What should be assessed during a head-to-toe (H2T) exam?

Components of a Comprehensive Head-to-Toe Examination

A comprehensive head-to-toe examination should include assessment of skin integrity, neurological function, vascular status, and musculoskeletal structure, with particular attention to high-risk areas such as the feet in patients with diabetes. 1

General Assessment

• Begin with vital signs including blood pressure measurements in both arms to identify potential subclavian artery stenosis (difference >15-20 mmHg between arms) 1
• Assess overall body habitus, looking for evidence of wasting, obesity, or lipodystrophy 1
• Evaluate general appearance, level of consciousness, and apparent distress 1

Head and Neck Assessment

• Inspect the head for deformities, lesions, and symmetry 1
• Assess cranial nerve function through:
  • Visual acuity and visual fields (CN II) 2
  • Pupillary response and extraocular movements (CN III, IV, VI) 2
  • Facial sensation and muscles (CN V, VII) 2
  • Hearing and balance (CN VIII) 2
  • Swallowing, tongue movement, and palate elevation (CN IX, X, XII) 2
• Palpate lymph nodes in the neck for enlargement or tenderness 1
• Auscultate carotid arteries for bruits 1

Cardiopulmonary Assessment

• Inspect chest wall for symmetry of movement and use of accessory muscles 1
• Palpate for tactile fremitus and chest wall tenderness 1
• Percuss lung fields for dullness or hyperresonance 3
• Auscultate lungs for breath sounds, crackles, wheezes, or rubs 1
• Auscultate heart for rate, rhythm, and presence of murmurs, gallops, or rubs 1

Abdominal Assessment

• Inspect for distension, visible peristalsis, or pulsations 1
• Auscultate for bowel sounds and bruits 1
• Percuss for tympany or dullness 3
• Palpate for tenderness, masses, organomegaly, or pulsatile masses 1

Musculoskeletal Assessment

• Assess range of motion of major joints 1
• Evaluate for joint deformities, swelling, or tenderness 1
• Test muscle strength in all extremities 1
• Assess for foot deformities such as bunions, hammertoes, and prominent metatarsals that increase plantar foot pressures and risk for ulcerations 1

Neurological Assessment

• Evaluate mental status and cognitive function 1
• Test sensory function using:
  • 10-g monofilament test for protective sensation 1
  • Pinprick or temperature perception 1
  • Vibration testing with 128-Hz tuning fork 1
  • Proprioception assessment using thumb/big-toe localizing test 4
• Assess deep tendon reflexes, including ankle reflexes 1
• Evaluate coordination and gait 1

Vascular Assessment

• Palpate peripheral pulses (femoral, popliteal, dorsalis pedis, and posterior tibial) 1
• Assess for capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 1
• Note any signs of peripheral arterial disease including decreased walking speed, leg fatigue, or claudication 1
• Evaluate for edema and its distribution 1

Skin Assessment

• Inspect skin for integrity, color, moisture, temperature, and turgor 1
• Identify any lesions, ulcerations, calluses, or wounds 1
• Pay particular attention to feet and pressure points in patients at risk for skin breakdown 1

Special Considerations for Diabetic Patients

• Perform comprehensive foot examination at least annually, including:
  • Skin integrity assessment 1
  • Foot deformity evaluation 1
  • Neurological assessment with 10-g monofilament and at least one other test 1
  • Vascular assessment including pulses 1
• Obtain history of ulceration, amputation, Charcot foot, vascular surgery, smoking, retinopathy, and renal disease 1
• Inspect feet at every visit for patients with sensory loss or prior ulceration/amputation 1

Common Pitfalls and Caveats

• Absence of dorsalis pedis pulse alone is not diagnostic of peripheral arterial disease as it can be congenitally absent in some individuals 1
• Monofilament testing alone is insufficient for neurological assessment; combine with at least one other test (pinprick, temperature, vibration, or ankle reflexes) 1
• Comprehensive examination may need to be modified based on patient's condition and presenting symptoms 1
• Consider adding bedside ultrasonography (insonation) as a fifth pillar to traditional inspection, palpation, percussion, and auscultation for enhanced diagnostic capability 3
• Ensure proper exposure while maintaining patient dignity and comfort during examination 1

By following this systematic approach to the head-to-toe examination, clinicians can effectively identify abnormalities that may impact patient morbidity, mortality, and quality of life.