History/Physical Examination

eTABLE 3-2 HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLIST

Notes or Notes or
Preparation or Activity Performed Comments Preparation or Activity Performed Comments
General Survey: Observe general state of health with Motor (CN VII, shows teeth,
patient seated purses lips, raises eyebrows)
1. Assemble all equipment and Looks up, wrinkles forehead
supplies. (CN VII)
Raises shoulders against
Procedure resistance (CN XI)
2. Explain to the patient what you Inspect, palpate, auscultate neck
are going to do, why it is for
necessary, and how he or she Skin (vascularity and visible
can cooperate. pulsations)
3. Wash hands and observe Symmetry
standard (universal) precautions. Range of motion
4. Provide for patient privacy. Pulses and bruits (carotid)
Record findings for Midline structure (trachea,
Body features thyroid gland, cartilage)
Level of consciousness and Lymph nodes (preauricular,
orientation postauricular, occipital,
Speech mandibular, tonsillar,
Body movements and carriage submental, anterior and
Physical appearance posterior cervical,
Nutritional status infraclavicular, supraclavicular)
Stature Inspect, assess, palpate eyes for
Visual acuity
Vital Signs Eyebrows
Record findings for Position and movement of
Blood pressureboth arms for eyelids (CN VII)
comparison Visual fields
Apical/radial pulse Extraocular movements (CN
Respiration III, IV, VI)
Temperature Cornea, sclera, conjunctiva
Height and weight Pupillary response (CN III)
Body mass index (BMI) Red reflex
calculation Inspect, palpate nose and
sinuses for
Integument External nose: shape, blockage
Inspect and palpate skin for Internal nose: patency of nasal
Color passages, shape, turbinates or
Breakdown, lacerations, polyps, discharge
lesions Frontal and maxillary sinuses
Scars, tattoos, piercings Inspect, assess, palpate ears for
Bruises, rash Placement
Edema Pinna
Moisture Auditory acuity (whispered
Texture voice, ticking watch) (CN VIII)
Temperature Mastoid process
Turgor Auditory canal
Vascularity Tympanic membrane
Inspect and palpate nails for Inspect, assess, palpate mouth for
Color Lips (symmetry, lesions, color)
Lesions Buccal mucosa (Stensens and
Size Whartons ducts)
Flexibility Teeth (absence, state of
Shape repair, color)
Angle Gums (color, receding from
Capillary refill time teeth)
Tongue for strength
Head and Neck (asymmetry, ability to stick out
Inspect and palpate head for tongue, side to side,
Shape and symmetry of skull fasciculations) (CN XII)
Masses Palates
Tenderness Tonsils and pillars
Hair Uvular elevation (CN IX)
Scalp Posterior pharynx
Skin Gag reflex (CN IX and X)
Temporal arteries Jaw strength (CN V)
Temporomandibular joint Moisture
Sensory (cranial nerve [CN] V, Color
light touch, pain) Floor of mouth

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc. Continued
 eTABLE 3-2 HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLISTcontd
Notes or Notes or
Preparation or Activity Performed Comments Preparation or Activity Performed Comments
Extremities Auscultate for rate and
Observe size and shape, rhythm, character of S1 and S2
symmetry and deformity, heart sounds in the aortic,
involuntary movements; inspect pulmonic, Erbs point,
and palpate arms, fingers, wrists, tricuspid, and mitral areas;
elbows, shoulders for bruits at carotid, epigastrium;
Strength breath sounds at right middle
Range of motion lobe.
Joint pain
Swelling Abdomen
Pulses (radial, brachial) Inspect for scars, shape,
Test reflexes symmetry, bulging, muscular
Triceps position and condition of
Biceps umbilicus, movements
Brachioradialis (respiratory, pulsations,
Inspect and palpate legs for presence of peristaltic waves).
Strength Auscultate for peristalsis,
Range of motion bruits.
Joint pain Percuss, then palpate to
Swelling, edema confirm positive findings;
Hair distribution check liver (size, tenderness);
Sensation (light touch, pain, spleen; kidney (size,
temperature) tenderness); urinary bladder
Pulses (dorsalis pedis, (distention).
posterior tibialis) Palpate femoral pulses,
Test reflexes inguinofemoral nodes, and
Patellar abdominal aorta.
Achilles
Plantar Neurologic
Observe motor status
Posterior Thorax Gait
Inspect for muscular Toe walk
development, respiratory Heel walk
movement, approximation of Drift
anteroposterior diameter Coordination
Palpate for symmetry of Finger to nose
respiratory movement, Romberg sign
tenderness of costovertebral Heel to opposite shin
angle, spinous processes, Observe the following:
tumors or swelling, tactile Proprioception (position sense
fremitus. of great toe)
Percuss for pulmonary
resonance. Genitalia*
Auscultate for breath sounds. Male external genitalia
Auscultate for egophony, Inspect penis, noting hair
bronchophony, and whispered distribution, prepuce, glans,
pectoriloquy. urethral meatus, scars, ulcers,
eruptions, structural
Anterior Thorax alterations, discharge.
Assess breasts for Inspect epidermis of
configuration, symmetry, perineum, rectum.
dimpling of skin. Inspect skin of scrotum;
Assess nipples for rash, palpate for descended testes,
direction, inversion, retraction. masses, pain.
Inspect for apical impulse, Female external genitalia
other precordial pulsations. Inspect hair distribution; mons
Palpate the apical impulse and pubis, labia (minora and
the precordium for thrills, lifts, majora); urethral meatus;
heaves, tenderness. Bartholins, urethral, and
Inspect neck for venous Skenes glands (may also be
distention, pulsations, waves. palpated, if indicated);
Palpate the lymph nodes in introitus; any discharge.
the subclavian, central axillary, Assess for presence of
and brachial areas. cystocele, prolapse.
Palpate breasts. Inspect perineum and rectum.

*If the nurse has the appropriate education, the speculum and bimanual examination of women and the prostate gland examination of men can be performed after this inspection.

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.