Study & NCLEX

Head-to-Toe Assessment: Complete Physical Assessment Guide

Assessment is the first phase of the nursing process, and every phase after it (diagnosis, planning, implementation, evaluation) is only as good as the data y…

Medically reviewed by Jonathan Kim, DO

Last reviewed Jun 11, 2026·Next review Jun 11, 2027

clinical-guide

Assessment is the first phase of the nursing process, and every phase after it (diagnosis, planning, implementation, evaluation) is only as good as the data you collect here. Weak data collection produces weak clinical judgment. A head-to-toe assessment is the systematic, full-body exam you run to establish a baseline, determine current health status, and catch problems before they escalate.

What is Head-to-Toe Assessment?

A head-to-toe assessment is a comprehensive data-collection method: you examine the entire body from head to toe in a systematic order so nothing gets skipped. By the end you should have enough information to understand the patient's overall physical status, flag potential issues, and shape the treatment plan.

Assessment Techniques

Four techniques drive the physical exam:

Inspection. Use vision, smell, and hearing to observe and detect normal and abnormal findings.
Palpation. Use the hands to assess texture, temperature, moisture, mobility, consistency, pulse strength, size, shape, and tenderness.
Percussion. Tap body parts to produce sound waves that reveal underlying structures.
Auscultation. Use a stethoscope to listen to heart sounds, blood flow, bowel movement, and air movement through the airways.

How to Use This Guide

Every system below follows the same structure. Collect four kinds of subjective data, then move to the physical exam.

History of present health concern. Details of the current problem.
Past health history. Prior problems, treatments, surgeries, and their results.
Family history. Relevant conditions in blood relatives. Include as many relatives as the patient can recall: both genetic predisposition and shared family environment matter.
Lifestyle and health practices. Habits, exposures, and how the problem affects daily life and relationships. Keep these open-ended to get the patient talking.

Work up every symptom the patient reports with the COLDSPA mnemonic: Character, Onset, Location, Duration, Severity, Patterns, and Associated factors.

Physical Assessment Guide

Start with the general survey and chief complaint, then assess each body system in order.

1. General Appearance/Survey

The general survey is your first read on the patient and gives early clues to overall health. It covers your overall impression of the patient, the mental status exam, and vital signs.

2. Chief Complaint

The chief complaint is the main reason the patient is seeking care, the symptom or problem that concerns them most. Ask for it first. It frames the rest of the assessment and treatment.

3. Health History

The health history sets up the entire assessment. It identifies nursing problems, focuses the physical exam, and surfaces the strengths and limitations in the patient's lifestyle and current health status.

4. Assessment of the Integument

Skin, hair, and nails are external structures with specialized functions. Their disorders can be local or the surface sign of a systemic problem, so collect current symptoms, past and family history, and lifestyle data.

History of present health concern

Skin

Any current skin problems: rashes, lesions, dryness, oiliness, drainage, bruising, swelling, increased pigmentation? What aggravates it? What relieves it?
Describe any birthmarks, tattoos, or moles, and any change in their color, size, or shape.
Any change in your ability to feel pain, pressure, light touch, or temperature? Any pain, itching, tingling, or numbness?

Hair and Nails

Any hair loss or change in the condition of your hair?
Any change in the condition or appearance of your nails?

Past health history

Describe any previous skin, hair, or nail problems, including treatment or surgery and how well it worked.
Any allergic skin reactions to food, medications, plants, or environmental substances?
Any fever, nausea, vomiting, GI, or respiratory problems?
Female patients: Are you pregnant? Are your periods regular?

Family history

Has anyone in your family had a recent illness, rash, other skin problem, or allergy?
Any family history of skin cancer?

Lifestyle and health practices

Do you sunbathe or use tanning booths? How much exposure? What sun protection do you use?
Are you regularly exposed to chemicals that can harm the skin?
Do you sit or lie in one position for long periods?
Any exposure to extreme temperatures?
What is your daily routine for skin, hair, and nail care?
What do you typically eat in a day? How much fluid do you drink?
Do skin problems limit your normal activities or relationships?
How much stress is in your life?
Do you perform a skin self-exam once a month?

Skin Physical Assessment

Inspection of the skin

Inspect general skin coloration. Pigment accounts for intensity of color and hue.
Inspect for color variations. Check localized areas for variation.
Check skin integrity. Watch pressure points (sacrum, hips, elbows). If you find breakdown, use a scale to document the degree.
Inspect for lesions. Note color, shape, and size. If you suspect a fungus, shine a Wood's light (ultraviolet light filtered through special glass) on the lesion.

Palpation of the skin

Assess texture. Use the palmar surface of the three middle fingers.
Assess thickness. If you find lesions, glove up and palpate them between thumb and finger; note drainage and other characteristics.
Assess moisture. Check under skin folds and in unexposed areas.
Assess temperature. Use the dorsal surfaces of the hands.
Assess mobility and turgor. With the patient lying down, gently pinch the skin on the sternum or under the clavicle with two fingers.
Detect edema. Press down with your thumbs on the feet or ankles.

Hair

Inspection and palpation of the hair

Inspect the scalp and hair. Have the patient remove clips, pins, and wigs, then inspect for color and condition.
Assess for cleanliness, dryness or oiliness, parasites, and lesions. At 1-inch intervals, separate the hair from the scalp and inspect and palpate. Wear gloves if you suspect lesions or hygiene is poor.
Inspect amount and distribution of scalp, body, axillary, and pubic hair. Note unusual growth elsewhere.

Nails

Inspection of the nails

Inspect grooming and cleanliness. Nails should be clean and manicured.
Inspect color and markings. Pink tones are normal; some longitudinal ridging is normal.
Inspect shape. There is normally a 160-degree angle between the nail base and the skin.

Palpation of the nails

Assess texture. Nails are hard and basically immobile.
Assess consistency. Note whether the nail plate is attached to the nailbed.
Test capillary refill. Press the nail tip briefly and watch for color change.

5. Assessment of the Head and Neck

Head and neck assessment targets the cranium, face, thyroid gland, and lymph node structures of the head and neck.

History of present health concern

Pain. Any neck pain, headaches, or facial pain? Any difficulty moving your head or neck?
Other symptoms. Any lumps or lesions on the head or neck that do not heal? Any dizziness, lightheadedness, spinning, or loss of consciousness? Any change in skin, hair, or nail texture? Any change in energy, sleep, or emotional stability? Any palpitations, blurred vision, or change in bowel habits?

Past health history

Describe any previous head or neck problems, how they were treated, and the results.
Any radiation therapy to the neck region?

Family history

Any family history of head and neck cancer or migraine headaches?

Lifestyle and health practices

Do you smoke or chew tobacco? How much?
Do you wear a helmet for horseback riding, cycling, motorcycling, or other open sports vehicles? A hard hat for hazardous work?
What is your typical posture when relaxing, sleeping, and working?
What recreational activities do you take part in?
Have head or neck problems interfered with your relationships or your role at home or work?

Head and Face

Inspection

Inspect the head for size, shape, and configuration.
Inspect for involuntary movement. The head should be held still and upright.
Inspect the face for symmetry, features, movement, expression, and skin condition.

Palpation

Palpate the head. It is normally hard and smooth without lesions.
Palpate the temporal artery, located between the top of the ear and the eye.
Palpate the temporomandibular joint. Place your index finger over the front of each ear as the patient opens the mouth.

Neck

Inspection

Inspect the neck. With the neck slightly extended, observe for position, symmetry, and lumps or masses. Shine a light across the side of the neck to highlight swelling.
Inspect movement of neck structures. Have the patient swallow a sip of water and watch the thyroid cartilage and thyroid gland move.
Inspect the cervical vertebrae. Have the patient flex the neck (chin to chest, ear to shoulder, twist left and right, backward and forward).
Inspect range of motion. Have the patient turn the head right and left (chin to shoulder), touch each ear to the shoulder, touch chin to chest, and lift the chin to the ceiling.

Palpation

Palpate the trachea. Place a finger in the sternal notch, feel each side, and palpate the tracheal rings. The first ring above the smooth tracheal rings is the cricoid cartilage.
Palpate the thyroid gland. Locate landmarks with index finger and thumb; have the patient swallow as you palpate.

Auscultation

Auscultate the thyroid gland only if inspection or palpation found enlargement. Place the bell over the lateral lobes and have the patient hold their breath to obscure tracheal breath sounds.

Lymph nodes of the head and neck

Palpation

Palpate the preauricular, postauricular, and occipital nodes. No swelling, enlargement, or tenderness should be present.
Palpate the tonsillar nodes at the angle of the mandible on the anterior edge of the sternomastoid muscle.
Palpate the submental nodes, a few centimeters behind the tip of the mandible.
Palpate the superficial cervical nodes superficial to the sternomastoid muscle.
Palpate the posterior cervical nodes posterior to the sternomastoid and anterior to the trapezius in the posterior triangle.
Palpate the deep cervical chain nodes deep within and around the sternomastoid muscle.
Palpate the supraclavicular nodes by hooking your fingers over the clavicles and feeling deeply between the clavicles and sternomastoid muscles.

6. Assessment of the Eye and Vision

A thorough eye exam requires understanding the external and internal eye structures, the visual fields and pathways, and the visual reflexes.

History of present health concern

Visual problems

Any recent vision changes? Sudden or gradual?
Spots or floaters? Blind spots, constant or intermittent? Halos or rings around lights?
Trouble seeing at night? Double vision?
Any eye pain or itching? Redness or swelling? Excessive watering or tearing, one eye or both? Any discharge?

Past health history

Any prior eye or vision problems? Any eye surgery?
Describe any past treatments and whether they worked.

Family history

Any family history of eye problems or vision loss?

Lifestyle and health practices

Are you exposed to substances at work or home that can harm your eyes? Do you wear safety glasses?
Do you wear sunglasses in the sun?
What medications do you take?
Has vision loss affected your self-care or work?
When was your last eye exam? Do you wear corrective lenses regularly? If you wear contacts, how long do you wear them and how do you clean them?

Vision

Test distant visual acuity. Position the patient 20 feet from the Snellen or E chart and have them read each line until they cannot make out the letters or their direction.
Test near visual acuity. Use for middle-aged patients and anyone reporting reading difficulty. Have the patient hold a handheld vision chart 14 inches from the eyes and cover one eye with an opaque card while reading top to bottom.
Test visual fields for gross peripheral vision. For the confrontation test, position yourself about 2 feet from the patient at eye level. Have the patient cover the left eye while you cover your right eye, then look directly at each other with the uncovered eyes. Fully extend your left arm at midline and slowly move one finger upward from below until the patient sees it.

External eye structures

Inspection and palpation

Inspect the eyelids and eyelashes. Note width and position of the palpebral fissures and the ability of the eyelids to close. Note eyelid position relative to the eyeballs. Observe for redness, swelling, discharge, or lesions.
Observe eyeball position and alignment. Eyeballs are symmetrically aligned without protruding or sinking.
Inspect the bulbar conjunctiva and sclera. With the head straight, have the patient look side to side and up. Observe clarity, color, and texture.
Inspect the palpebral conjunctiva. Glove up. Inspect the lower lid by placing your thumbs at the level of the lower bony orbital rim and gently pulling down.
Inspect the lacrimal apparatus. Assess the lacrimal glands (lateral aspect of upper eyelid) and puncta (medial aspect of lower eyelid).
Inspect the cornea and lens. Shine a light from the side for an oblique view, then look through the pupil at the lens.
Test pupillary reaction to light. Darken the room and have the patient focus on a distant object to test the direct response.
Test accommodation. Hold your finger or a pencil 12 to 15 inches from the patient and have them stay focused on it as you move it toward the eyes.

Palpation

Palpate the lacrimal apparatus. Glove up and palpate the nasolacrimal duct for blockage with one finger just inside the lower orbital rim.

Internal eye structures

Inspection

Inspect the optic disc. Keep the light beam on the pupil and move in from a 15-degree angle until you are very close to the eye (about 3 to 5 cm), almost touching the eyelashes. Note shape, color, size, and physiologic cup.
Inspect the retinal vessels. Follow each set out to the periphery. Note the number of sets of arterioles and venules.
Inspect the retinal background. Search from the disc to the macula, noting color and any lesions.
Inspect the fovea (sharpest area of vision) and macula. Shine the beam toward the side of the eye or have the patient look into the light.
Inspect the anterior chamber. Rotate the lens wheel slowly to +10, +12, or higher.

7. Assessment of the Ear

Hearing assessment starts the moment you meet the patient and tells you how well they interact with their environment.

History of present health concern

If the patient reports ear infections or suspected hearing loss, collect as much related data as possible.

Changes in hearing

Any recent changes in hearing? Are all sounds affected, or just some?

Other symptoms

Any ear drainage? Note amount and odor.
Any ear pain? Any accompanying sore throat, sinus infection, or tooth or gum problem?
Any ringing or crackling? Any spinning, dizziness, or imbalance?

Past health history

Any prior ear infections, trauma, or earaches?
Describe any past treatments and whether they worked.

Family history

Any family history of hearing loss?

Lifestyle and health practices

Do you work or live around frequent or continuous loud noise? How do you protect your ears?
Do you spend a lot of time in the water? How do you protect your ears?
Has hearing loss affected your self-care, work, or socializing?
When was your last hearing exam? How do you care for your ears?

External ear structures

Inspection and palpation

Inspect the auricle, tragus, and lobule. Note size, shape, and position. Observe for lesions, discoloration, and discharge.
Palpate the auricle and mastoid process. Normally these are not tender.

Internal ear structures

Inspection

Inspect the external auditory canal with the otoscope. A small amount of odorless cerumen is the only normal discharge.
Inspect the tympanic membrane (eardrum). Note color, shape, consistency, and landmarks.
Perform Weber's test if the patient reports diminished or lost hearing in one ear. Strike a tuning fork softly against the back of your hand and place it on the center of the patient's head or forehead. Ask whether the sound is better in one ear or the same in both.
Perform the Rinne test, which compares air and bone conduction. Strike a tuning fork and place the base on the mastoid process. Have the patient say when the sound stops, then move the prongs to the front of the external auditory canal and ask whether it is audible again.
Perform the Romberg test. Have the patient stand with feet together and arms at the sides, eyes open and then closed.

8. Assessment of the Mouth, Throat, Nose, Sinus

Subjective data here helps detect disease and abnormalities that affect activities of daily living.

History of present health concern

Tongue and mouth

Any tongue or mouth sores or lesions? Painful? How long? Do they recur? Single or many?
Any redness, swelling, bleeding, or pain in the gums or mouth? How long? Any toothache? Lost any permanent teeth?

Nose and sinuses

Any sinus pain? Any nosebleeds (how much, what color)?
Any frequent clear or mucous drainage? Can you breathe through both nostrils? Stuffy nose during the day or night?
Any seasonal allergies? Describe the timing and symptoms.
Any change in your ability to smell or taste?

Throat

Any difficulty chewing or swallowing? How long? Any pain?
Any sore throat? How long, how often?
Any hoarseness? How long?

Past health history

Any oral, nasal, or sinus surgery? History of sinus infections? Do you use nasal sprays?

Family history

Any family history of mouth, throat, nose, or sinus cancer?

Lifestyle and health practices

Do you smoke or use smokeless tobacco? How much? Interested in quitting?
Do you drink alcohol? How much and how often?
Do you grind your teeth?
How do you care for your teeth or dentures? How often do you brush and floss? When was your last dental exam?
Braces: How do you care for them? Do you avoid certain foods? Describe a typical day's diet.
Dentures: How do they fit?
Do you brush your tongue?
How often are you in the sun? Do you use lip sunscreen?

Mouth

Inspection and palpation

Inspect the lips for consistency and color.
Inspect the teeth and gums. Note number, color, condition, and alignment of the teeth.
Inspect the buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks. Note Stenson's ducts (parotid ducts) on the buccal mucosa across from the second upper molars.
Inspect and palpate the tongue. Have the patient stick out the tongue. Inspect color, moisture, size, and texture. Observe for fasciculations (fine tremors) and midline protrusion. Palpate any lesions for induration.
Assess the ventral surface. Have the patient touch the tongue to the roof of the mouth and use a penlight to inspect.
Inspect for Wharton's ducts, the openings from the submandibular salivary glands on either side of the frenulum on the floor of the mouth.
Observe the sides of the tongue. Use a square gauze pad to hold the tongue to each side and palpate for lesions, ulcers, or nodules.
Check tongue strength. Place your fingers on the outside of the cheek and have the patient press the tongue tip against the inside of the cheek to resist.
Check the anterior tongue's taste by placing drops of sugar water and salt water on the tip and sides with a tongue depressor.
Inspect the hard (anterior) and soft (posterior) palates and uvula. Have the patient open wide while you use a penlight. Observe color and integrity.
Note odor while the mouth is open.
Assess the uvula. Depress the tongue and shine a penlight in. Have the patient say "Aaah" and watch the uvula and soft palate move.
Inspect the tonsils for color, size, and exudate or lesions. Tonsils should be graded.
Inspect the posterior pharyngeal wall. Shine the penlight on the back of the throat and note color, exudate, or lesions.

Nose

Inspection and palpation

Inspect and palpate the external nose. Note color, shape, consistency, and tenderness.
Check patency of airflow by occluding one nostril at a time and having the patient sniff.
Inspect the internal nose. Use an otoscope with a short, wide-tip attachment. Stabilize and gently tilt the head back with your nondominant hand, then insert the tip without touching the nasal septum.

Sinuses

Palpation

Palpate the sinuses. Press up on the brow with your thumbs for the frontal sinuses; press up on the maxillary sinuses for the maxillary sinuses.

Percussion

Percuss the sinuses. Lightly tap over the frontal and maxillary sinuses for tenderness.

Transillumination

Transilluminate the sinuses. For the frontal sinuses, hold a strong, narrow light snugly under the eyebrows and shield it with your other hand. For the maxillary sinuses, hold the light over the sinus and have the patient open the mouth.

9. Assessment of the Thoracic and Lung

Subjective data here points to underlying respiratory problems, associated nursing diagnoses, and risk for lung disorders.

History of present health concern

Difficulty breathing

Any difficulty breathing? Describe it. Any other symptoms with it?
Difficulty at rest or only with specific activities?
Difficulty when you sleep? Do you use more than one pillow or elevate the head of the bed?
Do you snore? Have you been told you stop breathing at night?

Chest pain

Any chest pain? Is it linked to a cold, fever, or deep breathing?

Coughing

Any cough? When and how often?
Any sputum? Color, amount, recent change, odor?
Do you wheeze when coughing or active?

GI symptoms

Any heartburn, frequent hiccups, or chronic cough?

Past health history

Any prior respiratory problems?
Any thoracic surgery, biopsy, or trauma?
Tested or diagnosed with allergies?
Any chest x-ray, tuberculosis (TB) skin test, or influenza immunization? Any other pulmonary studies?
Recent travel outside the country? Close contact with anyone known or suspected to have SARS?

Family history

Any family history of lung disease or other pulmonary illness?
Did family members smoke in your home growing up?

Lifestyle and health practices

Have you ever smoked? Do you smoke now? At what age did you start? How much, now and in the past? What do you associate with smoking? Have you tried to quit?
Are you exposed to environmental conditions that affect your breathing? Where do you work? Are you around smokers?
Any difficulty with usual daily activities?
What stress are you under, and how does it affect your breathing?
Are you taking medications for breathing problems or other medications that affect breathing? Any home treatments? Any herbal or alternative therapies for colds or respiratory problems?

Posterior thorax

Inspection

Inspect for nasal flaring and pursed-lip breathing. Nasal flaring is not a normal finding.
Observe the color of the face, lips, and chest. Skin tone should be even, without unusual discoloration.
Inspect the color and shape of the nails. Pink tones should be seen in the nailbeds. There is normally a 160-degree angle between the nail base and the skin.
Inspect configuration. With the patient seated, arms at the sides, stand behind and observe the scapulae and the shape of the chest wall.
Observe use of accessory muscles. Watch the patient breathe; accessory muscles are not normally used.
Inspect positioning. Note posture and the ability to support weight while breathing comfortably.

Palpation

Palpate for tenderness and sensation. Start near the midline at the level of the left scapula, move left to right comparing bilaterally, then work downward and out to the lateral bases.
Palpate for crepitus, also called subcutaneous emphysema: a crackling sensation when air passes through fluid or exudate. Follow the same sequence.
Palpate surface characteristics. Glove up to palpate any lesions noted on inspection.
Palpate for fremitus. Following the sequence, use the ball or ulnar edge of one hand to assess fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall).
Assess chest expansion. Place your hands on the posterior chest wall with thumbs at the level of T9 or T10 and press together a small skin fold.

Percussion

Percuss for tone. Start at the apices of the scapulae, percuss across the tops of both shoulders, then percuss the intercostal spaces across and down, comparing sides. Percuss the lateral bases, comparing sides.
Percuss for diaphragmatic excursion. Have the patient exhale forcefully and hold. Starting at the scapular line, percuss the intercostal spaces of the right posterior chest wall downward until tone changes from resonance to dullness. Then have the patient inhale deeply and hold, and percuss from the mark downward until resonance changes to dullness.

Auscultation

Auscultate for breath sounds. Place the diaphragm firmly on the posterior chest wall at the apex of the lung at C7. Have the patient breathe deeply through the mouth at each site so you can hear inspiratory and expiratory sounds.
Auscultate for adventitious sounds, which are superimposed over normal breath sounds.
Auscultate voice sounds. Bronchophony: have the patient repeat "ninety-nine" while you auscultate the chest wall.

Other techniques

Egophony: have the patient repeat the letter E while you listen over the chest wall.
Whispered pectoriloquy: have the patient whisper "one-two-three" while you auscultate the chest wall.

Anterior thorax

Inspection

Inspect shape and configuration. With the patient seated, arms at the sides, stand in front and assess.
Inspect the position of the sternum from anterior and lateral views. Watch for sternal retraction.
Inspect the slope of the ribs from anterior and lateral views.
Observe the quality and pattern of respiration: rate, rhythm, and depth.
Inspect intercostal spaces as the patient breathes normally.
Observe for use of accessory muscles during normal breathing.

Palpation

Palpate for tenderness, sensation, and surface masses. Start over the left clavicle, move left to right comparing bilaterally, then work downward toward the midline at the level of the breasts and outward at the base to the lateral lung.
Palpate for fremitus using the anterior sequence and the same technique as the posterior thorax.
Palpate anterior chest expansion. Place your hands on the anterolateral wall with thumbs along the costal margins pointing toward the xiphoid process.

Percussion

Percuss for tone. Percuss the apices above the clavicles, then the intercostal spaces across and down, comparing sides.

Auscultation

Auscultate for breath, adventitious, and voice sounds. Place the diaphragm firmly on the anterior chest wall. Auscultate from the apices slightly above the clavicles to the bases at the sixth rib. Listen at each site for at least one respiratory cycle.

10. Assessment of the Breast and Lymphatic System

This covers the exam of nonpregnant women's breasts. If the patient reports symptoms, work them up with a symptom analysis.

History of present health concern

Any lumps or swelling in the breasts? Where? When first noticed? Has it grown? Linked to other problems? Does it change with your menstrual cycle?
Any lumps or swelling in the underarm area?
Any redness, warmth, or dimpling? Any rash on the breast, nipple, or axilla?
Any change in the size or firmness of the breasts?
Any breast pain? Where? Tied to a specific time in your cycle? Triggered by an activity?
Any nipple discharge? Describe color, consistency, and odor. When did it start? Which nipple?

Past health history

Any prior breast disease, surgery, biopsy, implants, or trauma? When and what was the result?
Age at first period? Have you reached menopause?
Have you given birth? Age at first child?
First and last day of your last menstrual cycle?

Family history

Any family history of breast cancer? Who?

Lifestyle and health practices

Are you taking hormones, contraceptives, or antipsychotics?
Excessive exposure to radiation, benzene, or asbestos at home or work?
Typical daily diet? How much alcohol daily? How much coffee, tea, and cola daily?
Do you exercise regularly? What kind of bra do you wear?
How important are your breasts to your self-image? Any fears about breast disease?
Do you examine your own breasts? When? Noted any lump, swelling, skin irritation, dimpling, nipple pain or retraction, redness, scaliness, or discharge? Reported it to your provider?
When was your last clinical breast exam? Last mammogram?

Female breasts

Inspection

Inspect size and symmetry. Have the patient disrobe and sit with arms hanging freely. Explain what you are observing to ease anxiety.
Inspect color and texture. Note overall skin tone and any lesions.
Inspect superficial venous pattern. Observe visibility and pattern of breast veins.
Inspect the areolas. Note color, size, shape, and texture of both.
Inspect the nipples. Note size and direction of both, plus any dryness, lesions, bleeding, or discharge.
Inspect for retraction and dimpling. Have the patient raise both arms overhead, then press the hands against the hips, then press the hands together.

Palpation

Palpate texture and elasticity. Smooth, firm, elastic tissue is normal.
Palpate tenderness and temperature. Generalized nodularity and tenderness can be normal with the menstrual cycle or hormonal medications.
Palpate for masses. Note location, size in centimeters, shape, mobility, consistency, tenderness, and the condition of the overlying skin.
Palpate the nipples. Glove up and gently compress with thumb and index finger. Note any discharge.
Palpate mastectomy or lumpectomy site. Palpate the scar and any remaining breast and axillary tissue for redness, lesions, lumps, swelling, or tenderness.

Axillae

Inspection and palpation

Inspect and palpate the axillae. With the patient seated, inspect the skin for rashes or infection. Hold the patient's elbow with one hand and use the three fingerpads of the other to palpate firmly. Palpate high into the axilla, then move down against the ribs for the central nodes and down the posterior axilla for the posterior nodes.

Male breasts

Inspection and palpation

Inspect and palpate the breasts, areolas, nipples, and axillae. Note swelling, nodules, or ulceration. Palpate the flat disc of underdeveloped breast tissue under the nipple.

11. Assessment of the Heart and Neck Vessels

Subjective data here helps identify abnormal conditions that affect the patient's daily function and role.

History of present health concern

Chest pain and palpitations

Any chest pain? When did it start? Describe type, location, radiation, duration, and frequency. Rate it 0 to 10, with 10 the worst possible. Does activity make it worse? Any sweating with it?
Any palpitations?

Other symptoms

Do you tire easily or feel fatigue? When did it start, sudden or gradual? Any particular time of day?
Any difficulty breathing or shortness of breath?
Do you wake at night needing to urinate? How many times?
Any dizziness?
Any swelling (edema) in the feet, ankles, or legs?
Any frequent heartburn? When? What relieves it? How often?

Past health history

Diagnosed with a heart defect or murmur?
Ever had rheumatic fever?
Any heart surgery or cardiac balloon interventions?
Any electrocardiogram? When, and do you know the results?
Any lipid profile? Do you know your cholesterol levels?
Do you take medications or other treatments for heart disease? How often and why?
Do you monitor your own heart rate or blood pressure?

Family history

Any family history of hypertension, myocardial infarction, coronary heart disease, elevated cholesterol, or diabetes mellitus?

Lifestyle and health practices

Do you smoke? How many packs per day and for how many years?
What stress are you under, and how do you cope?
What do you usually eat in a 24-hour period?
How much alcohol per day or week?
Do you exercise? What type and how often?
How do your daily activities differ from 5 or 20 years ago? Do fatigue, chest pain, or shortness of breath limit you? Can you care for yourself?
Has heart disease affected your sexual activity?
How many pillows do you sleep on? Do you get up to urinate at night? Do you feel rested in the morning?
How important is a healthy heart to your self-image? Any fears about heart disease?

Neck Vessels

Inspection

Observe the jugular venous pulse. Stand on the patient's right side. With the patient supine and the torso elevated 30 to 45 degrees, have them turn the head slightly to the left. Shine a tangential light onto the neck to bring out pulsations and shadows.
Evaluate jugular venous pressure by watching for distention of the jugular vein.

Auscultation and palpation

Auscultate the carotid arteries if the patient is middle-aged or older or you suspect cardiovascular disease. Place the bell over the carotid artery and have the patient briefly hold their breath so breath sounds do not conceal vascular sounds.
Palpate the carotid arteries one at a time, placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle.

Heart

Inspection

Inspect pulsations. With the patient supine and the head of the bed elevated 30 to 45 degrees, stand on the right side and look for the apical impulse and any abnormal pulsations.

Palpation

Palpate the apical pulse. From the right side, with the patient supine, use the palmar surfaces of your hand to palpate the apical impulse in the mitral area.
Palpate for abnormal pulsations at the apex, left sternal border, and base.

Auscultation

Auscultate heart rate and rhythm. Place the diaphragm at the apex and listen to the rate and rhythm of the apical impulse.
If the rhythm is irregular, auscultate for a pulse rate deficit: palpate the radial pulse while auscultating the apical pulse and count for a full minute.
Auscultate to identify S1 and S2. S1 is the first heart sound ("lub"), S2 the second ("dub"). Use the diaphragm to best hear both; have the patient breathe regularly for S2.
Auscultate for extra heart sounds. Use the diaphragm first, then the bell, over the entire heart area. Note any extra sound during the systolic pause.
Auscultate for murmurs with both the diaphragm and bell in all areas, since murmurs have varied pitches. Auscultate in different positions, since some murmurs change with position.
Auscultate in other positions. In the left lateral position, use the bell at the apex. Sitting up, leaning forward, and exhaling, use the diaphragm over the apex and along the left sternal border.

12. Assessment of the Peripheral Vascular System

Ask about symptoms the patient may dismiss as minor, and about personal and family history of vascular disease and lifestyle factors that impair peripheral vascular health.

History of present health concern

Any color, temperature, or texture changes in your skin?
Any leg pain or cramping? Describe it (aching, stabbing). How often? With activity? Does it wake you?
Any ropelike, bulging, or contorted leg veins? Any sores or open wounds on the legs? Where? Painful?
Any swelling (edema) in the legs or feet? Worst at what time of day? Any pain with it?
Any swollen glands or lymph nodes? Tender, soft, or hard?
Male patients: Any change in usual sexual activity?

Past health history

Any past circulation problems in the arms and legs?
Any heart or blood vessel surgery or treatments, such as coronary artery bypass grafting, aneurysm repair, or vein stripping?

Family history

Any family history of diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglycerides?

Lifestyle and health practices

Do you smoke or use any tobacco, now or in the past? How much and how long?
Do you exercise regularly?
Female patients: Do you take oral or transdermal contraceptives?
How much stress do you normally have?
How have circulation problems affected your function?
Do leg ulcers or varicose veins affect how you feel about yourself?
Do you take prescribed medications to improve circulation?
Do you wear support hose for varicose veins?

Arms

Inspection

Observe arm size and venous pattern, and look for edema. Arms are bilaterally symmetric with minimal variation. No edema or prominent venous patterning.
Observe coloration of the hands and arms. Color varies with skin tone but should be the same bilaterally.

Palpation

Palpate the fingers, hands, and arms for temperature. Skin is warm to the touch bilaterally from fingertips to upper arms.
Assess capillary refill time. Compress the nailbed until it blanches, release, and time the return of color.
Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength.
Palpate the ulnar pulses. Apply pressure with your first three fingertips to the medial aspect of the inner wrists.
Palpate the brachial pulses if you suspect arterial insufficiency. Place the first three fingertips of each hand at the right and left medial antecubital creases.
Palpate the epitrochlear lymph nodes. Take the patient's left hand in your right as if shaking hands, flex the elbow about 90 degrees, and use your left hand to palpate behind the elbow in the groove between the biceps and triceps.
Perform the Allen test to evaluate patency of the radial or ulnar arteries. Start with ulnar patency: have the patient rest the hand palm-up and make a fist. Occlude the radial and ulnar arteries with your thumbs; the palm stays pale. Release the ulnar artery and watch for color to return.

Legs

Inspection, palpation, and auscultation

Observe skin color from the toes to the groin. Have the patient lie supine, drape the groin, and place a pillow under the head.
Inspect hair distribution. Hair covers the legs and the dorsal surface of the toes.
Inspect for lesions or ulcers. Legs are free of lesions or ulceration.
Inspect for edema, unilateral and bilateral. Note veins, tendons, and bony prominences.
Palpate edema. If noted, press the area with your fingertips, hold a few seconds, then release to determine pitting versus nonpitting.
Palpate temperature of the feet and legs with the backs of your fingers, comparing the same areas bilaterally.
Palpate the superficial inguinal lymph nodes. Expose the inguinal area, keeping genitals draped, and feel over the upper medial thigh for the vertical and horizontal groups.
Palpate the femoral pulses. Have the patient bend and externally rotate the knee. Press deeply and slowly below and medial to the inguinal ligament, then release until you feel the pulse.
Auscultate the femoral pulses. If you suspect occlusion, place the stethoscope over the femoral artery and listen for bruits.
Palpate the popliteal pulses. Have the patient partially raise the knee. Place your thumbs on the knee and your fingers deep in the bend, then apply pressure to locate the pulse.
Palpate the dorsalis pedis pulses. Dorsiflex the foot and apply light pressure lateral to and along the extensor tendon of the big toe.
Palpate the posterior tibial pulses behind and just below the medial malleolus. Palpating both at once aids comparison.
Inspect for varicosities and thrombophlebitis. Have the patient stand, since varicose veins may not show when supine. Inspect for superficial vein thrombophlebitis.
Check for Homan's sign. Flex the knee about 5 degrees, place your hand under the calf, and quickly squeeze the muscle against the tibia. Ask the patient to report pain or tenderness.

13. Assessment of the Abdomen

Collect subjective data on the abdominal organs and digestive function, plus nutrition, usual bowel habits, and lifestyle, as part of the overall history or a focused complaint.

History of present health concern

Abdominal pain

Any abdominal pain? Rate severity 1 to 10, with 10 the worst.
How did it begin? Where is it located? Does it move or change?
Timing and relation to events? What brings it on, worsens it, or relieves it?
Any associated nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or skin?

Indigestion

Any indigestion? What causes or aggravates it?

Nausea and vomiting

Any nausea? Triggered by anything?
Any vomiting? Describe the vomitus and any triggers.

Appetite

Any change in appetite affecting how much you eat or your weight?

Bowel elimination

Any change in bowel patterns?
Constipation or diarrhea? Any accompanying symptoms?
Any yellowing of the skin or eyes, itchy skin, dark urine, or clay-colored stools?

Past health history

Any GI disorders: ulcers, gastroesophageal reflux, inflammatory or obstructive bowel disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis?
Any urinary tract disease: infections, kidney disease or nephritis, or kidney stones?
Ever had or been exposed to viral hepatitis?

Family history

Any family history of colon, stomach, pancreatic, liver, kidney, or bladder cancer, or liver, gallbladder, or kidney disease?

Lifestyle and health practices

Do you drink alcohol? How much and how often?
What and how much do you eat each day? How much caffeine?
How much and how often do you exercise?
What stress are you under, and how does it affect your eating or elimination?
If you have a GI disorder, how does it affect your lifestyle and self-image?

Abdomen

Always assess the abdomen in this order: inspection, auscultation, percussion, palpation. Changing the order alters the frequency of bowel sounds and makes your findings less accurate.

Inspection

Observe skin coloration. Abdominal skin may be paler than the general skin tone since it is rarely exposed.
Note vascularity. Scattered fine veins may be visible.
Note any striae. Old, silvery-white striae from past pregnancies or weight gain are normal.
Inspect for scars. Ask the source and use a centimeter ruler to measure length. Document location by quadrant and reference lines, plus shape, length, and characteristics.
Assess for lesions and rashes. The abdomen is free of lesions or rashes, though flat or raised brown moles are normal.
Inspect the umbilicus. Note color, location, and contour.
Inspect abdominal contour. Look across the abdomen at eye level from the side, from behind the head, and from the foot of the bed. Measure girth as indicated.
Assess symmetry with the patient supine and relaxed.
Inspect abdominal movement with breathing. Respiratory movement may be visible, especially in male patients.
Observe aortic pulsations. A slight pulsation of the abdominal aorta is visible in the epigastrium and extends full length in thin people.
Observe for peristaltic waves. Normally not seen, though they may appear as slight ripples in very thin people.

Auscultation

Auscultate for bowel sounds with the diaphragm, warmed before you place it.
Auscultate for vascular sounds with the bell over the abdominal aorta and the renal, iliac, and femoral arteries.
Auscultate for a friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm.

Percussion

Percuss for tone. Lightly and systematically percuss all quadrants.
Percuss the liver span. For the lower border, begin in the RLQ at the mid-clavicular line and press upward, noting the change from tympany to dullness. For the upper border, percuss over the upper right chest at the MCL downward, noting the change from lung resonance to liver dullness.
Percuss the spleen. Begin posterior to the left mid-axillary line (MAL) and percuss downward, noting the change from lung resonance to splenic dullness.
Perform blunt percussion on the liver. Place your left hand flat against the lower right rib cage and strike it with the ulnar side of your right fist.

Palpation

Perform light palpation. Using the fingertips, start in a nontender quadrant and compress to a depth of 1cm in a dipping motion, then lift and move on.
Deeply palpate all quadrants to delineate organs and detect subtle masses. Using the palmar surface of the fingers, compress to a maximum depth (5 to 6 cm). Use bimanual palpation against resistance or for deeper structures.
Palpate for masses. Note location, size, shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a mass with a normally palpated organ.
Palpate the umbilicus and surrounding area for swellings, bulges, or masses, which are normally absent.
Palpate the aorta. Use your thumb and first finger, or two hands, to palpate deeply in the epigastrium just left of midline. Assess the pulsation of the abdominal aorta.
Palpate the liver. Stand at the right side, place your left hand under the back at the level of the eleventh to twelfth ribs, and lay your right hand parallel to the right costal margin. Have the patient inhale, then compress upward and inward. Note consistency and tenderness.
Palpate the spleen. From the right side, reach over the abdomen with your left arm and place your hand under the posterior lower ribs, pulling up gently. Place your right hand below the left costal margin, fingers toward the head. Have the patient inhale and press inward and upward.
Palpate the kidneys. For the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL.
Palpate the urinary bladder when history or findings warrant. Begin at the symphysis pubis and move upward and outward to estimate bladder borders.

14. Assessment of the Female Genitalia

This topic touches body image, fear of cancer, and sexuality. Stay aware of the patient's sensitivities and your own. Keep the patient's culture in mind, and recognize that your gender can affect rapport and accuracy.

History of present health concern

Menstrual cycle

Date of your last period? Are your cycles regular? How long do they last? Describe the typical flow and any clotting.
Any other symptoms before or during your period?
Age when you started your period?
Have your periods stopped or become irregular? Any spotting between periods? What symptoms?

Menopause

Are you still having periods? Have they changed?
Any symptoms of menopause?
Are you on hormone replacement therapy? What type and dosage? Are you satisfied with it?
Any concerns about menopause?

Vaginal discharge, pain, masses

Any vaginal discharge unusual in color, amount, or odor?
Any pain or itching in the genital or groin area?
Any lumps, swelling, or masses?

Urination

Any difficulty, burning, or pain with urination? Any change in color or odor? Any blood?
Any difficulty controlling your urine?

Sexual dysfunction

Any problems with sexual performance?
Any recent change in sexual activity or libido?
Any fertility problems?

Past health history

Describe any prior gynecologic problems and treatment results.
When was your last pelvic exam? Was a Pap test done? Result?
Ever diagnosed with a sexually transmitted disease? What, and how was it treated?
Ever been pregnant? How many times? How many children? Any chance you are pregnant now? Any miscarriages or abortions?
Ever diagnosed with diabetes?

Family history

Any family history of reproductive or genital cancer? What type, and which relative?

Lifestyle and health practices

Do you smoke?
How many sexual partners do you have?
Do you use contraceptives? What kind, how often?
Any genital problems affecting your life?
What is your sexual preference?
Do you feel comfortable communicating with your partner about sex? Any fears or stress related to sex?
Any concerns about fertility, and how has it affected your relationships?
Do you perform monthly genital self-exams?
How do you feel about menopause? Do you take estrogen replacement therapy?
Ever tested for HIV? Result and reason?
What do you know about toxic shock syndrome? About STDs and their prevention?
Do you wear cotton underwear and avoid tight jeans?
After a bowel movement or urination, do you wipe front to back?
Do you douche frequently?

External female genitalia

Inspection

Inspect the mons pubis. Wash your hands and glove up. Note the distribution of pubic hair and watch for signs of infestation.
Observe and palpate the inguinal lymph nodes. No enlargement or swelling should be present.
Inspect the labia majora and perineum for lesions, swelling, and excoriation.
Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. Separate the labia majora with your gloved hand and inspect for lesions, excoriation, swelling, and discharge.

Palpation

Palpate Bartholin's glands if there is labial swelling or a history of it. Place your index finger in the vaginal opening and your thumb on the labia majora, and palpate with a gentle pinching motion from the inferior posterior labia majora to the anterior portion.
Palpate the urethra if the patient reports urethral symptoms or you suspect inflammation of Skene's glands. Insert your gloved index finger into the superior vagina and milk the urethra from the inside, pushing up and out.

Internal female genitalia

Inspection

Inspect the size of the vaginal opening and the angle of the vagina. Insert your gloved index finger, note the opening size, and attempt to touch the cervix. Maintaining tension, gently pull the labia majora outward and note hymenal configuration and transections.
Inspect the vaginal musculature. Keep your finger in the opening and have the patient squeeze around it. Use your middle and index fingers to separate the labia minora and have the patient bear down.
Inspect the cervix. With the speculum positioned to visualize the cervix, observe color, size, position, the surface, and the os. Look for discharge and lesions.
Inspect the vagina. Unlock the speculum and slowly rotate and remove it, inspecting as you go. Note color, surface, consistency, and any discharge.

15. Assessment of the Male Genitalia

This can be a sensitive topic for the patient and the examiner. Stay aware of your own feelings about body image, fear of cancer, and sexuality.

History of present health concern

Pain

Any pain in the penis, scrotum, testes, or groin?

Lesions

Any lesions on the penis or genital area? Do they itch, burn, or sting? Describe them.

Discharge

Any penile discharge? How much, what color, what odor?

Lumps, swelling, masses

Any lumps, swelling, or masses in the scrotum, genitals, or groin? Any change in scrotal size?
Any heavy, dragging feeling in the scrotum?

Urination

Any difficulty urinating? How many times at night?
Any change in color, odor, or amount of urine?
Any pain or burning with urination?
Any incontinence or dribbling?

Sexual dysfunction

Any recent change in sexual activity or desire?
Any difficulty attaining or maintaining an erection? Any problem or pain with ejaculation?
Any trouble with fertility?

Past health history

Describe any prior medical problems, treatment, and results.
When was your last testicular exam by a physician? Result?
Ever tested for HIV, human papillomavirus, herpes simplex, chlamydia, gonorrhea, or trichomoniasis? Results and reason?

Family history

Any family history of cancer? What type, and which relative?

Lifestyle and health practices

How many sexual partners do you have? What birth control do you use, if any?
Are you satisfied with your current activity and sexual functioning?
Any concerns about fertility, and how has it affected your relationship?
What is your sexual preference?
Any fears or stress related to sex? Do you feel comfortable communicating with your partner about sex?
What do you know about STDs and their prevention?
Any current or past exposure to chemicals or radiation?
Describe a typical day's activity. Any heavy lifting?
Do you perform testicular self-exams? When was the last?

Penis

Inspection and palpation

Inspect the base of the penis and pubic hair. With the patient standing and facing you, note pubic hair growth pattern and any excoriation, erythema, or infestation.
Inspect the skin of the shaft for rashes, lesions, or lumps.
Palpate the shaft for any abnormalities, including hardened or tender areas.
Inspect the foreskin in uncircumcised men for color, location, and integrity.
Inspect the glans for size, shape, lesions, or redness.
Palpate for urethral discharge by gently squeezing the glans between your index finger and thumb.

Scrotum

Inspection

Inspect size, shape, and position. Have the patient hold the penis out of the way. Observe for swelling, lumps, or bulges.
Inspect the scrotal skin for color, integrity, lesions, or rashes. Spread the scrotal folds and lift the sac to inspect the posterior skin.

Palpation

Palpate the scrotal contents. Palpate each testis and epididymis between your thumb and first two fingers. Note size, shape, consistency, nodules, and tenderness.

Auscultation

Auscultate a scrotal mass. Bowel sounds may be heard over a hernia but will not be heard over a hydrocele.

Transillumination

Transilluminate the scrotal contents if a mass or swelling is noted. Darken the room and shine a light from behind the scrotum through the mass. Look for a red glow.

Inguinal area

Inspection

Inspect for inguinal or femoral hernia. Inspect for bulges as the patient turns the head and coughs or bears down.

Palpation

Palpate for inguinal hernia and inguinal nodes. Have the patient shift weight to the left to palpate the right inguinal canal, and vice versa. Place your right index finger into the right scrotum and press upward, invaginating the loose skin. Palpate up the spermatic cord to the triangular, slitlike external inguinal ring, and try to push through and continue up the canal.
Palpate inguinal lymph nodes. If palpable, note size, consistency, mobility, and tenderness.
Palpate for femoral hernia. Palpate the front of the thigh in the femoral canal area and have the patient bear down or cough. Feel for bulges, then repeat on the other thigh.
Inspect and palpate for scrotal hernia. Have the patient lie down and note whether the bulge disappears. If it remains, auscultate for bowel sounds, then gently palpate and try to push it up into the abdomen.

16. Assessment of the Anus, Rectum, Prostate

Subjective data here flags risk for disease of the anus, rectum, and prostate.

History of present health concern

Bowel patterns

Usual bowel pattern? Any recent change? Any pain passing a bowel movement?
Any constipation? Any diarrhea, with nausea or vomiting? Any trouble controlling your bowels?

Itching and pain

Any itching or pain in the rectal area?

Stool

Color of your stool? Hard or soft? Any blood on or in it? How much? Any mucus?

Past health history

Any anal or rectal trauma or surgery? Born with any congenital deformities of the anus or rectum? Any prostate surgery? Any hemorrhoids or hemorrhoid surgery?
When was your last stool test for blood? Any proctosigmoidoscopy?
When was your last digital rectal examination (DRE)?
Ever had a prostate-specific antigen (PSA) blood test? When, and what was the result?

Family history

Any family history of polyps, colon or rectal cancer, or prostate cancer?

Lifestyle and health practices

Do you use laxatives, stool softeners, enemas, or other bowel medications?
Do you engage in anal sex?
Do you take any prostate medications?
How much high-fiber food and roughage do you eat daily? Any foods high in saturated fat?
Do you exercise regularly? Do you use calcium supplements?
Postmenopausal women: Do you use hormone replacement therapy?
Has any anal or rectal problem affected your daily living?

Anus and rectum

Inspection

Inspect the perianal area. Spread the buttocks and inspect the anal opening and surrounding area.
Inspect the sacrococcygeal area for swelling, redness, dimpling, or hair.

Palpation

Palpate the anus. Tell the patient you are starting the internal exam. Lubricate your gloved index finger and have the patient bear down. Place the pad of your finger on the anal opening, and when the sphincter relaxes, insert gently with the pad facing down.
Palpate the rectum. Insert your finger as far as possible, then turn your hand clockwise to palpate as much rectal surface as possible. Note tenderness, irregularities, nodules, and hardness.
Palpate the peritoneal cavity. In men, palpate above the prostate in the area of the seminal vesicles on the anterior rectal surface. In women, palpate the anterior rectal surface in the area of the rectouterine pouch. Note tenderness or nodules.

Prostate gland

Palpation

Palpate the prostate on the anterior rectal surface, turning your hand fully counterclockwise so the pad of your index finger faces the patient's umbilicus. Note size, shape, consistency, and any nodules or tenderness.
Inspect the stool. Withdraw your gloved finger, inspect any fecal matter, note the color, and test for occult blood. Give the patient a towel to wipe the anorectal area.

17. Assessment of the Musculoskeletal System

This assessment gauges the patient's level of functioning with activities of daily living.

History of present health concern

Any recent weight gain?
Any difficulty chewing, with tenderness or pain?
Any joint, muscle, or bone pain? Where? What does it feel like? When did it start and how long does it last? Any stiffness, swelling, or limited movement?

Past health history

Describe any past joint, muscle, or bone problems or injuries, the treatment, and any after-effects.
When were your last tetanus and polio immunizations?
Ever diagnosed with diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, or osteoporosis?
Middle-aged women: Have you started menopause? Are you on estrogen replacement therapy?

Family history

Any family history of rheumatoid arthritis, gout, or osteoporosis?

Lifestyle and health practices

What do you do to promote muscle and bone health?
What medications do you take?
Do you smoke? How much and how often?
Do you drink alcohol or caffeine? How much and how often?
Describe a typical 24-hour diet. Can you tolerate milk or milk products? Do you take calcium supplements?
How much time do you spend in sunlight? Describe any routine exercise.
Describe your occupation, posture at work and leisure, and the shoes you usually wear.
Any difficulty with daily living? Do you use assistive devices?
Have musculoskeletal problems affected your relationships, socializing, or sexual activity, or changed how you view yourself? Added stress?

Gait

Inspection

Observe gait as the patient enters and walks around the room.
Assess fall risk in older or impaired patients with the "nudge test." Stand behind the patient, put your arms around them, and gently nudge the sternum.

Temporomandibular joint

Inspection and palpation

Inspect and palpate the TMJ. With the patient seated, place your index and middle fingers just anterior to the external ear opening. Have the patient open the mouth wide, move the jaw side to side, and protrude and retract the jaw.
Test range of motion. Have the patient open the mouth and move the jaw laterally against resistance. As the patient clenches the teeth, feel the temporal and masseter muscles contract to test cranial nerve V.

Sternoclavicular joint

Inspection and palpation

With the patient seated, inspect the sternoclavicular joint for midline location, color, swelling, and masses, then palpate for tenderness or pain.

Cervical, thoracic, lumbar spine

Inspection and palpation

Observe the cervical, thoracic, and lumbar curves from the side and from behind, with the patient standing erect. Note differences in the height of the shoulders, iliac crests, and buttocks.
Palpate the spinous processes and the paravertebral muscles on both sides for tenderness or pain.
Test ROM of the cervical spine. Have the patient touch chin to chest and look up at the ceiling.
Test ROM of the thoracic and lumbar spine. Have the patient bend forward and touch the toes. Observe symmetry of shoulders, scapula, and hips.
Test for back and leg pain. For low back pain radiating down the back, perform Lasegue's test (straight leg raising) to check for a herniated nucleus pulposus. Have the patient lie flat and raise each relaxed leg independently to the point of pain, then dorsiflex the foot.
Measure leg length if you suspect one leg is longer. With the patient supine and legs extended, measure from the anterior superior iliac spine to the medial malleolus, crossing the tape on the medial side.

Shoulders, arms, elbows

Inspection and palpation

Inspect and palpate the shoulders and arms. With the patient standing or sitting, inspect anterior and posterior symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat.
Test shoulder ROM. With both arms straight down, have the patient move the arms forward and backward with elbows straight, bring both hands together overhead, then move both hands in front of the body past midline.
Inspect the elbows in flexed and extended positions for size, shape, deformity, redness, or swelling.
Test elbow ROM. Have the patient flex the elbow and bring the hand to the forehead, straighten the elbow, hold the arm out, turn the palm down, then up.

Hands, wrists, fingers

Inspection and palpation

Inspect the wrist for size, shape, symmetry, color, and swelling, then palpate for tenderness and nodules. Palpate the anatomic snuffbox (the hollow on the back of the wrist at the base of the fully extended thumb).
Test wrist ROM. Have the patient bend the wrist down and back, then hold it straight and move the hand outward and inward.
Test for carpal tunnel syndrome with Phalen's test. Have the patient place the backs of both hands together while flexing the wrists 90 degrees downward, and hold for 60 seconds.
Inspect the fingers for size, shape, symmetry, swelling, and color. Palpate from distal to proximal, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.
Test finger ROM. Have the patient spread the fingers, make a fist, bend the fingers down and up, move the thumb away from the other fingers, and touch the thumb to the base of the small finger.

Hips

Inspection and palpation

With the patient standing, inspect the symmetry and shape of the hips. Palpate for stability, tenderness, and crepitus.
Test hip ROM. With the patient supine, have them raise the extended leg; flex the knee to the chest while keeping the other leg extended; move an extended leg away from and then toward the midline; and bend the knee and turn the leg inward and outward.

Knees

Inspection and palpation

With the patient supine, then sitting with knees dangling, inspect for size, shape, symmetry, swelling, deformities, and alignment. Observe for quadriceps atrophy.
Test for swelling with the bulge test, which detects a small amount of knee fluid. With the patient supine, firmly stroke the medial side of the knee upward 3 to 4 times to displace fluid, then press on the lateral side and look for a bulge on the medial side.
Perform the ballottement test. With the patient supine, firmly press your nondominant thumb and index finger on each side of the patella, then push the patella down on the femur with your dominant fingers.
Test knee ROM. Have the patient bend each knee toward the buttocks, straighten the knee, and walk normally.
Test for pain and injury. With the patient supine, have them flex one knee and hip. Place your thumb and index finger on either side of the knee and hold the heel up with your other hand. Rotate the lower leg and foot laterally, then slowly extend the knee, noting pain or clicking.

Ankles and feet

Inspection and palpation

With the patient sitting, standing, and walking, inspect position, alignment, shape, and skin.
Palpate the ankles and feet for tenderness, heat, swelling, and nodules. Palpate the toes from distal to proximal, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.
Test ROM. Have the patient point the toes up then down, turn the soles outward then inward, rotate the foot outward then inward, and curl the toes under then up.

18. Assessment of the Neurologic System

The neurologic system affects and is affected by every other body system. Whatever the source of the problem, it often hits the patient's total lifestyle and level of functioning.

History of present health concern

Numbness and tingling

Any numbness or tingling? When and where?

Seizures

Any seizures? Describe what happens before one and where on the body it starts. Anything that triggers it? Do you lose bladder control? How do you feel afterward? Do you take medications? Do you wear medical identification? Do you take precautions around driving or dangerous machinery?

Headaches

Any headaches? When do they occur, and what do they feel like?

Dizziness

Any dizziness, lightheadedness, or balance or coordination problems? How often? With activity? Any falls or clumsy movements?

Senses

Any decrease in smell or taste? Any ringing in the ears or hearing loss? Any change in vision?

Difficulty speaking

Any difficulty understanding others, making yourself understood, forming words, or expressing your thoughts?

Difficulty swallowing

Any difficulty swallowing?

Muscle control

Any loss of bowel or bladder control, or urine retention? Any muscle weakness or tremors? Where?

Memory loss

Any memory loss?

Past health history

Any head injury, with or without loss of consciousness? Describe any physical or mental changes and treatment.
Any meningitis, encephalitis, spinal cord injury, or stroke? Describe any changes and treatment.

Family history

Any family history of high blood pressure, stroke, Alzheimer's disease, epilepsy, brain cancer, or Huntington's chorea?

Lifestyle and health practices

Do you take any prescription or nonprescription medications? How much alcohol? Any recreational drugs (marijuana, tranquilizers, barbiturates, cocaine)?
Do you smoke?
Do you wear a seatbelt? Protective headgear for cycling or sports?
Describe your usual daily diet.
Any prolonged exposure to lead, insecticides, pollutants, or other chemicals?
Do you frequently lift heavy objects or perform repetitive motions?
Can you perform your normal daily living?
Has the neurologic problem changed how you view yourself or added stress?

Neurological status, mental status, and LOC

Inspection

Observe level of consciousness. Call the patient's name and note the response. If none, call louder, then shake gently, then apply a painful stimulus.
Observe posture and body movements. Watch for tense, nervous, fidgety, or restless behavior, which may reflect anxiety or simple apprehension about the exam.
Observe dress, grooming, and hygiene, keeping the setting and reason for assessment in mind.
Observe facial expressions, especially eye contact and affect.
Observe speech for tone, clarity, and pace.
Observe mood and feelings. Ask, "How are you feeling today?" and "What are your plans for the future?"
Observe thought processes and perceptions for clarity and content.
Observe cognitive abilities. Ask for the patient's name and family members' names, the time, and where they live or are now. Note the ability to focus and stay attentive. Ask, "What did you have to eat today?" or "What is the weather like today?" and "When did you get your first job?" or "When is your birthday?" Have the patient repeat 4 unrelated words (not rhyming, not the same meaning), then repeat them in 5 minutes, again in 10 minutes, and again in 30 minutes.
Perform the Mini-Mental State Examination when time is limited and you need a quick, standard measure of cognitive function.

Cranial nerves

Inspection

Test CN I (olfactory). Seat the patient at your eye level for all cranial nerve testing. Have them clear the nose, close the eyes, occlude one nostril, and identify a scented object you hold.
Test CN II (optic). Use the Snellen chart for each eye. Have the patient read a paragraph for near vision. Assess visual fields by confrontation, and use an ophthalmoscope to view the retina and optic disc of each eye.
Assess CN III (oculomotor), IV (trochlear), and VI (abducens). Inspect the eyelid margins. Assess extraocular movements; if nystagmus appears, note the direction of the fast and slow phases. Assess pupillary response to light and accommodation in both eyes.
Assess CN V (trigeminal). Motor: have the patient clench the teeth while you palpate the temporal and masseter muscles. Sensory: tell the patient you will touch the forehead, cheeks, and chin with the sharp or dull side of a safety pin or paper clip, and have them close their eyes and report sharp or dull and where.
Test CN VII (facial). Motor: have the patient smile, frown, wrinkle the forehead, show teeth, puff out the cheeks, purse the lips, raise the eyebrows, and close the eyes tightly against resistance.
Test CN VIII (acoustic/vestibulocochlear). Test hearing in each ear and perform the Weber and Rinne tests to assess the cochlear (auditory) component.
Test CN IX (glossopharyngeal) and X (vagus). Have the patient open wide and say "ah" while you depress the tongue. Test the gag reflex by touching the posterior pharynx with the tongue depressor.
Test CN XI (spinal accessory). Have the patient shrug the shoulders against resistance (trapezius) and turn the head against resistance to each side (sternocleidomastoid).
Test CN XII (hypoglossal). Have the patient protrude the tongue, move it to each side against the resistance of a tongue depressor, then return it.

Motor and cerebellar systems

Inspection

Assess the condition and movement of muscles. Assess size and symmetry, then strength and tone, of all muscle groups. Note involuntary movements such as fasciculations, tics, or tremors.
Evaluate balance. Have the patient walk naturally across the room and note posture, freedom of movement, symmetry, rhythm, and balance. Have them walk heel-to-toe, then on the heels, then on the toes. Perform the Romberg test: have the patient stand erect with arms at the sides and feet together, and note any unsteadiness or swaying.
Assess coordination with the finger-to-nose test. Have the patient extend the arms out to the side with eyes open, then touch the tip of the nose first with the right index finger, then with the left.

Sensory systems

Inspection

Assess light touch, pain, and temperature. For each test, have the patient close both eyes and report what and where they feel. Scatter stimuli over distal and proximal parts of all extremities and the trunk to cover most dermatomes. Use a wisp of cotton for light touch, the blunt and sharp ends of a safety pin or paper clip for pain, and test tubes of hot and cold water for temperature.
Test vibratory sensation. Strike a low-pitched tuning fork on the heel of your hand and hold the base on a bony surface of the fingers or big toe. Have the patient report what they feel.
Test position sense. With the patient's eyes closed, move a toe or finger up or down and have them report the direction.
Assess tactile discrimination (fine touch), eyes closed. Stereognosis: place a familiar object (a quarter, paper clip, or key) in the patient's hand and have them identify it. Point localization: briefly touch the patient and have them identify the point. Graphesthesia: write a number on the palm with a blunt instrument and have them identify it.