Head to Toe Physical Assessment Script 2023

Complete Head to Toe Physical Assessment Script 2023. EYES → PERRLA & EOMI Inspect • External Inspection o Eyelashes → point out & away o Conjunctiva/sclerae/cornea → clear & moist o Pupil → size & shape o (3-5mm b/l, round) • 3 Finger Test o Visual fields on confrontation (CN 2 – Optic) (Jazz hands) ▪ Start laterally → Ask pt. stare straight in front & let me know when you see my fingers o 6 cardinal fields of gaze (CN 3, 4, & 6 – Oculomotor, Trochlear & Abducens) (Cat Whiskers) ▪ Ask pt. follow my finger & not move your head o Accommodation & Convergence (CN 2 & 3) (Follow Finger) ▪ Ask pt. to follow my finger as I bring it closer to pt. face & away • 2 Light Test (Pen light) o Direct (CN 2) constrict & consensual (CN 3) light reflexes, consensually constricts o Corneal light reflex → strabismus (shine light & see that the light falls in the same place in both eyes) • 1 Ophthalmoscope Exam (Right Eye to Right Eye) o Catch red light reflex & move closer into pt. o Optic disc → clear, well defined, creamy yellow o 4 sets of retinal vessels o Macula → 2 optic discs away “Pt is PERRLA & EOMI - Pupils are equal, round, reactive to light & accommodation ; Extra ocular movements intact” EARS • Assess gross hearing (CN 8 – Vestibular Cochlear) o Normal conversation o Whisper test/finger rub o Ask pt. to close their eyes & point to the ear where they hear the finger rub o If abnormal, continue to Weber (midline) & Rinne (AC>BC) test Inspect • Auricle → symmetry, lesions, nodules • Special attention to back & top of ears as it is a common site for skin cancer Palpate • Tragus & mastoid → tenderness Otoscopic Exam • Maneuver Auricle o Adults Pinna → up & back o Peds Pinna → down & back • Inspect canals → cerumen (ear wax), foreign bodies, inflammation, discharge • Inspect TM & note presence of the following/abnormalities o Not bulging or retracted o Pearly gray color o Bony prominences o Cone of light (R ‘ 5; L ‘ 7)