Head-to-Toe Physical Examination Final:

Examination:
Emma Ericson (patient 1)

Wash/sanitize hands & put on gloves

Hello, my name is Jaden and I’ll be your nurse today!

General survey/mental state:

Can you tell me your name for me?
Do you know where you’re at right now?
Who is the current President of the United States?
What brings you in today?
(Alert and Orient x3)
Can you rate your pain on a scale of 0/10 for me? 0 being no pain and 10 being the worst pain
you’ve ever experienced?

Overall behavior, mood, and speech are appropriate. No signs of distress. Patient
speaks/understands fluent English- no need for interpreter.

Alright, I’m going to go ahead and get started with my examination now, is that alright?

Skin/nails:
Inspection: Upon inspection of the skin, color is tan, pink. No signs of any cyanosis or pallor. No
lesions, tumors, or masses on skin surface. Scattered nevi on top and lower extremities and
trace amount on trunk.
Palpation: I’m going to go ahead and feel your skin now.
Temperature is warm and dry across all areas of skin surface.
I’m going to go ahead and check your turgor now.
I’m just going to slightly pinch up a piece of skin by your clavicle. Turgor is good
and indicated good hydration.
I’m going to take a look at your nails now.
Nails beds are pink, and nails are strongly adhered to nail beds. Appear to be well-
groomed. Nails are symmetric on both hands.
I’m going to go ahead and check your capillary refill now. *check all 10 fingers*
Capillary refill is less than 2 seconds= good
Nail angle is 160 degrees which suggests no clubbing

Okay, now that I’ve finished the skin and nails, I’m going to move on to your head and face.
Head/face:
Inspection: Upon inspection, the head appears to be symmetric along with her facial features.
No signs of any lesions, tumors or masses. No signs of any facial drooping that would suggest
previous stroke or Bells Palsy.
Palpation: I’m going to go ahead and feel around your head. Head is symmetric with no tumors
or masses.
Hair is evenly distributed, no signs of balding that would suggest alopecia. Color is
blonde. No signs of any parasitic activity.
Temporal pule= 2+

I’m going to go ahead and move on to your eyes:

Eyes: upon first inspection: the eyes are symmetric. No signs of ptosis or drooping of the
eyelids. No lesions around the eyes. Eyelashes and brows are evenly distributed and
match scalp color. No signs of any discharge.
Conjunctiva is clear with pink underneath. Sclera is white. No signs of jaundice.
Iris is blue and intact (circular shape)
I’m going to go ahead and shine my penlight in your eyes.
Go ahead and look straight for me. Pupil size goes from a 5mm-3mm. Pupils are
equal, round, and reactive to light bilaterally.
Now I’m going to go ahead and have you focus on something on the wall behind
me, now follow my penlight. Eyes converge and accommodate bilaterally.

I’m going to look at your ears now:

Ears: upon first inspection, ears are symmetric. Color matches face (tan-pink). No lesions
around the ears. She appears to have three lobe piercings bilaterally and one piercing
on her pinna.
I’m going to go ahead and palpate the different parts of your ears, just let me know if
anything is tender.
Pinna, lobule, tragus- were any of those areas tender or painful?
I’m going to feel the bony process behind your ear called the mastoid process now.
Is this tender at all? No masses, tumors, or inflammation.
I’m now going to shine my light into yours ears.
No discharge or earwax. No redness, swelling or irritation visible.

Now, your nose:

Nose: upon first inspection of the nose, it should be midline. The skin color should
match the rest of the face, tannish pink. No lesions, masses, or tumors. Septum should
be midline with no deviation or perforation.
Palpation: ask if there is any tenderness. Feel around the sinuses.
I’m going to go ahead and shine my light up into your nose now.
Nasal mucosa is pink, cilia is present. No signs of any drainage.
I’m going to go ahead and test the patency of your nostrils.
Go ahead and cover one nostril, take a deep breath in and out. Now, cover the
other one and do the same thing.
 Nares are patent bilaterally. No signs of any dyspnea or obstruction.

Lastly, I’m going to take a look at your mouth:

Mouth: Upon first inspection of the mouth, lips are pink and symmetrical. No lesions
around the mouth. Lips are moist. No signs of excessive dryness or cracking. No signs of
cyanosis to indicate dyspnea.
Go ahead and open your mouth.
Teeth are slightly off-white. No loose or missing teeth and no signs of decay.
Appear to be in good repair.
Gums, buccal mucosa, sublingual area, tongue, hard and soft palate all pink.
Go ahead and stick your tongue out for me.
No signs of any tremors.
Can you say “ah” for me?
Uvula rises midline upon phonation
Tonsils should be 1+. 4+ is touching.

Now that I have finished your face, I’m going to take a look at your neck.

Neck:
Inspection: Upon inspection, the neck is tannish pink, same as the head and face. No signs of
any lesion, tumors, or masses. Trachea is midline.
Palpation: I’m going to go ahead and feel around your neck, let me know if there is any
tenderness.
I’m going to check your carotid pulses now, one at a time.
Carotids are 2+ bilaterally
I’m now going to take a listen to your neck for any bruits. Bruits are just a swooshing sound in
your carotids. LISTEN WITH BELL!
No signs of any bruits, bilaterally.

Now I’m going to move on to your lymph nodes.

Lymph nodes:
Inspection: upon inspection, there is no visible inflammation of the lymph nodes.
Palpation: I’m going to feel your lymph nodes now, let me know if you feel any tenderness.
- Pre auricular
- Post auricular
- Occipital
- Jugulodigastric
- Submandibular
- Submental
- Anterior Cervical
 - Posterior Cervical
- Deep Cervical
Go ahead and shrug your shoulders for me.
- Supraclavicular
Where any of those areas tender or painful?
Lymph nodes were non-palpable, non-tender. No signs of lymphadenopathy.

We’re going to move on to your thorax/lungs.

Thorax/Respiratory:
Inspection: Upon inspection, the skin is tannish pink, there are no lesion, masses or tumors
present. Ribs appear to be symmetric. No signs of cyanosis around the mouth to show dyspnea.
No distention/hypertrophy of neck muscles to show trouble breathing.
Now I’m going to check your chest expansion.
Go ahead and take a deep breath in and out. Same for the back.
Chest expands symmetrically both anteriorly and posteriorly.
Now, I’m going to take a listen to your breath sounds. USE DIAPHRAM! When you feel my
stethoscope move, go ahead and take a deep breath in and exhale. If I’m going too fast, let me
know.
Anterior breath sounds (6-8 places)
Lateral breath sounds (4 places) both sides
Posterior breath sounds (6-8 places)
Breath sounds are clear (vesicular). No signs of any adventitious sounds. No
wheezing, crackles, stridor or other abnormal breath sounds.

I’m going to have you lay down now.

LOWER EXAM TABLE HEAD.
TURN ON LAMP.
PULL OUT FOOT TABLE.

I’m going to take a look at your heart now.

Cardiac:
Inspection: Upon inspection, the precordium is tannish pink. No lesions, masses, or tumors.
Get on eye level and look for apical impulse. If can’t feel it, palpate.
I’m going to take a listen to your heart/valves now.
USE DIAPHRAM AND BELL!
Aortic: Left side; 2nd intercostal space
Pulmonic: Right side; 2nd intercostal space
Tricuspid: Right side; 4th intercostal space
Mitral: Right side; 5th intercostal space
Heart sounds are normal. No extra heart sounds, murmurs, heaves, or thrills.
Move head from side to side and point out Jugular Vein (both sides)

I’m going to move on to your abdomen now.

Abdomen:
Inspection: Upon inspection, skin is tannish pink. No lesions, masses or tumors visible. GET
DOWN ON EYE LEVEL. Abdominal aortic pulsation is visible. Abdomen is symmetric and the
contour is good.
I’m going to take a listen to your bowel sounds.
USE DIAPHRAM!
- Right Lower
- Right Upper
- Left Upper
- Left Lower
Normoactive bowel sounds in all four quadrants.
Now I’m going to percuss over the same quadrants. Percussion is a light tapping.
Tympanic across all four quadrants.
Lastly, I’m going to lightly palpate in the same order. Palpation is a light messaging.
No presence of tumors or masses.

I’m going to keep you laying down while I move on to your musculoskeletal system.
TURN OFF LAMP.

Musculoskeletal:
Inspection: Upon inspection, muscles seem to be evenly distributed bilaterally in both upper
and lower extremities. No signs of atrophy or muscle depletion. No signs of joint inflammation
or swelling.
Palpation: Muscles are again, evenly distributed and are consistent in all extremities.
I’m going to go ahead and test your ROM of your lower extremities:
- Hip:
o Extension
o Flexion (knee to chest)
o Abduct
o Adduct
o Internal Rotation
o External Rotation
- Knee:
o Flexion (knee to chest)
I’m going to go ahead and have you sit up for me.
PUSH FOOT TABLE IN.
HEAD OF EXAM TABLE UP TO 45 DEGREES
Point out disappearance of Jugular Pulsation
I’m going to continue ROM of your head and neck.
- Head/Neck ROM
o Flexion
o Hyperextension
o Lateral bend
o Rotate (head. Rolls)
 Head/Neck strength
- Elbow ROM
o Flexion
o Extension
 Forearm/upper arm strength
- Wrist ROM
o Flexion
o Hyperextension
o Wrist rolls
- Fingers ROM
o Abduct
o Adduct
o Flexion
o Extension
o Play Piano
o Supination
o Pronation
 Hand strength
I’m going to go ahead and test your thigh and calf strength now.
- Ankle ROM
o Dorsiflexion
o Plantar Flexion
o Eversion
o Inversion
 Foot strength
- Toe ROM
o Flexion
o Extension

Now I’m going to move on to your peripheral vascular system.

Peripheral Vascular:
Inspection: Upon inspection, color is tannish pink. Warm and dry. No lesions, masses, or
tumors.
Now I’m going to check your capillary refill of your toes.
Less than 2 seconds for all toes.
I’m also going to check for edema, which is just swelling.
Trace edema (1+)
Now I’m going to check the rest of your body’s pulses.
- Brachial 2+ bilaterally
- Radial 2+ bilaterally
- Popliteal 2+ bilaterally
- Posterior Tibial 2+ bilaterally
- Dorsalis Pedis 2+ bilaterally

Pulses are strong 2+ throughout the body.

Neuromuscular:

Now, I’m going to check your patellar reflexes. Just relax for me.
Reflex is 2+
If she doesn’t respond, have her link her hands and pull
I’m going to have you perform two neuromuscular tests for me:
1. Point your fingers out to the sides and extend both of your arms fully. Go ahead and
close your eyes and touch your finger to your nose with both arms.
2. Now I’m going to have you take the heel of your foot and drag it down your shin of your
other leg. Go ahead and do the same thing to the other side.

Now I’m going to have you stand up for me and I’m going to finish the musculoskeletal system.

Musculoskeletal: (cont.)
- Shoulder ROM
o Flexion
o Hyperextension
o Abduction
o Adduction
o Internal rotation
o External rotation
o Circumduction (both ways)
 Shoulder strength (shrug shoulders)
Go ahead and bend over for me so I can look at your spine.
Spine is midline. No signs of scoliosis or kyphosis.
- Spin ROM
o Flexion
o Hyperextension
 o Lateral Bend
o Rotate

Now I’m going to have you perform two standing tests:

1. Romberg test: go ahead and close your eyes.
2. Tandem Walking test: Go ahead and walk heel to toe for me in a straight line. Turn
around and walk back the same way.

Alright, that concludes my examination. Do you have any questions for me?

It was nice to meet you and thank you!

Documentation:

General Survey/Mental State:

E.E. is a 19 yo female- A&O x3. No gross physical deformities. Appears well-groomed and well-
nourished. Ht/Wt are proportional and appears stated age. Appropriate speech, behavior, and mood.
Moves all extremities with ease and smooth coordination and gait. Appears to be comfortable, relaxed,
and in no apparent distress. Denies pain on the 0/10 pain scale.

Skin and Nails:

Skin: tannish pink color. No cyanosis or pallor. Scattered nevi on upper and lower extremities. No
ecchymosis or edema. No lesions, tattoos, or body piercings (except ears). Good turgor.
Nails: well-groomed, nail beds pink, nails well-adhered to nail beds. Quick capillary refill. Nail angle of
160 degrees. No clubbing.

Head and Face:

Scalp/Head: Normocephalic, no masses, lesions, or tenderness. Hair is blonde, evenly distributed and no
parasitic activity.
Face: symmetric, no lesions or periorbital edema. Temporal pulse- 2+ bilaterally.
Eyes: symmetric, moist and glossy. No drainage or crusting. Lids/lashes/brows: eyelashes and brows are
present and evenly distributed. No ptosis or lid lag. Conjunctiva clear, sclera white, iris blue with regular
margins. PERRLA 5mm/3mm.
Ears: symmetric, no lesions/nodules. No tenderness/pinna, lobules, tragus. 3 piercings on the lobule
bilaterally and 1 piercing on the pinna on the left ear. External ear canal- clear, no drainage or build up of
cerumen. Mastoid process- no edema or tenderness.
Nose: symmetric, no lesions or tenderness. Septum- midline with no deviation or perforation. Nasal
mucosa pink, no lesions or redness. Nares patent bilaterally.
Mouth: Lips pink and moist. No excessive dryness or cracking. No lesions around the mouth. Teeth- off
white color. In good repair, no loose or missing teeth. No signs of tooth decay. Gums, buccal mucosa,
sublingual area, tongue- pink and moist with no lesions. Tongue- midline, no tremors. Hard/soft palate-
pink, no lesions or deviation. Tonsils- 1+, pink, no drainage. Uvula rises and falls midline with
phonation.

Neck and Lymph Nodes:

Neck: symmetric, no lesions, no tenderness, trachea midline. Carotid pulse- 2+ bilaterally, no bruits. No
JVD at 45 degrees.
Lymph Nodes: No lymphadenopathy x 10 nodes in head, neck, and chest: preauricular, postauricular,
occipital, jugulodigastric, submandibular, submental, anterior cervical, posterior cervical, deep cervical,
and supraclavicular. No swelling or inflammation. No tenderness.

Thorax/Respiratory:
Respirations are easy and relaxed. Regular rate. AP transverse diameter is 1:2. Thorax is warm and dry.
No lesions or tenderness. Anterior/posterior chest expansion- moderate depth, ribs symmetric/equal
bilaterally. Anterior, posterior, and lateral breath sounds are clear, vesicular sounds. No adventitious
sounds.

Cardiac:
No lifts or heaves. Apical impulse- no visible pulsation, but palpable at 5ICS, LMCL <1cmx2cm. Heart
sounds- regular rate and rhythm. S1>S2 at apex. S2>S1 at base. No murmurs or extracardiac sounds at
aortic, pulmonic, tricuspid, and mitral valve areas.

Abdomen:
Flat, symmetric, no pulsation, distention, scars, or striae, or other lesions. Normoactive bowel sounds/all
quadrants. Tympany throughout. Soft, no masses or tenderness with light palpation.

Peripheral Vascular:
Upper and lower extremities tannish pink, warm and dry, no varicosities or pitting edema, no calf pain.
Brachial, radial, popliteal, posterior tibial, dorsalis pedis pulses- 2+ bilaterally.

Neuromuscular:
Head & neck, upper & lower extremities- muscles and joints symmetric in size bilaterally, non-tender,
strength= 5+ bilaterally, ROM… head, neck, shoulders, elbows, wrists, fingers, hips, knees, ankles, toes-
smooth coordinated movements through full ROM, no limitations. Spine- normal S-curve, midline,
tenderness, or edema, flexible with full ROM. Coordinated, steady gait, smooth mobility of all extremities
with tandem walking. Romberg negative. Patellar reflex- 2+ bilaterally. Finger-to-nose coordination and
heel-to-shin movement smoothly intact.