Complete Head-to-Toe Physical Assessment Script 2023

GENERAL ORDER OF THE EXAM * • Inspect  visually observe pt • Palpate  use hands to feel pt • Percuss  light striking of body parts to produce sounds • Auscultate  listening to body w/stethoscope o Bell = low-pitch sound o Diaphragm = high-pitch sound *All systems except GI 4 CLASSICAL ASSUMPTIONS • A & O x 4 (person, place, time, situation) • Vital signs WNL • Visual acuity assessed via Snellen chart (CN 2 – Optic) • Patient is in NAD PREPARATION • Knock on entry • Introduce yourself o “Hi, my name is Sumiyah, and I’m a nursing student. I will be performing a physical exam on you today.” • Hand hygiene GENERAL SURVEY • Physical Appearance o Age, sex, race/ethnicity • Body Structure o Tall/short o Underweight/overweight/average weight o Proportionality of weight to height • Mobility o Ease in ambulation o Ease in movement of limbs • Behavior/Mood o Response to questions o Grooming/hygiene o Affect/speech/eye contact Ex: “Pt is a (#) y/o (gender ident.) of avg. & proportional height & weight, who moves easily & responds to questions. They are well groomed & have appropriate affect to situation.” SKIN Inspect • Entire body  color, lesion, hair distribution • Finger/Toenails  pitting or clubbing • Describe lesions noting number, location, arrangement & type & document later Palpate (Use the back of the hand) • Moisture, temperature, texture, turgor (pinch back of hand), checking for tenting • Note areas of tenderness or induration “I will continue to inspect the rest of the body bilaterally throughout the remainder of my exam” HEAD  NCAT Inspect • Skull  general size & contour • Scalp  lesions or inhabitants • Hair  quantity, texture, distribution, balding • Face  symmetry (eyebrows, palpebral fissures in line with helices of ears, nasolabial folds) Palpate • Skull  deformities or tenderness • Temporal Artery  induration & intensity (2+ = normal) • TMJ  pain, popping or crepitus (pt. open/close mouth) Neuro Test • CN 7 (Facial - motor)  pt. smile, frown, puff cheeks, resist eye opening • CN 5 (Trigeminal - motor)  pt. clench jaw – masseter muscle engaged • CN 5 (Trigeminal - sensory)  light touch x6 (ask pt. close your eyes & say “now” when you feel it) “Pt is normocephalic – atraumatic” NECK Inspect • Obvious masses or pulsations Palpate • Lymph nodes of head & neck; identify chains  o Preauricular, postauricular, occipital o Tonsillar, submandibular, submental o Anterior cervical, posterior cervical & deep cervical (lean R/L) o Supraclavicular, infraclavicular o Non-palpable or <1cm, mobile, & non- tender • Carotids  pulses • Trachea  deviation • Thyroid  size, symmetry, tenderness, consistency, nodules (palpate from behind) Neuro Test • CN 11 – Spinal Accessory (motor)  shrug shoulders, turn head against resistance “CN 2 – 12 are intact” 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