Head-to-toe Checklist

Items Findings
A. General Appearance
1. Appears stated age Mr. W 28 years old male and who appears healthy and
looks his stated age.
2. Level of consciousness Patient awake and alert, he able promptly and
spontaneously to state his name, location, and the date or
time, and he able to be oriented to self. With the number of
GCS 15 as follows:
 Eye: Spontaneous (4)
 Motor: obey verbal command (6)
 Verbal: Oriented and appropriate (5
3. Skin color  Normal in appearance in all body with light brown
color, texture is smooth, temperature is warm, and, no
signs of rashes, bruises, flaking.
 The skin mobility ease to rise, and the turgor ability to
return to place promptly after was released.
 No lession, no tattos, no piercings, and no jaundice.
4. Nutritional status Current weight: 63 kg
Ussual weight: 66 kg
Height: 167 cm
 Percent usual body weight (current weight / usual
weight x 100%)
= (63/66X100%)
= 95.45 % (normal nutrition)
 Recent weight change (usual weight-current weight /
usual weight x 100%)
= (66 – 63/ 66 x 100%)
= 4.54 % (normal or no unintentional loss)
 BMI (weight (kg) / height (meters)2)
= (63/1.672)
= 22.58 (normal weight)
 Waist-to-Hip Ratio (waist circumference / hip
circumference)
= 33/38
= 0.86 (no obesity)
  Eyes: corneas are clear, shiny, membranes are pink and
moist.
5. Posture and position comfortably Patient able to standing and looks spine straight. From the
erect side, the thoracic curve is normal convex and has elliptical
shape with an anteroposterior-to-transverse diameter
documented as 1:2, and the lumbar curve is concave. There
is no kyphosis, no lordosis and no abnormal finding such
as barrel chest, pectus exavatum and puctus carinatum.
Patient sits comfortably with arms relaxed at sides and
head turned to examiner.
6. Obvious physical deformities There is no obvious physical deformities
7. Mobility: 1) Patient able to walk slightly as follows examiner; foot
(1) Gait placement is accurate
(2) Use of assistive devices 2) No use of assistive devices when walking or stnading
(3) Range of motion (ROM) of joints 3) Full mobility for each joint and that movemnet is
(4) No involuntary movement delibearet, accurate, smooth, and coordinated. Muscle
status and joint status were strength, equal bilaterally
and fully resist when apply opposing force in all of
extremities.
4) No involuntary movement in for extremities
8. Facial expression The patient maintains eye contact and expression are
appropriate to the situation.
9. Mood and affect The patient is comfortable and cooperative with the
examiner and interacts pleasanty.
10. Speech: articulation, pattern, The stream of talking is fluent, with an even pace. The
content appropriate, native patient conveys ideas clearly. Word choice is appropriate
language for culture and education. And the native language is
Bahasa Indonesia
11. Hearing Patient able to hear clearly and no signs and symptoms that
indicate hear impairment.
 Rinne test: sound is heard twice as long by air
conductionas than bone conduction.
 Weber test: sound is equally loud in both ears and not
lateralize sinistra or dextra.
12. Personal hygiene Patient appears clean and groomed appropriately for his
age and status as a student, no use deodorant, and take a
bath twice a day.
 The nails in all of the fingers are short, no cerumen in both
of ears.
B. Measurement
1. Weight 63 kg
2. Height 167 cm
3. Vision using Snellen eye chart no available equipment
C. Skin
1. Examine both hands and inspect  Normal in appearance in both hands with light brown
the nails color, texture is smooth, temperature is warm, and, no
signs of rashes, bruises, flaking.
 The skin mobility ease to rise, and the turgor ability to
return to place promptly after was released.
 The texture feels smooth and firm with an even surface
 No lession, no tattos, no piercings, no edem, and no
jaundice.
 The nail surface slightly curved, smooth, rounded and
clean, for the color all of the nails have pink nail bed
underneath.
 Capillary refill: color return instant within less than 2
seconds after the nail be pressed.
2. For the rest of the examination, Skin color is light brown, no cyanosis, no jaundice, and
examine skin with corresponding there are mole in left face, right shoulder and axilla. A little
regional examination scar in right foot and left foot.
D. Vital Signs
1. Radial pulse 72 x/minute, regular and weak
2. Respiration rate 20 x/minute, regular and without assecories muscle
3. Blood pressure No available equipment (110/70 mmHg usually)
4. Body temperature No available equipment (36.80 C ussually)
E. Head, nose, neck, throat
1. Inspect and palpate scalp The shape is normocephalic and the skull feels symmetric
thoroughly (any lesion, mass or and smooth, there is no tenderness and mass when palpate,
trauma?) no lession and short hair with black color and normal
distribution, no dandruff and clean.
2. Observe face to check symmetry, Shape of the facial structures symmetrical, eyebrows
temporal wasting, temporalis and symmetry, temporal area feel smooth movement with no
masseter muscle atrophy limitation or tenderness and there is some acne scare in the
face.
3. Inspect conjunctiva, eyelid, sclera Sclera- white
Conjunctiva- pink
Eyelid: the upper lids overlap the ssuperior part completely
with the lower lids when closed, no redness, swelling,
discharge or lession.
4. Evaluate extraocular muscle Pupils appear round, reguler and equal size in both eyes
function (up, down, right, left) up (isocor), react to light and accomodation, the size is 4 mm.
and out, down and in (cranial nerve No nystagmus, no ptosis, and able to move six cardinal
III, IV, VI) positions of gaze elicits without weakness during
movement.
5. Observe papillary responses to  Direct light reflex: contriction of the same-sided pupil.
light both directly and consensually  Consensual light reflex: simultaneous constriction of
(cranial nerve II, Ⅲ) the other pupil.
6. Estimate visual field in each eye Patient able to see the target at first seen when the pencil as
separately in 4 quadrant (cranial a target midline between examiner and slowly advance it
nerve II) in from the periphery in several directions (left, right, up,
and down).
7. Using an ophthalmoscope, observe No available equipment
the optic disc, physiological cup,
retinal vessels and fovea (cranial
nerve II)
8. Observe/palpate ears, preauricular  The ears are equal size bilaterally and no swelling or
and postauricular nodes/region thickening.
 The ear skin color is consistent with his facial skin
color, the skin is intact with no lumps and lesion.
 The pinna is feel firm, and he feel no pain or tenderness
when the examiner palpate and move his pinna.
 There is no any cerumen present in ear canal.
9. Weber/Rinne test (cranial nerve  Weber test: patient feel sound equally loud in both ear,
VIII) and the sound does not lateralize.
 Rinne test: patient heard sound from air conduction
(AC) longer rather than by bone conduction (BC)
AC>BC.
10. Test for frontal and maxillary sinus The sinus area feel firm pressure, there is no pain present
tenderness while palpation.
11. Inspect lips, gums, teeth, floor of Lips: the lips color is pink, looks dry and there is no
mouth, tongue, pharynx/tonsils lesion.
 Gums: the gums looks pink and the teeth are tight and well
defined, there is 32 teets.
 There is no swelling, retraction of gingival margins
 There is no bleeding or changing color in his gums
Floor of mouth and tongue: the color is pink, dorsal
surface looks roughened from the papillae, ventral surface
looks smooth, glistening and show veins, there is saliva
present while examination, there is no white patches or
lesion
Pharynx/ tonsils: Color of the tonsil is pink and there is
no tonsil enlargement or swelling.
12. Ask patient “stick out their tongue”  There is no tremor and wasting in his tongue
and move it side to side, check any  Patient’s tongue can move freely side to side (right, left,
deviation (cranial nerve XII) up, and down)
13. Observe elevation of the plate) When depress the tongue with tongue blade and asked to
(cranial nerve IX, X) say “aahhh”:
 His uvula and soft palate rise in the midline of mouth
cavity.
 His tonsillar pillar move medially.
 Gag reflex positive (+).
14. Palpate salivary glands including When palpate the salivary glands including parotid and
parotid and submandibular gland submandibular gland:
 Two pairs of salivary glands are accessible to palpable
 Parotid glands are not palpable.
 Submandibular glands palpable at the mandible at the
angle of the jaw.
 Patient not feel pain, and there is not enlargement.

15. Test neck range of motion to sides, There is no limitation of movement during active motion.
forward, backward The movement is supple, smooth and controlled and his
neck can movable freedom.
16. Palpate c-spine There is no palpable node
17. Palpate thyroid gland  When patient swallow, thyroid can inspect moves up
and falls into its resting position.
 The thyroid cannot palpable.
18. Palpate lymph nodes including There is no nodes enlargement and palpable nodes
occipital, anterior cervical,
 posterior cervical, submental,
supraclavicular and infraclavicular
19. Check the position of trachea His trachea is in midline and there is no deviation from
midline and the space is symmetric on both sides.
20. Auscultate carotid arteries  There is no bruit sound
F. Chest and heart
1. Inspect the chest: configuration of  Thoracic cage
the thoracic cage, skin Anterior: The thorax is symmetric, the ribs are sloping
characteristics, and symmetry of downward with symmetric interspaces, sternum appear
shoulders and muscles, respirations as a straight line, barrel chest (-), funnel chest (-),
and skin characteristics pigeon chest (-), clavicle are placed symmetrically in
each hemi thorax.
Posterior: The spinous processes appear as a straight
line in the middle line of the body, the thorax is
symmetric, the scapulae are placed symmetrically in
each hemi thorax, scoliosis (-), kyphosis (-)
 Skin characteristic: There is no color changes in his
chest area, cyanosis (-), lesion (-), trauma (-), lips and
nail beds are free from cyanosis and the nails
configuration are normal.
 Symmetry of shoulders placed and movement are
symmetric, patient did not used accessory muscles
(scalene, sternomastoideus, trapezius) when breathing.
 Respiratory pattern: is regular, relaxed, automatic,
effortless, and produce no noise, air moving in and out
with each respiration, chest expand symmetrically with
respiration rate : 20 x/minute.
2. Inspect each side of neck for a There is any pulsation, but there is no enlargement and
jugular venous pulse distention.
3. Estimate jugular venous pressure, if The internal jugular vein pulsations 2 cm above sterna
indicated. angel when elevated 30 0.
4. Palpate: symmetric expansion; Respiration expansion is symetric, vibration transmitted
tactile fremitus; lumps, or symmetrical on each side and no lump, no tenderness.
tenderness
5. Palpate precordium for any When palpate using palmar aspects four fingers, there is no
abnormal thrill abnormal thrill.
6. Palpate the apical impulse and note Palpable apical impulse in left side ICS V, a medial to the
the location. midclavicular line.
7. Percuss over all lung fields Resonant sound of entire lung fields.
8. Percuss diaphragmatic excursion When percuss the map out the lung border both in
expiration and in inspiration the sound border from
resonance to tympany is 4 cm.
9. Percuss costovertebral angle, noting When percus the costovertebral angle, patient did not feel
tenderness any pain or tenderness.
10. Auscultate breath sounds; note The sound is bronchovesicular in area of trachea and
adventitious sounds (crackles, vesicular in entire lung fields, no adventitious sound.
wheeze or rhonchi)
11. Auscultate apical rate and rhythm. Apical rate is 72 x/minute and reguler rhytm
12. Auscultate with the diaphragm of When auscultation with diaphragm S1 sound appears at
the stethoscope to study heart tricuspid and mitral valve area, S2 sound appears at aortic
sounds, inching from apex up to the valve area and pulmonic valve area, There is not extra
base, or vice versa. heart sound, neither murmur sound.
H. Abdomen
1. Inspect: contour, symmetry, skin Contour: the contour flat, no scar, and no distency.
characteristics, umbilicus, and Symmetry: the shape of abdomen symmetric bilaterally,
pulsations. there is no localized, bulging, visible mass, or asymmetric
shape.
Skin: the surface is smooth and with homogeneous light
brown color, but more bright than another part of body, no
striae.
Umbilicus: the umbilicus in midline and inverted with no
sign of discolororation, inflamation or hernia
Pulsations: the pulsation of the aorta in the left side of
abdomen and a little bit hard to looks pulsation from the
aorta in this area.
2. Auscultate bowel sounds. The bowel sound in all of the quadrant 10 times/minute
3. Auscultate for vascular sounds over There is no vascular sound such as bruits in all part of
the aorta and renal arteries. abdomen (aorta, left and right renal arteries, iliac artery
and feromal artery).
4. Percuss all quadrants. General tymphany sound was found in all four quadrants
of abdomen.
5. Persuss height of the liver span in The height of liver span is 8 cm, there is no enlarged in
right midclavicular line. liver span.
 6. Percuss the location of the spleen. The location of the spleen is around 11th to 12th rib and
there is no enlargement of spleen.
7. Palpate: light palpation in all  There is no muscle rigidity, there is no larger masses
quadrants, then deep palpation in and tenderness on the abdomen when light palpation.
all quadrants.  Deep palpation found there is no abnormal enlargement
of palpable organ like liver and another organ in
abdomen regio, and also there is no tenderness and
mass.
8. Test the abdominal reflexes, if No abnormal abdominal reflexes (-).
indicated.
9. Test for appendicitis (obturator,  Obturator test: when flexing the hip (90 0 at the knee)
psoas and Rovsing sign) while examiner rotate internal and externally, patient
feel no pain (-).
 Psoas: patient supine position, and lift his right leg
straight up, flexing at the hip and push down over the
lower part of the right tight while patient keep hold the
leg up and no pain in result (-).
 Rovsing sign: push slowly and deep in left lower
quadrant, and the result no pain in right lower quadrant
(the pain is not spread into right lower quadrant) tes
negative.
H. Musculoskeletal
1. Inspect/palpate both hands and Deformities (-)
arms for deformities, lesions, Lesions (-)
clubbing, skin color, nailbeds, Clubbing (-)
temperature, muscle tenderness, Muscle tenderness (-)
joint tenderness. Joint tenderness (-)
Skin color: normal in appearance in both hand and arms
with light brown color, texture is smooth, temperature is
warm, and, no signs of rashes, bruises, flaking.
Nailbeds: nail surface slightly curved, smooth, rounded
and clean, for the color all of the nails have pink nail bed
underneath.
2. Inspect/palpate both legs for Deformities (-)
deformities, lesions, clubbing, skin Lesions (-)
color, nailbeds, temperature, Clubbing (-)
muscle tenderness, joint Muscle tenderness (-)
 tenderness; separate toes and Joint tenderness (-)
inspect. Skin color: normal in appearance in both legs with light
brown color with hair normal distribution, texture is
smooth, temperature is warm, and, no signs of rashes,
bruises, flaking.
Nailbeds: nail surface slightly curved, smooth, rounded
and clean, for the color all of the nails have pink nail bed
underneath.
3. Observe posture and curvature.  Posture is erect
 Shoulders, scapulae and gluteal fold → equal in
horizontal position
 Body curvature is normal (there is a double S-shape in
his vertebral column)
Concave shape in neck and lumbar area
Convex shape in thoracic and sacroccygeal
 Scoliosis (-), kyphosis (-), lordosys (-)
4. Exam injury knee (cruciate  Mc Murray Test (check injury in meniscus)
ligament, collateral ligament and 1. Internal rotate → patients feel no pain, and there is
meniscus) no “click” sound.
2. External rotate → patient feel no pain, and there is
no “click” sound.
 Posterior and anterior drawer sign
1. Posterior drawer sign: move backward no feel pain,
its mean patient did not have injury in posterior
cruciate ligament.
2. Anterior drawer sign: move forward no feel pain, its
mean patient did not have injury in anterior cruciate
ligament
 Exam lateral and medial collateral ligament
1. Medial collateral ligament
Right hand: push medial ankle outward and patient
no feel pain.
Left hand: supply opposite force in lateral side of
knee and patient no feel pain, its mean medial
collateral ligament patient didn’t torn.
2. Lateral collateral ligament
Right hand: push lateral ankle inward no feel pain
 Left hand: supply opposite force in medial side of
knee no feel pain “pop out”, its mean lateral
collateral ligament patients didn’t torn.
5. Test ROM and muscle strength of Hips ROM, patient able to:
hips, knees, ankles, and feet. 1. Hip flexion of 90 0
2. Hip flexion of 120 0
3. Internal rotationof 40 0
4. Abduction of 40 to 45 0
5. Hyperextension of 15 0
The quadriceps muscle in the thigh of knee did not founnd
atrophy.
Ankle and foot ROM:
1. Patient able to plantar flexion of 45 0
2. Patient able to dorsiflexion of 20 0
3. Patient able to eversion of 30 0
And patient able to maintain dorsiflexion and plantar
flexion against by examiner resistance.
6. Test ROM and muscle strength of Muscle strength of shoulder: patient able to shrug the
shoulder, elbow and wrist. shoulders, flexed forward and up, and abduct against from
examiner’s resistance.
Shoulder ROM:
1. Patient able to forward flexion of 180 0 and
hyperextension up to 50 0
2. Patient able to internal rotation of 90 0
3. Patient able to abduction of 180 0
4. Patient able to adduction of 50 0
5. Patient able to external rotation of 90 0
Muscle strength of elbow: patient able to flex the elbow
against the examiner's resistance.
Elbow ROM:
1. Patient able to flexion of 150cto 160 0 and extension at 0
2. Patient able to movement of 90 0 in pronation and
supination.
Muscle strength of wrist and hand: patient able to
stabilize by holding the examiner’s hand at the patient’s
mid forearm.
Wrist and hand ROM:
 1. Patient able to hyperextension of 70 0
2. Patient able to palmar flexion of 90 0
3. Patient able to flexion of 90 0 and hyperextension of 300
4. Patient able to ulnar deviation of 50 to 60 0 and radial
deviation of 20 0
5. Patient able to abduction of 20 0, fist tight. And the
response equal bilaterally.
6. Patient able to perform and the response equal
bilaterally.
7. Note muscle strength as person sits
up.
I. Peripheral vessels
1. Palpate pulses: radial, brachial Palpate both radial pulse, there is pulsation regular rate,
arteries. the vessel wall elastic and equal force between of both and
the scale 2+ (normal).
Brachial arteries there is pulsation regular rate, no force
between of both.
2. Palpate pulses: popliteal, posterior Popliteal: there is pulsation regular rate in thelower leg.
tibial, dorsalis pedis. Posterior tibial: there is pulsation regular rate between the
malleolus and the achilles tendon with passive dosiflexion
of the foot.
Dorsalis pedís: there is pulsation regular rate in the lateral
extensor tendon of the big toe.
3. Palpate for temperature and The temperature along the leg down to the feet warm and
pretibial edema or pitting edema. equal bilaterally in both of the legs.
Edema: no indentation although a pit commonly is seen
when firmly depress the skin over the tibia or the medial
malleolus for 5 seconds (normal no pitting edema)
4. Inspect legs for varicose veins. The veins did not appear visible, dilated and tortuous.
J. Neurologic
1. Test orientation to person, time, Patient awake and alert, he able promptly and
place, attention, recall (note the spontaneously to state his name, location, and the date or
questions you asked) time, and he able to be oriented to self when examiner ask
question.
1. What’s your name?
2. Whre do you live now?
3. What day is today, what date today?
 4. What time is it now?
2. Deep tendon reflexes including Biceps reflex (+) constraction of the biceps muscle and
Biceps/brachloradialis reflex and flexion of the forearm
Triceps reflex Brachioradialis reflex (+) flexion and supination of the
forearm
Triceps reflex (+) extension of the forearm
3. Patella reflex/Achilles reflex Patella reflex (knee jerk) (+) extension of the lower leg is
the expected
Achilles reflex (ankle jerk) (+) the foot plantar flexes
against examiner’s hand
4. Test Barbiskin sign Plantar reflex (Barbiskin sign) (-) plantar flexion of the
toes and inversion and flexion of the forefoot
5. Test light touch/pin prick on both Pain: patient able to describe the sensation felt sharp or
side of trunk dull, when the examiner touched lightly the sharp point or
the dull using broken fragment tongue blade lengthwise.
Light touch: patient able to feel the sensation of the cotton
to the skin when the cotton brush it over the skin in
random.
6. Test light touch and pin prick on 4 Patient able to feel, describe and identification the
limbs sensation of the cotton to the 4 limbs when the cotton
brush it over the skin.
7. Test position sense (kinesthesia) Patient able to describe the sensation felt movement of the
exxtremities when the examiner move a finger up and
down in extremities.
8. Test vibration sense in at least both Patient able to describe the sensation felt vibration such as
ankles vibration or buzzing, when the examiner touched lightly
tuning fork on the heel of hand, and on a bony surface of
the fingers and great toe.
9. Test muscle tone and strength in  Size: Muscle group the same size limits for age and
flexion and extension (including symmetric bilaterally.
hands, wrists, elbows, shoulder,  Strength: all of the extremities has full ROM against
hips, knees, and ankles) the gravity and full resistance (normal) with grade 5 in
each lower and upper extremities.
 Tone: When the examiner move the extremities through
a passive range of motion, the examiner will feel
movement of the extremities a mild even resistance to
movement.
10. Romberg test Patients able to maintain posture and balance, even he was
close the eyes and hold the position.