Chapter 20

Head-to-Toe Examination

Adult

Components of the Examination

There is no one correct way to order the parts of the physical examination. You are encouraged to consider and then to adapt and edit the following suggested approach for the unique needs of the particular patient and the relevant demands of the moment.

General Inspection

Start examination the moment the patient is within your view. As you first observe the patient, for example, in the waiting room, take note of the following characteristics:

• Signs of distress or disease

• Habitus

• Manner of sitting

• Degree of facial relaxation

• Relationship with others in room

• Degree of interest in what is happening in room

• Manner with which you are met

• Moistness of palm when you shake hands

• Eyes—luster and expression of emotion

• Skin color

• Facial expression

• Mobility:

• Use of assistive devices

• Gait

• Sitting, rising from chair

• Taking off coat

• Dress and posture

• Speech pattern, disorders, foreign language

• Difficulty hearing, assistive devices

• Stature and build

• Musculoskeletal deformities

• Vision problems, assistive devices

• Eye contact with you

• Orientation, mental alertness

• Nutritional state

• Respiratory problems

• Significant others accompanying patient

Patient Instructions (Plan Each Step to Minimize the Patient’s Effort and to Conserve Energy)

• Empty bladder.

• Remove as much clothing as is necessary (always respecting modesty).

• Put on a gown.

Measurements

• Measure weight and calculate the body mass index.

• Measure height.

• Assess distance vision—Snellen chart.

• Document vital signs—temperature, pulse, respiration, blood pressure in both arms, pain assessment.

Patient Seated, Wearing Gown

Stand in front of patient seated on examining table.

Head and Face

• Inspect skin characteristics.

• Inspect symmetry and external characteristics of eyes and ears.

• Inspect configuration of skull.

• Inspect and palpate scalp and hair for texture, distribution, and quantity of hair.

• Palpate facial bones.

• Palpate temporomandibular joint while patient opens and closes mouth.

• Palpate sinus regions; if tender, transilluminate them (may be helpful, but sensitivity and specificity are uncertain when considered separate from other findings).

• Inspect ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue, and puff out cheeks (CN V, VII).

• Test sensation using light touch on forehead, cheeks, chin (CN V).

Eyes

• External examination:

• Inspect eyelids, eyelashes, palpebral folds.

• Determine alignment of eyebrows.

• Inspect sclerae, conjunctivae, irides.

• Palpate lacrimal apparatus.

• Test near-vision—Rosenbaum chart (CN II).

• Eye function:

• Test pupillary response to light and accommodation.

• Perform cover-uncover test and corneal light reflex.

• Test extraocular eye movements (CN III, IV, VI).

• Assess visual fields (CN II).

• Test corneal reflexes (CN V).

• Ophthalmoscopic examination:

• Test red reflex.

• Inspect lens.

• Inspect disc, cup margins, vessels, retinal surface.

Ears

• Inspect alignment and placement.

• Inspect surface characteristics.

• Palpate auricle.

• Assess hearing with whisper test or ticking watch (CN VIII).

• Perform otoscopic examination:

• Inspect canals.

• Inspect tympanic membranes for landmarks, deformities, inflammation.

• Perform Rinne and Weber tests.

Nose

• Note structure, position of septum.

• Determine patency of each nostril.

• Inspect mucosa, septum, turbinates with nasal speculum.

• Assess sense of smell when clinically necessary (CN I).

Mouth and Pharynx

• Inspect lips, buccal mucosa, gums, hard and soft palates, floor of mouth for color and surface characteristics.

• Inspect oropharynx: note anteroposterior pillars, uvula, tonsils, posterior pharynx, mouth odor.

• Inspect teeth for color, number, surface characteristics.

• Inspect tongue for color, characteristics, symmetry, movement (CN XII).

• Test gag reflex and “ah” reflex (CN IX, X).

• Assess sense of taste test when clinically indicated (CN VII, IX).

Neck

• Inspect for symmetry and smoothness of neck and thyroid.

• Inspect for jugular venous distention (also when patient is supine).

• Perform active and passive range of motion; test resistance against examiner’s hand.

• Test strength of shoulder shrug (CN IX).

• Palpate carotid pulses. Be sure to palpate one side at a time (also when patient is supine).

• Palpate tracheal position.

• Palpate thyroid.

• Palpate lymph nodes—preauricular and postauricular, occipital, tonsillar, submental, submandibular, superficial cervical chain, posterior cervical, deep cervical, supraclavicular.

• Auscultate carotid arteries and thyroid.

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1. The History
2. Age-Specific Examination: Infants, Children, and Adolescents
3. Heart
4. Musculoskeletal System

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