head to toe assessment-dengue
TRANSCRIPT
Head to Toe Assessment
BODY PART
◊ HEAD
Skull
Scalp/ Hair
Face
Eyes/ Vision
TECHNIQUE USED
◊ palpation
◊ inspection ◊ palpation
◊ inspection
◊ inspection ◊ palpation
FINDINGS
◊ proportional to the size of the body,
round, with prominences in the
frontal area anteriorly & the
occipital area
posteriorly, symmetrical in all
planes, gently curved
◊ scalp is white, clean, free from
masses, lumps, nits, dandruff & lesions,
with no areas of tenderness upon
palpation; hair is
black, evenly distributed & covers
the whole scalp, thick & shiny
◊ oblong shaped, symmetrical, smooth
& no involuntary muscle movements
◊ eyes are parallel & evenly placed,
symmetrical, non-protruding, with
scant amount of secretions, both
eyes black & clear;
sclera is white & clear; eyebrows
are black, symmetrical, thick,
can raise both
symmetrically & without difficulty,
evenly distributed & parallel with each
other; eyelashes are evenly
INTERPRETATION
◊ Normal
◊ Normal
◊ Normal
◊ Normal
Ears/ Hearing
◊ inspection
◊ palpation
distributed & turned
outward; upper eyelids cover a
small portion of the iris, cornea & the
sclera when the
eyes are open, when the eyes are closed
the lids meet completely,
symmetrical & the color is the same as
the surrounding
skin; lid margins are clear, without
scaling or secretions; lower
palpebral
conjunctiva are shiny, moist,
transparent & salmon pink in color;
iris are proportional to the size of the
eye, round &
symmetrical; pupils are from pinpoint to
almost the size of the iris, round,
symmetrical,
constricts with increasing light &
accommodation; able to move eyes in
full range of
direction
◊ ears are parallel,
symmetrical, proportional to the
size of the head,
bean-shaped, helix is in line with the
outer canthus of the eye, skin is the
same color as the
surrounding area & clean; ear canal is
pinkish, clean, with scant amount of
cerumen & a few cilia; able to hear
◊ Normal
Nose
Mouth/ Lips
◊ NECK
◊ THORAX &
LUNGS
◊ inspection ◊ palpation
◊ inspection
◊ palpation
◊ inspection ◊ palpation
◊ inspection
◊ palpation ◊ percussion
whisper spoken 2
feet away; 2 piercing are found in
left ear and 1 piercing in right ear
◊ nose is in midline, symmetrical, patent;
internal nares are clean, dark pink with
few cilia
◊ lips are pinkish,
symmetrical, lip margin is well-
defined, smooth & moist; gums are
pinkish, smooth,
moist, no swelling, no retraction, no
discharge; 32 teeth are present, aligned,
with no dental caries; tongue is
pinkish, slightly
rough on top, smooth along the
lateral margins, moist, shiny & freely
movable;
cheeks are pinkish, moist & smooth;
frenulum is in midline, straight &
thin; soft palate is
pinkish, smooth & moist; hard palate
is slightly pinkish; uvula is at the
center, symmetrical & freely movable
◊ proportional to the size of the body
& head, symmetrical & straight, no
palpable lumps,
masses or areas of tenderness
◊ chest contour is
symmetrical, spine is straight, no lumps,
◊ Normal
◊ Normal
◊ Normal
◊ Normal
◊ HEART
◊ BREAST
◊ ABDOMEN
◊ UPPER EXTREMITIES
◊ auscultation
◊ inspection
◊ palpation
◊ percussion ◊ auscultation
◊ inspection ◊ palpation
◊ inspection
◊ auscultation ◊ percussion
◊ palpation
◊ inspection ◊ palpation
no masses, no
tender areas, with clear breath sounds
◊ no abnormal
pulsations,
pulsations are palpable & visible in
apical area
◊ symmetrical, pinkish nipples, no
cracks & discharges,
uniform in skin color, smooth &
intact, no lumps, masses &
tenderness
◊ abdominal skin
is unblemished, no scars, color is
uniform with the body color,
abdomen is
rounded with symmetric
movements caused by respiration;
umbilicus is
concave
◊ symmetrical, with visible veins, fine
hair evenly
distributed, warm, dry & elastic upon
palpation, with area of tenderness on the
left arm; palms are pinkish, warm, soft
& elastic; nails are
transparent, smooth & convex with light
pink nail beds & white translucent
tips; 5 fingers in
each hand; both shoulders, arms,
elbows, hands & wrists can be
moved in different range of motion with
◊ Normal
◊ Normal
◊ Normal
◊ Normal
◊ LOWER
EXTREMITIES
◊ inspection
◊ palpation
relative ease; c
marks of petechial rashes
◊ skin is smooth,
fine hair is evenly
distributed, absence of varicose veins,
muscles symmetrical, length
symmetrical, 5 toes in each foot, sole &
dorsal surface is
smooth with pink nail beds & white
translucent tips; both legs, knees,
ankles, & toes can
be moved in different range of
motion with relative ease; scar on both
patellar; c non pitting bipedal
edema
◊ Normal