Name:_Yuliana Costansa Luturmas

Head-to-toe Checklist
Please find a person and do the full examination, do not skip any of the skills in this
checklist. You may not have to write the procedure for each skill, however, providing related
information to describe the findings is needed. Please truly perform the examination. I can
perceive whether the findings are from the real performance or not. A point of 0 to 5 will be
added to your global score of this health assessment course based on the quality of your
written.
Items Findings
A. General Appearance
1. Appears stated age 22 years Old
2. Level of consciousness Composmentis
3. Skin color Chocolasste
4. Nutritional status Good
5. Posture and position comfortably - Left tilt (sleep)
erect - Normal (sit)
6. Obvious physical deformities Normal
7. Mobility:
(1) Gait (1). Kipra (normal)
(2) Use of assistive devices (2). –
(3) Range of motion (ROM) of joints (3). Normal
(4) No involuntary movement (4). -
8. Facial expression Normal
9. Mood and affect Calm down
10. Speech: articulation, pattern, Normal, Indonesia (Minahasa)
content appropriate, native
language
11. Hearing Normal
12. Personal hygiene Clean
B. Measurement
1. Weight 65 kg
2. Height 149 cm
3. Vision -
C. Skin
1. Examine both hands and inspect Clean
the nails
2. For the rest of the examination,
 Name:_Yuliana Costansa Luturmas

examine skin with corresponding

regional examination
D. Vital Signs
1. Radial pulse 62x/m
2. Respiration rate 20x/m
3. Blood pressure 120/80 mmhg
4. Body temperature 36 0C
E. Head, nose, neck, throat
1. Inspect and palpate scalp Clean, no lesions and symmetrical benthic
thoroughly (any lesion, mass or
trauma?)
2. Observe face to check symmetry, Symmetrical face, no abnormalities
temporal wasting, temporalis and
masseter muscle atrophy
3. Inspect conjunctiva,eyelid,sclera - Conjuntiva (normal)
- Eyelid (normal)
- Sklera (-)
4. Evaluate extraocular muscle Normal
function ( up, down, right, left) ,up
and out,down and in(cranial nerve
III, IV, VI)
5. Observe papillary responses to Normal
light both directly and consensually
(cranial nerve II, Ⅲ)
6. Estimate visual field in each eye Normal
separately in 4 quadrant(cranial
nerve II)
7. Using an ophthalmoscope, observe Normal
the optic disc, physiological cup,
retinal vessels and fovea (cranial
nerve II)
8. Observe/palpate ears, preauricular Normal
and postauricular nodes/region
9. Weber/Rinne test (cranial nerve Normal
VIII)
10. Test for frontal and maxillary sinus Nothing
 Name:_Yuliana Costansa Luturmas

tenderness
11. Inspect lips, gums, teeth, floor of - Lips (pink, symmetrical)
mouth, tongue, pharynx/tonsils - Gums (normal, no problem)
- Tooth (one tooth on the back of the
right, perforated, clean, white teeth)
- Floor of mounth (normal, clean)
- Tongue (clean, symmetrical, normal
pharyn/tonsils)
12. Ask patient “stick out their tongue” Normal
and move it side to side, check any
deviation(cranial nerve XII)
13. Observe elevation of the plate) Normal
(cranial nerve IX,X)
14. Palpate salivary glands including Normal
parotid and submandibular gland
15. Test neck range of motion to sides, Normal
forward, backward
16. Palpate c-spine Normal
17. Palpate thyroid gland Normal
18. Palpate lymph nodes including Normal
occipital, anterior cervical,
posterior cervical, submental,
supraclavicular and infraclavicular
19. Check the position of trachea Normal
20. Auscultate carotid arteries Normal
F. Chest and heart
1. Inspect the chest: configuration of - Chest cavity configuration (normal)
the thoracic cage, skin - Skin characteristic (normal)
characteristics, and symmetry of - Shoulders and muscles (syemmetrical)
shoulders and muscles, respirations - Respiratory and skin characteristic
and skin characteristics (normal)
2. Inspect each side of neck for a Normal
jugular venous pulse
3. Estimate jugular venous pressure, if Nothing
indicated.
4. Palpate: symmetric expansion; Normal, nothing
 Name:_Yuliana Costansa Luturmas

tactile fremitus; lumps, or

tenderness
5. Palpate precordium for any Nothing
abnormal thrill
6. Palpate the apical impulse and note Normal
the location.
7. Percuss over all lung fields Normal
8. Percuss diaphragmatic excursion Normal
9. Percuss costovertebral angle, noting Nothing
tenderness
10. Auscultate breath sounds; note Normal
adventitious sounds(crackles
,wheeze or rhonchi)
11. Auscultate apical rate and rhythm. Normal
12. Auscultate with the diaphragm of Hearth sound (Normal)
thestethoscope to study heart
sounds, inching from apex up to the
base, or vice versa.
H. Abdomen
1. Inspect: contour, symmetry, skin Normal. Syemmetrical
characteristics, umbilicus, and
pulsations.
2. Auscultate bowel sounds. Normal
3. Auscultate for vascular sounds over Nothing
the aorta and renal arteries.
4. Percuss all quadrants. Normal
5. Percuss height of the liver span in Nothing
right midclavicular line.
6. Percuss the location of the spleen. Normal
7. Palpate: light palpation in all Nothing, normal
quadrants, then deep palpation in
all quadrants.
8. Test the abdominal reflexes, if Normal
indicated.
9. Test for Normal
appendicitis(obturator,psoas and
 Name:_Yuliana Costansa Luturmas

Rovsing sign)
H. Musculoskeletal
1. Inspect/palpate both hands and Syemmetrical, normal
arms for deformities, lesions,
clubbing, skin color, nailbeds,
temperature, muscle tenderness,
joint tenderness.
2. Inspect/palpate both legs for Normal
deformities, lesions, clubbing, skin
color, nailbeds, temperature,
muscle tenderness, joint
tenderness; separate toes and
inspect.
3. Observe posture and curvature. Normal
4. Exam injury knee(cruciate Nothing
ligament,collateral ligament and
meniscus)
5. Test ROM and muscle strength of Normal
hips, knees, ankles, and feet.
6. Test ROM and muscle strength of Normal
shoulder,elbow and wrist.
7. Note muscle strength as person sits Normal
up.
I. Peripheral vessels
1. Palpate pulses: radial, brachial Normal
arteries.
2. Palpate pulses: popliteal, posterior Normal
tibial, dorsalispedis.
3. Palpate for temperature and Normal
pretibial edema or pitting edema.
4. Inspect legs for varicose veins. Nothing
J. Neurologic
1. Test orientation to person, time, Normal
place, attention, recall (note the
questions you asked)
2. Deep tendon reflexes including Normal
 Name:_Yuliana Costansa Luturmas

Biceps/brachioradialis reflex and

Triceps reflex
3. Patella reflex/Achilles reflex Normal
4. Test Babinski sign Normal
5. Test light touch/pin prick on both _
side of trunk
6. Test light touch and pin prick on 4 _
limbs
7. Test position sense in at least both Normal
ankles
8. Test vibration sense in at least both Normal
ankles
9. Test muscle tone and strength in Normal
flexion and extension (including
hands, wrists, elbows, shoulder,
hips, knees, and ankles)
10. Romberg test Normal