Head to Toe Assessment

1. Head Normocephalic, evenly well distributed hair, noted no areas of pain or

tenderness during palpation.
2. Eyes EOM is intact. Able to follow penlight with gaze, and pupils are
similarly round, reacting to light and accommodation.
3. Ears Able to understand and hear spoken language correctly, with minimal
cerumen build – up in the ear canal, sliver and intact tympanic
membrane.
4. Nose and sinuses Nose is patent, septum is located midline, no flaring noted, able to
distinguish the scent of alcohol and perfume, and no episodes of
epistaxis during the shift, and sinuses are not tender on palpation.
5. Mouth Complete set of adult teeth, pearly white in color, and no mal aligned
tooth, had braces for 1 year and a half year. No dental caries noted.
Oral mucosa is moist and pinkish, no lesions noted, tonsils are not
inflamed, Grade 1 bilaterally present, uvula is located midline.
6. Neck ROM intact, able to change direction of head slowly but with without
complaints of pain, carotid pulse are bilaterally symmetrical, full and
strong pulses, 2+, jugular vein is not distended, superficial cervical
lymph nodes are palpable but non tender. Thyroid is located midline,
no enlargement noted, trachea is located midline.
7. Chest The chest is normal in shape; there are no muscle retractions while
breathing.
8. Cardiac A dynamic pericardium; normal rate, regular rhythm, PMI at 5 0 ICS
LMCL, no murmur noted, no visible pulsations in the precordium,
palpable apical pulse.
9. Breast/Chest Skin color is similar with the rest of the body, nipple is dark colored,
no discharges.
10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft,
no direct tenderness or rebound tenderness upon palpation, tympanic,
no organomegaly.
11. Genitals Genitals are normal with pubic hair, no sores and blisters, and no foul
odor.
12. Musculoskeletal Muscle strength at the right side is 4/5 while the rest of extremities
are 5/5.
No visible tremors noted no complaints of pain.
13. Integumentary Skin is pale and other parts of the body’s color are standard and don’t
indicate abnormalities as as the skin’s integrity.