Diana De Guzman HEAD TO TOE QUICK STUDY GUIDE Neurologic: HA?, Head injury? Dizziness? Vertigo (room spinning)? Seizures? Tremors? Numbness/tingling? Dysphagia?; Hx of Stroke?, Spinal cord injury? Cranial Nerve I (Olfactory): Sense of smell; test the patency of each nostril by having patient cover 1 nostril at a time and sniff; then use different scent for each nostril with pt’s eyes closed & 1 nostril occluded have them sniff. (test on pt. with head trauma, loss of smell) [ABNORMAL: BIL. DECREASE IN SMELL-ANOSMIA; UNILATERAL LOSS OF SMELL-NEUROGENIC ANOSMIA; CAUSE: URI; FRONTAL LOBE LESION] Cranial Nerve II (Optic): Test visual acuity (defect or absent central vision) & visual fields (defect in PERIPHERAL VISION, hemianopsia) by confrontation – peripheral vision – cover 1 eye & ask pt. to state when sees fingers [ABNORMAL: VISUAL FIELD LOSS; INCREASING INTRAOCULAR PRESSURE-DECREASE IN PERIPHERAL VISION; RETINAL DETACHMENT-SHADOW OR DIMINISHED VISION] Cranial Nerve III (Oculomotor), IV (Trochlear), VI (Abducens): III: Test corneal light reflex: have pt stare at your nose, then shine light in between the 2 eyes (“stars in eyes”, want stars in same area on both eyes) [ABNORMAL : Ptosis (drooping upper lid) occurs with myasthenia gravis]; PERRLA (Pupil Equal, Round, React to Light & Accomodation): shine light on pupil one at a time. Come from pt’s side then shine light on one eye, observe pupil on eye with light and quickly look at other eye without light for comparison. Check pupils for size, regularity, equality (want pupil constriction; Pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina; When 1 eye is exposed to bright light, a direct light reflex occurs [constriction of that pupil] as well as a consensual light reflex [simultaneous constriction of the other pupil]; ABNORMAL: DILATION Eyes accommodate from far sight to near by looking at something at a distance, focus on pen light in front of them, & then bring pen light closer to them); want convergence of eye to a single point; Adaptation of the eye for near vision 6 Cardinal Positions of Gaze: pt. will just follow finger by just moving their eyes & not their head (extraocular muscle movement: want inward, up & inward, up & outward, down & outward) [ABNORMAL: FAILURE TO MOVE EYE UP, IN, DOWN; NYSTAGMUS-back & forth oscillation of eyes]. IV & VI: 6 Cardinal Positions of Gaze: pt. will just follow finger by just moving their eyes & not their head (IV: want downward, inward eye movements; VI: want lateral movement of eyeballs) [ABNORMAL: NYSTAGMUS-back & forth oscillation of eyes]

Cranial Nerve V (Trigeminal): Assess muscles of mastication by Palpating the temporal and masseter muscles as person clenches teeth [ABNORMAL: DECREASED STRENGHTH ON ONE OR BOTH SIDES] & try to separate jaws by pushing down on the chin (normally you cant); Test light touch sensation with patient’s eyes closed (forehead, cheek, chin) Cranial Nerve VII (Facial): Inspect face for expression and symmetry-frown, close eyes tight, lift eyebrow, show teeth, puff cheeks out and press air out (mouth, eyes, cheeks) Cranial Nerve VIII (Vestibulocochlear/Acoustic): Test hearing acuity by normal conversation heard and whispered voice test while constantly pressing on tragus & whispering on side where you’re not pressing on tragus (document distance when normal conversation is heard) Cranial Nerve IX (Glossopharyngel), X (Vagus): IX: Test for ability to swallow by using tongue blade to elicit gag reflex & palpating trachea while patient swallow. X: Testing for sensation of pharynx by asking pt to say “ahh” when tongue is depressed down with a tongue blade (want uvula and soft palate to rise in midline & tonsillar pillars should move medially) Cranial Nerve XI (Spinal): Examine sternomastoid and trapezius muscles for equal size. Check equal strength by asking to turn head forcibly against resistance applied to chin. Then shoulder shrug against resistance, (want equal strength on both sides)[ABNORMAL: ATROPY; MUSCLE WEAKNESS; PARALYSIS; STROKE; SURGICAL REMOVAL OF LYMPH NODES] Cranial Nerve XII (Hypoglossal): Note position of tongue. Ask pt to stick out tongue (note presence of vibration, tremors; and deviation of tongue, want deviation to midline) [ABNORMAL: DEVIATION TOWARD PARALYZED SIDE; ask person to say “light, tight, dynamite” (note sound of letters L, T, D, N, is clear & disctinct) Test sensation by random, light touch on face, arms, hands, legs, feet Test sensation by dull/sharp touch Test deep tendon reflexes: √ Quadriceps Reflex (Knee Jerk) – L2 to L4 √ Plantar Reflex (Babinski) – L4 to S2 Skin Examine skin with corresponding region: √ Color and pigmentation; √ Temperature; √ Moisture; √ Texture; √ Turgor; √ Lesions Pulse Strength: 3+ increased, full, bounding; 2+ normal; 1+ weak; 0 absent

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Heart and Neck Vessels (IPA-Inspect, Palpate, Auscultate): Chest pain? Dyspnea? SOB? Orthopnea? Cough? Swelling of feet/legs?; Hx of High cholesterol?, Heart murmur?, Heart disease?; Family Hx of HTN?, Obesity?, CAD?, Stroke?, Palpate for capillary refill <3 seconds Inspect the neck: symmetry, lumps, pulsations Inspect each side of the neck for a jugular venous pulse, turning head slightly to the other side Inspect & palpate (lymph nodes); palpate the carotid pulse (1 at a time) Palpate the trachea (want midline) Listen for carotid bruits (using bell, on 3 different sites, on left & right) Inspect the precordium for any pulsations and/or heave (lift) – (& palpate for thrills/vibrations with base of fingers) Palpate the apical impulse (for 1 full minute) & note the location (5th intercostal space, midclavicular line) Auscultate the heart sounds (S1 (apex) and S2 (base)) – Z pattern (APETM-Aortic, Pulmonic, Erbis Point, Tricuspid, Mitral) (A-R 2nd intercostals, P-L 2nd, E-L 3rd, T-L 4th, M-L 5th & lubb is louder) Chest, Posterior and Lateral (IPA-Inspect, Palpate, Auscultate): Cough? SOB? Chest pain with breathing?; Hx of respiratory infections-COPD, Emphysema, Tuberculosis? Smoke? Environmental cause? Last TB test? Last chest x-ray? Inspect the posterior chest: configuration (A/P vs transverse dm-A/P should be less than transverse 2:1; thorax is symmetric, shape: elliptical-egg shaped or oval), skin characteristics, & symmetry of shoulders & muscles Palpate: symmetrical chest expansion; using circular motion, inspect for lumps or tenderness Palpate length of spinous processes (pt. bend over while you inspect spine) Auscultate breath sounds: 9 areas - Vesicular over Peripheral lung fields [low, soft, insp>exp]; bronchovesicular over major bronchi, between spacula [moderate, insp=exp]; bronchial over trache [insp<exp] - Note adventitious sounds Chest, Anterior(IPA-Inspect, Palpate, Auscultate): Cough? SOB? Chest pain with breathing?; Hx of respiratory infections-COPD, Emphysema, Tuberculosis? Smoke? Environmental cause?; Last TB test? Last chest x-ray? Inspect the anterior chest: respirations [rate, rhythm, & depth], skin Palpate: symmetrical chest expansion; using circular motions palpate for lumps or tenderness Auscultate breath sounds: 5 areas; Note adventitious sounds

Abdomen (IAPP-Inspect, Auscultate, Percuss, Palpate): Appetite? Bowel movement-normal routine, color, consistency, straining? Dysphagia? Food intolerance? Abdominal pain? Nausea? Vomiting? Use laxatives? Hx of GI problems? Any abdominal operations? Meds? Alcohol? Diet? Inspect the abdomen: contour (round, protuberant, scaphoid, flat & inverted or everted bellybutton), symmetry (quadrants), umbilicus (midline), pulsations (aortic), skin characteristics (note striae, nevi, scars & use quadrants when noting location), hair distribution Auscultate bowel sounds in all quadrants-Present/Active Percuss abdomen in all quadrants Light palpation using circular movements in all quadrants Peripheral Vascular: Upper and Lower Extemities: Leg pain? Cramps? Skin changes? Swelling in arms/legs? Swollen glands? Meds? Palpate for capillary refill <3 seconds Inspect the extremities: symmetry (swelling/atrophy), hair distribution, varicose/spider veins, skin characteristics Palpate pulses bilaterally: begin temporal artery (can palpate at same time) to posterior tibial (inner side of ankle), dorsalis pedis (on top of foot) Palpate for temperature (starting from face to lower extremities, feeling with back of hand not the palm) and pretibial edema or lymphedema (push at edema, note pitting; depress for 5sec. & release) Musculoskeketal – (Grade 0-5): Joints – pain, stiffness, swelling, heat, redness, limitation of movement? Muscles – pain (cramps), weakness? Bones – pain, deformity, trauma (fracture)? ADLs? Test ROM & muscle strength of hands (grip), elbows (flexion & extension), & shoulders (flexion, extension, hyperextension, internal-hands at the back, external-hands behind head), abduction & adduction) Test ROM and muscle strength of hips (laying down-legs straight up & down, knee flexion-knee to nose, internal & external rotation, abduction & adduction), ankles (rotation, plantar-toes downward, dorsal-toes to nose), feet (sitting at edge of bed with bed at lowest setting and feet touching floor-perform inversion and eversion, knees (stand with patient and perform ROM at same time with patient) Person to walk across room, turn, & then return (note gait and swinging of arms) Muscle Grade: 5-Full ROM; Full resistance; 4-Full ROM; some resistance; 3-Full ROM; no resistance; 2-Full ROM; eliminated PROM; 1-Slight Contraction; 0-No Contraction PROM=pt needs help moving, AROM=pt independent moving