Head to toe assessment

 

The head to toe physical  

You will complete a head to toe physical on a volunteer. You will need to record your assessment and then document your findings. 

General survey: state findings aloud

Head

Eyes

Ears

Nose

Throat

Neck

Respiratory

Cardiac

GI/GU (do not assess their genitals)

Musculoskeletal

Neuro

Please be sure to position you and your patient in such a way that I can see what you are performing as well as placement of hands for palpation/percussion and the position of your stethoscope.

To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Resources.

Assignment Requirements

Before finalizing your work, you should:

• be sure to read the Assignment description carefully (as displayed above)
• consult the Grading Rubric to make sure you have included everything necessary; and
• utilize spelling and grammar check to minimize errors.

Your writing Assignment should:

• follow the conventions of Standard English (correct grammar, punctuation, etc.);
• be well ordered, logical, and unified, as well as original and insightful;
• display superior content, organization, style, and mechanics; and

How to Submit

Submit your Assignment to the unit Dropbox before midnight on the last day of the unit.

When you are ready to submit your Assignment, select the unit Dropbox then attach your file. Please submit both the video and findings into the same Dropbox. Save with your name in the title. Make sure to save a copy of the Assignment you submit.

Assignment Details

The head to toe physical 

 

You will complete a head to toe physical on a volunteer. You will record this on video- please try to keep it less than 30 minutes in length- preferably closer to the 15 minute timeframe. Please be sure to position you and your patient in such a way that I can see what you are performing as well as placement of hands for palpation/percussion and the position of your stethoscope. If you are taking time to observe something (like general survey, chest expansion, etc), then please tell me that is what you are doing. Finally, once you have completed the video, please write up your findings.

Outline
(you do not need to go in order if you do not want to- I encourage you to create your own flow if you wish):

·

General survey (would include vitals and measurements but do not need to do for this assignment)

· Very brief, quick skin assessment of what is visible

· Overall quick impression of patient (dress, body habitus, age appearance)

· Head

· Assess shape and for any abnormalities

· Palpate sinuses

· Eyes

· Assess conjunctive and sclera

· Assess and grade pupil reaction

· Assess EOM

· Ears

· Exterior ear appearance

· Palpate tragus and mastoid bone

· Internal ear examination (if you do not have an otoscope, please just verbalize how you would perform it and your findings)

· Nose

· Exterior nose appearance

· Nare patency, any rhinorrhea or congestion

· Mucous membrane appearance

· Throat

· General dentition observation

· Appearance of tongue and mucous membranes

· Grading and appearance of tonsils

· Appearance of posterior pharynx

· Neck

· Palpate some of the main lymph nodes

· Palpate thyroid gland

· Respiratory

· Assess for any respiratory distress or chest abnormalities

· Assess for chest expansion and chest movement

· Auscultate for breath sounds

· Auscultate for egophony, bronchophony and pectoriloquy

· Palpate for tactile fremitus

· Percuss for diaphragmatic excursion and throughout lung fields

· Cardiac

· Assess JVP (best as possible if you are not able to elevate HOB to 30-45 degrees; or use pillows to bring head up some)

· Palpate and grade carotid pulses

· Assess capillary refill

· Assess for any edema

· Auscultate carotid arteries

· Auscultate heart sounds throughout all fields

· GI/GU (do not assess their genitals)

· Assess for CVA tenderness

· Inspect skin and contour of abdomen

· Auscultate abdominal sounds

· Percuss the abdomen

· Palpate throughout abdomen and subrapubic area

· Palpate for possible aortic aneurysm

· Assess for abnormal signs

· Blumberg sign (rebound tenderness)

· Murphy’s sign

· Rovsing’s sign

· Psoas sign

· Obturator sign

· Markle Sign (heel jar test)

· Musculoskeletal (just doing common testing for Family Practice setting)

· Neck (extension, flexion, rotation, side-bending)

· Back (straight-leg raise, extension, flexion, rotation, side-bending)

· Shoulder (flexion, extension, rotation, abduction, adduction, Apley Scratch test, Drop-arm test, Empty-can test)

· Elbow (flexion, extension)

· Wrist/Hand (flexion wrist, extension wrist, rotation wrist, abduction and adduction of fingers, Tinel’s sign, Phalen’s sign (do not have to hold for full 60 seconds))

· Hip (flexion, extension, rotation, abduction, adduction)

· Knee

(flexion, extension, Drawer testing, valgus and varus stress test)

· Ankle/Foot (flexion ankle, extension ankle, rotation akle)

·

Neuro

· Assess mental status

· Orientation

· LOC

· Attitude

· Speech

· Quick, brief memory check (just two or three questions, not like an MMSE or anything)

· Assess cranial nerves 2-12

· Assess motor system

· Gait (usually would include normal gait, heel-to-toe walk, heel walk, toe walk but in this case, you can just do normal gait)

· Stance

· Muscle bulk and tone

· Quick check of strength in arms, hands, legs, feet (probably already completed in musculoskeletal section though so you do not have to repeat)

· Assess the sensory system

· Detection of touch (sharp and light touch) on a few areas of body

· Proprioception sense (either on a couple fingers or toes)

· Discrimination (graphesthesia or stereognosis)

· Assess and grade main DTRs

· Triceps

· Biceps

· Knee

· Perform Pronator Drift testing

· Perform Romberg testing

· Assess rapid alternating movements

·

Assess point-to-point movements (nose to finger or heel run down shin)

· Perform Babinski Sign

· Perform Kernig Sign