessory is intact.
• Hand hygiene performed.

Neck, Jugular Venous Distension, & Carotid Artery Assessment

• Inspection:
  • Verbalization: "I am inspecting first."
  • Findings: Neck is symmetrical without any masses, lesions, redness, swelling, or tenderness.
• Jugular Venous Distension (JVD):
  • Procedure: Position head of bed (HOB) at $30^\circ - 45^\circ$.
  • Findings: No jugular venous distension is noted.
• Carotid Arteries:
  • Procedure: Palpate carotid pulses.
  • Findings: Pulses are present at $2+$ grade; rate and rhythm are symmetrical bilaterally.
• Cervical Range of Motion:
  • Procedure: Have patient tilt head up, down, left, and right.
  • Findings: Cervical range of motion is smooth.

Lymphatic System Assessment

• Head Lymph Node Chain (Palpation Locations):
  • Preauricular: In front of the ear.
  • Posterior Auricular: Behind the ear.
  • Occipital: Base of the skull.
  • Superficial Cervical: Top of the sternocleidomastoid muscle.
  • Deep Cervical Chain: Deep within/down the muscle.
  • Posterior Cervical: Along the anterior border of the trapezius/shoulder muscle.
  • Supraclavicular: Above the clavicle bone.
• Arm & Axillary Lymph Node Chain (Palpation Locations):
  • Epitrochlear: Antecubital fossa / by the elbow.
  • Lateral Axillary: Along the humerus / bicep area.
  • Central Axillary: High in the middle of the axilla / armpit.
  • Subscapular: Posterior axillary fold / behind armpit in back.
  • Pectoral: Anterior axillary fold / border of pectoral muscle.
• Clinical Findings & Verbalization:
  • All lymph nodes are non-palpable and non-tender.

Musculoskeletal System, Joints, Gait, & Coordination Assessment

• Motor Response & Muscle Strength Procedures:
  • Upper Extremities: Hold arms out, resist pushing up and down; push against hands, squeeze examiner's fingers, wiggle fingers.
  • Lower Extremities: Hold legs out, resist pushing up and down; flex foot against hand resistance.
  • Clinical Findings: Patient follows commands; voluntary motor responses and muscle strength are equal bilaterally.
  • Hand hygiene performed.
• Joint Assessment:
  • Joints Evaluated: Shoulder, Elbow, Wrist, Knee, Ankle.
  • Findings: No heat, tenderness, swelling, deformity, resistance, or crepitus noted in any evaluated joints.
• Gait, Balance, & Coordination Procedures:
  • Walk $3$ steps forward.
  • Perform Romberg Test.
  • Slide heel down opposing shin.
  • Findings: Posture is upright, gait is steady, walking and coordination are intact, and Romberg test is negative.

Cardiovascular & Anterior Chest Assessment

• Inspection:
  • Visual check of anterior chest: Skin intact, symmetrical with no lesions, lumps, or drainage. No barrel chest noted.
• Heart Auscultation Landmarks & Verbalization:
  • Locate suprasternal notch and Angle of Louis.
  • Anatomical Auscultation Landmarks:
  • Aortic Area: $2^{\text{nd}}$ right intercostal space.
  • Pulmonic Area: $2^{\text{nd}}$ left intercostal space.
  • Erb's Point: $3^{\text{rd}}$ left intercostal space.
  • Tricuspid Area: $4^{\text{th}}$ left intercostal space.
  • Mitral (Apical) Area: $5^{\text{th}}$ left intercostal space, midclavicular line.
  • Timing Procedure: Auscultate apical pulse for $1\,\text{full minute}$.
• Apical Impulse Palpation:
  • Palpate apical impulse at the $5^{\text{th}}$ intercostal space, midclavicular line.
• Costal Angle:
  • Evaluated and measured at $< 90^\circ$.

Thoracic & Respiratory Assessment

• Anterior Lungs Auscultation:
  • Procedure: Auscultate front chest $10$ times following a ladder formation.
  • Findings: Lungs are clear bilaterally. Vesicular breath sounds heard throughout with no adventitious sounds.
  • Vital Signs: Respiratory rate is $16\,\text{breaths per minute}$, regular and unlabored with no accessory muscle use noted.
• Posterior Thorax & Lungs Assessment:
  • Inspection: Inspect back skin first. Skin is intact, warm, and dry. Spine is aligned symmetrically with no scoliosis.
  • Posterior Auscultation: Auscultate back $18$ times in a ladder formation. Lungs are clear bilaterally with vesicular breath sounds throughout and no adventitious sounds. Respirations remain unlabored without accessory muscle use.
  • Bronchophony Evaluation: Auscultate while patient repeats "99" across $10$ posterior spots. Findings: All transmitted voice sounds are muffled and indistinct throughout.
  • Tactile Fremitus Evaluation: Palpate while patient repeats "99" as hands move down $5$ position levels. Findings: Tactile vibrations felt symmetrically throughout.
  • Thoracic Ratio: Anterior-Posterior (AP) to transverse diameter ratio is $1:2$.
  • Thoracic Expansion Procedure: Measure expansion while patient takes $2$ deep breaths. Findings: Thoracic expansion is symmetrical.

Spine, Thoracic/Lumbar ROM, & Sacral Assessment

• Sacrum Assessment:
  • Inspect and palpate sacral region.
  • Findings: No lumps, tenderness, or edema noted.
• Thoracic & Lumbar Range of Motion:
  • Procedure: Have patient bend forward at the waist and rotate body side to side.
  • Findings: Thoracic and lumbar range of motion is fully intact.

Gastrointestinal & Genitourinary Assessment

• Abdominal Inspection:
  • Abdomen is symmetrical with expected size and contour.
  • Absence of masses, lesions, or visible aortic pulsations.
• Bowel Sound Auscultation:
  • Auscultate before palpation. Active bowel sounds heard in all $4$ quadrants.
• Abdominal Palpation:
  • Perform light palpation across all $4$ quadrants.
  • Findings: No tenderness, muscle resistance, distension, bulges, or masses noted.
• Bladder Assessment:
  • Palpate urinary bladder region.
  • Findings: Bladder is non-distended with no tenderness noted.

Peripheral Vascular System Assessment

• Pulse Anatomical Sites Evaluated:
  • Brachial Pulse: Inner elbow / antecubital fossa.
  • Radial Pulse: Thumb side of wrist.
  • Ulnar Pulse: Pinky side of wrist.
  • Femoral Pulse: Groin region.
  • Popliteal Pulse: Posterior to the knee.
  • Dorsalis Pedis Pulse: Dorsum / top of the foot.
  • Posterior Tibial Pulse: Posterior aspect of the inner ankle.
• Clinical Findings:
  • All peripheral pulses are present with $2+$ grade (normal force).
  • Pulse rate and rhythm are regular and symmetrical bilaterally.

Deep Tendon Reflexes Assessment

• Reflex Test Locations & Techniques:
  • Biceps Reflex: Strike thumb positioned over biceps tendon at inner elbow.
  • Triceps Reflex: Direct strike to triceps tendon on back of arm.
  • Brachioradialis Reflex: Strike tendon at inner wrist area.
  • Quadriceps Reflex: Direct strike to patellar tendon below knee cap.
  • Achilles Reflex: Strike Achilles tendon at back of ankle.