Comprehensive Head-to-Toe Physical Assessment Guide

General Inspection

The clinical assessment begins with an initial focused inspection of the patient. This inspection evaluates the patient's overall mobility, posture, body build, structural deformities, dress, and grooming. The patient's complexion is observed for any discoloration or abnormal pigmentation. Physical measurements include determining the patient's height and weight, which must be explicitly verbalized during performance evaluation.

Distance vision is assessed for Cranial Nerve II ($CN\,II$) using a well-lit Snellen or Sloan chart, testing each eye individually. In modified practical evaluation settings, gross vision is assessed in place of the Snellen chart by holding up a specific number of fingers and verifying whether the patient correctly identifies the quantity. Assessment of general inspection concludes with measuring and recording a complete set of vital signs.

Head and Face Assessment

Examination of the head and face begins with an inspection of the skin, eyes, ears, and skull structure. The scalp and hair are thoroughly inspected and palpated to confirm the absence of baldness, skin lesions, or abnormal structural lumps. The temporomandibular joints ($TMJ$) are palpated bilaterally while evaluating joint smooth movement and comfort.

Palpation is extended to the facial bones, frontal sinuses, and maxillary sinuses to detect tenderness or anatomical abnormalities. Cranial Nerve VII ($CN\,VII$) motor function is evaluated by instructing the patient to perform three facial movements: smiling, raising their eyebrows, and puffing out their cheeks. Cranial Nerve V ($CN\,V$) sensory function is tested by applying a Q-tip to touch three distinct facial regions: the forehead, cheeks, and chin.

External Ocular Assessment

Inspection of external eye structures begins with palpating the lacrimal glands, executed by gently lifting the patient's eyelids upward. Near vision is tested by instructing the patient to touch the examiner's or their own nose. Pupillary light response and accommodation are assessed to verify direct and consensual pupillary constriction.

Extraocular muscle function and cranial nerve innervation are evaluated by assessing extraocular movements as the patient tracks movement through the six cardinal points of gaze. Visual fields are subsequently assessed. Under specific practical validation guidelines, theoretical understanding is required for the corneal light reflex, the red reflex, and retinal inspection, though physical demonstration of these three specific techniques is omitted during clinical validation.

Ear and Auditory Assessment

Inspection of the ears involves examining the external structures and palpating the auricles. Hearing acuity is evaluated using the whisper test. The Rinne test is performed to compare bone and conduction hearing, and its execution must be explicitly verbalized during assessment evaluation.

Assessment findings confirm the absence of ear drainage. Under clinical validation guidelines, theoretical knowledge of inspecting the external auditory canals and tympanic membranes as well as performing the Rinne test is required, while physical demonstration of internal ear inspection with an otoscope is exempted.

Nasal Cavity Assessment

Inspection of the nose includes assessing nostril patency to verify that both nostrils are open and unobstructed. The internal nasal mucosa, nasal septum, and turbinates are inspected, confirming that the septum is non-deviated and that no abnormal mucosal drainage is present. Assessment of Cranial Nerve I ($CN\,I$) sensory function via a taste or smell test must be explicitly verbalized during physical assessment validation.

Oral and Pharyngeal Assessment

Inspection of the mouth and pharynx encompasses the external and internal oral structures: the lips, buccal mucosa, teeth, gums, and tongue. Objective findings document that the mucosa is pink and moist. The oropharynx is inspected while instructing the patient to say "Ah", confirming the absence of redness, swelling, or exudative drainage. The gag reflex is evaluated. Gustatory taste response assessment is noted and must be explicitly verbalized during practical assessment evaluation.

Cervical and Neck Assessment

Inspection of the neck structures evaluates alignment, symmetry, and muscle contour. Active range of motion of the neck is tested across anatomical planes. Spinal accessory motor function (Cranial Nerve XI, $CN\,XI$) is checked by testing shoulder shrug against manual resistance.

Palpation of the neck includes evaluating the carotid arteries, trachea, and thyroid gland, documenting that the carotid pulse exhibits a normal rhythm bilaterally. Regional lymph node chains are palpated systematically, including the preauricular, posterior auricular, tonsillar, submandibular, deep cervical, and posterior cervical nodes. Auscultation of both carotid arteries and the thyroid gland is conducted using the bell of the stethoscope to screen for vascular bruits.

Upper Extremity Assessment

Upper extremity evaluation involves inspecting the hands, arms, and shoulders. Muscle mass and motor strength are assessed by instructing the patient to push their hands upward against manual resistance and hold their hands outstretched while resisting downward force. Active joint ranges of motion are checked across all upper extremity joints.

Peripheral arterial pulses are evaluated, with brachial and radial pulses rated as $2+$ and regular bilaterally. The epitrochlear lymph nodes are palpated along the medial aspect of the inner arm adjacent to the brachial pulse.

Posterior Thorax, Back, and Lung Assessment

Inspection of the back evaluates skin integrity, thoracic shape, bilateral symmetry, and spinal muscle development. The spine and scapulae are inspected and palpated. Costovertebral angle ($CVA$) percussion is performed to assess for renal tenderness in the kidney region.

Respiratory mechanics are evaluated by observing excursion, noting respiratory characteristics, and verifying that thoracic expansion is symmetrical. Tactile fremitus is assessed by palpating the posterior chest wall while the patient repeats the phrase "$99$" to feel for tactile vibrations. Breath sounds are auscultated across $12$ distinct posterior anatomical locations. Theoretical study requirements apply to percussing the spine, percussing the costovertebral angle, percussing thoracic resonance, and percussing diaphragmatic excursion, with these specific percussion steps exempted from physical validation demonstration.

Anterior Thorax, Breast, and Cardiac Assessment

General inspection of the anterior chest includes evaluating skin integrity, underlying musculature, and respiratory effort. The chest wall is palpated for tenderness or deformities. The precordium is palpated to locate the Point of Maximal Impulse ($PMI$) across specific cardiac landmarks: aortic, pulmonic, tricuspid, and mitral areas. Regional lymph nodes, including axillary, sternal (breastbone), and clavicular (collarbone) nodes, are palpated.

Inspection of the breasts and precordium is conducted. Cardiac auscultation is performed, confirming that $S_1$ and $S_2$ heart sounds are present with no audible murmurs. During practical assessment validation, explicit verbalization is required for three specific actions: palpating the breasts in four seated positions, palpating each breast with the patient's arm elevated above their head, and stating cardiac auscultation findings. Theoretical reading requirements and demonstration exemptions apply to percussing the anterior chest for resonance, estimating jugular venous pressure ($JVP$) via jugular vein inspection, and auscultating heart sounds with the patient rotated onto their left side.

Abdominal Assessment

Inspection of the abdomen evaluates skin condition, contour, and surface characteristics. Auscultation is performed prior to palpation, listening in all four quadrants to confirm active bowel sounds. Auscultation for vascular bruits and venous hums is performed using the bell of the stethoscope over the renal/kidney areas and the liver.

Systematic palpation is conducted lightly, moderately, and deeply across all four quadrants, confirming that the abdomen is soft and non-tender. Specific abdominal organs are palpated, including the liver, appendix, and gallbladder. Femoral arterial pulses are assessed, and inguinal lymph nodes are palpated. Practical validation protocols exempt four-quadrant percussion, liver span estimation, splenic dullness testing, abdominal reflex testing, and observation of abdominal muscle contractions from physical demonstration.

Lower Extremity Assessment

Lower extremity inspection involves assessing the feet and legs, confirming that the skin is intact without cutaneous lesions or abnormalities. Skin temperature and texture are evaluated via palpation. Testing for peripheral edema confirms the absence of edema.

Peripheral arterial pulses in the lower extremities are assessed, documenting that the dorsalis pedis pulses are $2+$ and regular bilaterally, and the posterior tibial pulses are $2+$ and regular bilaterally. Range of motion of the toes is tested by having the patient curl their toes. Range of motion of the feet, ankles, and knees is evaluated by having the patient bring each knee up to the chest and rotate the ankles inward and outward.

Hip joints are inspected, and hip range of motion and motor strength are tested. Lower extremity coordination, muscle utilization, and ease of movement are evaluated by instructing the patient to push down against manual resistance like pressing a gas pedal and then push upward against resistance.

Neurologic System Assessment

Neurologic assessment evaluates sensory function, fine motor coordination, position sense, reflexes, spinal range of motion, proprioception, cerebellar function, and balance. Sensory discrimination is tested by having the patient distinguish sharp from dull tactile stimuli across the forehead, face, lower arms, hands, lower legs, and feet. Vibratory sensation is tested bilaterally over the patient's wrists and ankles. Two-point discrimination is evaluated on the palms, thighs, and back.

Cortical sensory function is assessed through stereognosis, where a familiar object is placed in the patient's hand with eyes closed for identification, and graphesthesia, where a number is traced on the patient's palm. Fine motor function and coordination are evaluated through three specific motor tasks: instructing the patient to touch each finger sequentially to the thumb of the same hand, perform the finger-to-nose-to-examiner's-finger test, and run each heel down the shin of the opposite leg.

Position sense (proprioception) is evaluated in the upper and lower extremities by moving a finger or toe up or down while the patient's eyes are closed and having them state the direction of movement. Deep tendon and superficial reflexes are assessed bilaterally, including the biceps, triceps, brachioradialis, patellar, Achilles, and plantar reflexes on the soles of both feet.

Spinal alignment and mobility are evaluated with the patient standing. The spine is palpated for tenderness, and spinal curvature is inspected while the patient bends forward and backward, flexes laterally to each side, and twists axially in each direction, supporting the patient's hips if unsteadiness is observed.

Balance and proprioception testing begins with the Romberg test, requiring explicit verbalization that the Romberg test was negative as the patient maintained balance with eyes open and closed. Dynamic balance is tested by having the patient close their eyes and stand on each foot separately, then open their eyes and hop on each foot. Overall gait is observed while the patient walks around the room, requiring explicit verbalization that the patient exhibits a steady gait and maintains balance. Fine balance is evaluated through tandem gait by having the patient walk heel-to-toe.