Head to Toe

Question 1

13 aspects of the general survey

Answer 1

1. General state of health,
2. Nutritional status
3. Signs of distress
4. Build
5. Posture
6. Gait
7. Grooming
8. Hygiene
9. Dress
10. Affect
11. Facial expressions
12. Speech
13. Awareness

Question 2

11 Sections of Documentation

Answer 2

1. Vital Signs
2. General Survey
3. Mental Status
4. Neurological
5. Reflexes
6. Skin/Hair/Nails
7. HEENT/Neck
8. Pulmonary/Thorax
9. Cardiovascular & Peripheral Vascular
10. Abdomen
11. Musculoskeletal

Question 3

Mental Status norms

Answer 3

Alert and oriented to person, place and time. Attentive, pleasant, and cooperative with examination. Responds to questions and commands appropriately.

Question 4

12 Cranial nerves

Answer 4

CN I: olfactory
CN II: optic
CN III: oculomotor
CN IV: trochlear
CN V: trigeminal
CN VI: abducens
CN VII: facial
CN VIII: acoustic
CN IX: glossopharyngeal
CN X: vagus
CN XI: spinal accessory
CN XII: hypoglossal

Question 5

CN I (Olfactory) norm

Answer 5

Identifies/smells coffee and cinnamon bilaterally

Question 6

CN II (Optic), III (Oculomotor) norms

Answer 6

Visual fields intact with confrontation. PERRLA. Convergence intact.

Question 7

CN III (Oculomotor), IV (Trochlear), VI (Abducens) norms

Answer 7

EOMs intact x6. No nystagmus, ptosis, or lid lag.

Question 8

CN V (Trigeminal) norms

Answer 8

Facial sensation intact to light touch on forehead, cheeks, and chin bilaterally. Temporal and masseter muscles strength 5/5 bilaterally.

Question 9

CN VII (Facial) norms

Answer 9

Face symmetrical with eyebrows raised, frowning, closing eyes, smiling, showing teeth, and puffed cheeks.

Question 10

CN VIII (Acoustic) norms

Answer 10

Hearing acuity sensitive to whisper bilaterally. Rinne AC > BC bilaterally. Weber midline.

Question 11

CN IX (Glossopharyngeal), X (Vagus) norms

Answer 11

Uvula midline and palate rises symmetrically on “ah”. No apparent hoarseness or dysphagia.

Question 12

CN XI (Spinal Accessory) norms

Answer 12

Sternomastoid and upper trapezius strength 5/5 with shoulder shrug and turning head against resistance bilaterally.

Question 13

CN XII (Hypoglossal) norms

Answer 13

Tongue midline without fasciculation. Able to stick out tongue and move tongue side to side symmetrically.

Question 14

Motor norms

Answer 14

Good muscle bulk and tone with no atrophy, contracture, or flaccidity. Flexion and extension muscle strength 5/5, equal bilaterally upper and lower extremities.

Question 15

Cerebellar norms

Answer 15

Natural gait steady with appropriate arm swing. Able to tandem gait and perform shallow knee bend bilaterally without difficulty. Rapid-alternating hand movements smooth and coordinated bilaterally. Romberg negative. No pronator drift. No involuntary movements or tremors.

Question 16

4 parts of Neurological assessment

Answer 16

1. Cranial nerves
2. Cerebellar
3. Motor
4. Sensory

Question 17

Sensory norms

Answer 17

Sensation to sharp and dull intact in upper and lower extremities. Vibratory sense and proprioception intact in lower extremities bilaterally. Stereogenesis and graphesthesia intact bilaterally.

Question 18

6 reflexes to test

Answer 18

1. Biceps
2. Brachioradialis
3. Triceps
4. Patellar
5. Achilles
6. Plantar

Question 19

Reflexes norms

Answer 19

Biceps, brachioradialis, triceps patellar, and Achilles reflexes 2+ bilaterally. Plantar reflex downward bilaterally.

Question 20

Skin/Hair/Nails norms

Answer 20

Skin tan, warm, dry, smooth, and intact with no lesions, erythema, scars or striae. Hair brown, evenly distributed, with smooth texture. Finger nail beds pink with capillary refill < 3 seconds and no clubbing bilaterally.

Question 21

Head/Face norms

Answer 21

Normocephalic, atraumatic, non-tender, symmetric skull without lumps, depressions, or deformities. Scalp with no scaling, erythema, nevi, or lesions. No frontal or maxillary sinus tenderness or edema bilaterally. No temporal artery tenderness, pulse 3+. Relaxed symmetric facial expression, without abnormal movements.

Question 22

Eye norms

Answer 22

Eyebrows and eyelashes symmetrical with even distribution bilaterally. Sclera white, conjunctiva pink. No corneal or lens opacities bilaterally. Corneal light reflex symmetrical. Red light reflex present and optic disc margins sharp bilaterally. No hemorrhages or AV nicking. No arteriolar narrowing.

Question 23

Ear norms

Answer 23

Symmetrical, appropriate size to head, with clear skin and no tenderness to pinna, tragus, mastoid process bilaterally. Canals patent with minimal wax. Tympanic membranes pearly gray with visible bony landmarks and cone of light bilaterally with no inflammation or perforation.

Question 24

Nose norms

Answer 24

Nose symmetric. Nares patent bilaterally, no septal deviation or perforation. No drainage. Turbinates and mucosa pink without swelling, exudate or perforation.

Question 25

Mouth and throat norms

Answer 25

Lips, gums, tongue, and oral mucosa pink, moist, intact without lesions or bleeding. Good dentation. Tonsils 1+ bilaterally, pharynx with no exudate.

Question 26

Neck norms

Answer 26

Neck supple, symmetric, no masses, lumps, or lesions. Trachea midline. Thyroid smooth with no enlargement, nodules, or tenderness. No pre-auricular, post-auricular, occipital, submental, submandibular tonsillar, superficial cervical, deep cervical, posterior cervical, or supraclavicular lymphadenopathy or tenderness. Normal range of motion of neck including flexion, extension, rotation and lateral bending.

Question 27

Pulmonary/Thorax norms

Answer 27

Anterior and posterior thorax symmetric without lesions. Respirations non-labored and no accessory muscle use. Chest expansion symmetric. Posterior thorax without tenderness or crepitus. Anterior thorax without thrills, heaves, or lifts. Tactile fremitus present and equal bilaterally. Diaphragmatic excursion 4 cm bilaterally. Lung sounds clear to auscultation bilaterally without rales, rhonchi, or wheezes. No CVA tenderness.

Question 28

Cardiovascular & Peripheral Vascular norms

Answer 28

No JVD. JVP measured at 2 cm with HOB at 30 degrees above the sternal angle. Carotid pulse 2+ bilaterally. No carotid bruit. Chest is symmetrical, no lesions. No lifts, heaves, or thrills. PMI palpated at 5th left intercostal space, mid clavicular line. Regular rate and rhythm. Crisp S1 and S2; No S3, S4, or murmurs, gallops, or rubs. No aortic regurgitation. Capillary refill < 3 seconds in fingers bilaterally without clubbing. No edema in lower extremities. Temporal, radial, brachial, popliteal, posterior tibial, and dorsalis pedis pulses 2+ bilaterally.

Question 29

7 pulse points to check

Answer 29

1. Temporal 2. Carotid 3. Brachial 4. Radial 5. Popliteal 6. Posterior Tibial 7. Dorsalis Pedis

Question 30

Abdomen norms

Answer 30

Flat, symmetric, without pulsations or lesions, umbilicus midline. Bowel sounds present in RLQ. No aortic, renal, iliac or femoral bruits. Percussion tympanic x4 quadrants. Liver 6 cm at right mid clavicular line. Liver edge is smooth. Soft with no tenderness or masses noted with light and deep palpation. Spleen and kidneys non-palpable.

Question 31

10 Musculoskeletal areas to check

Answer 31

1. TMJ 2. Spine 3. Shoulders 4. Elbows 5. Wrists 6. Fingers 7. Hips 8. Knees 9. Ankles 10. Feet

Question 32

Temporal mandibular joint norms

Answer 32

Able to open and close jaw with no clicking or tenderness. Range of motion present when protruding jaw, retracting jaw, and moving jaw side to side.

Question 33

Spine norms

Answer 33

Scapula, shoulder height, iliac crest, and gluteal folds equal height bilaterally. Normal curvature of spine with no kyphosis, lordosis, or scoliosis. No tenderness or spasm of spinous processes of vertebra or paravertebral muscles. Range of motion present for flexion, extension, rotation, and lateral bending.

Question 34

Joint norms

Answer 34

Symmetric with no obvious deformities, heat, erythema, swelling, edema, nodules, tenderness, bogginess, or joint laxity.

Question 35

Shoulder norms

Answer 35

Range of motion present of shoulders for flexion, hyperextension, abduction, adduction, internal rotation, and external rotation. Strength 5/5 against resistance.

Question 36

Elbow norms

Answer 36

Range of motion present of elbows for flexion, extension, supination, pronation. Strength 5/5 against resistance.

Question 37

Wrist and hand norms

Answer 37

Range of motion present of wrist and hands for flexion, extension, ulnar deviation, radial deviation, spreading fingers apart, and making a fist. Strength 5/5 against resistance.

Question 38

Hip norms

Answer 38

Range of motion present of hips for flexion, extension, abduction, adduction, internal rotation, and external rotation.

Question 39

Ankle and foot norms

Answer 39

Range of motion present of ankles and feet for flexion, extension, inversion, and eversion. Strength 5/5 against resistance.