Head to Toe Physical Assessment Script 2023/2024 (Complete)

NEUROLOGICAL Mental Status: o A & O x 4 (person, place, time, situation) Cranial Nerves: o “CN 2 – 12 are intact” Motor: o “I am assessing for normal muscle bulk and tone” • ROM o “ROM is intact” • **Muscle strength** o Perform (listed on previous page) Sensory: • Spinothalamic tract o Perception of light touch o Cotton ball on diff. dermatomes ▪ 5 different points o Perception of pain (sharp/dull test) ▪ Show and state what a sharp and dull touch is o “The spinothalamic is intact” • Posterior column tract o Vibratory sense ▪ Tuning fork on DIP of thumb and big toe ▪ Hit fork and then stop ▪ Ask pt. to close eyes & state when vibration stops o Proprioception ▪ Demo first. Tell me if thumb or big toe up/down ▪ Demonstrate what it looks like first ▪ Use hands on the outside of thumb of DIP ▪ Ask pt. to close eyes & state up or down o Graphesthesia ▪ Draw # in each hand – “3” or “8” ▪ Ask pt. what # was drawn o “The posterior column is intact” Deep Tendon Reflexes • Brachioradialis, biceps, triceps o Measure 2 inches using hammer o Hit your thumb & not pt. • Patellar, achilles, plantar o Ask pt. to lie down o Plantar: Use the back of the hammer to draw an “L” shape • “I am grading all reflexes at a 2+” Cerebellar Function • Coordination and skilled movements o Rapid alternating movements (patty cake, peddle bike, finger to thumb) o Finger to nose (3 areas each b/l, noting no tremors) ▪ Switch hands o Heel to shin • Romberg test (30 sec standing, eyes closed, & feet together) o Support hands o + exam = swaying • Pronator drift (30 sec standing, eyes closed, arms out) o Palms up o Over/under compensation (tap across both arms) • Evaluate gait and general postur