What are the steps for a comprehensive head-to-toe adult assessment?

Comprehensive Head-to-Toe Adult Assessment Guide

Initial Preparation and Vital Signs

• Begin by measuring vital signs: blood pressure (in both arms to identify potential subclavian artery stenosis), temperature, pulse rate, respiratory rate, and oxygen saturation 1, 2
• Calculate body mass index (BMI) by measuring height and weight 3
• Assess orthostatic blood pressure changes when indicated 3
• Note that vital sign ranges may need individualized reference ranges for older adults due to age-related physiological changes 4

General Assessment

• Evaluate overall appearance, level of consciousness, and apparent distress 1
• Assess body habitus for evidence of wasting, obesity, or lipodystrophy 1
• Note skin color, moisture, temperature, and turgor 1

Head and Neck Assessment

• Inspect head for deformities, lesions, and symmetry 1
• Examine eyes: visual acuity, pupillary response, extraocular movements, and fundoscopic examination (refer to eye specialist for dilated exam) 3
• Inspect ears: external ear, auditory canals, and tympanic membranes 1
• Examine nose and sinuses for patency and discharge 1
• Assess oral cavity: teeth, gums, tongue, palate, and pharynx 1
• Palpate thyroid gland and lymph nodes in the neck 3
• Auscultate carotid arteries for bruits 1

Cardiopulmonary Assessment

• Inspect chest wall for symmetry of movement and use of accessory muscles 1
• Palpate chest for tactile fremitus and tenderness 1
• Auscultate lungs for breath sounds, crackles, wheezes, or rubs 1
• Auscultate heart for rate, rhythm, and presence of murmurs, gallops, or rubs 1
• Abnormal vital signs, particularly oxygen saturation, respiratory rate, systolic blood pressure, and altered mental status, are strong predictors of adverse outcomes and should prompt immediate intervention 5

Abdominal Assessment

• Inspect abdomen for distension, visible peristalsis, or pulsations 1
• Auscultate for bowel sounds and bruits 1
• Palpate for tenderness, masses, organomegaly, or pulsatile masses 1
• Assess for hepatomegaly or splenomegaly 3

Genitourinary Assessment

• Perform appropriate genital examination based on patient's sex 1
• Assess for genital lesions or discharge 1
• For males, evaluate for testicular masses and perform prostate examination when indicated 1
• For females, perform breast examination and pelvic examination when indicated 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 risk for ulcerations 3, 1

Neurological Assessment

• Evaluate mental status and cognitive function 3, 1
• Assess cranial nerves 1
• Test sensory function using:
  • 10-g monofilament test (particularly for feet in diabetic patients) 3, 1
  • Pinprick or temperature perception 3, 1
  • Vibration testing with a 128-Hz tuning fork 3, 1
• 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) 3, 1
• Assess for capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 3, 1
• Note any signs of peripheral arterial disease, including decreased walking speed, leg fatigue, or claudication 3

Skin Assessment

• Perform comprehensive skin examination, noting any lesions, ulcerations, calluses, or wounds 1
• Pay particular attention to feet and pressure points in patients at risk for skin breakdown 3, 1
• For diabetic patients, inspect feet at every visit if they have sensory loss or prior ulceration/amputation 3

Laboratory and Diagnostic Evaluation

• Initial laboratory evaluation should include:
  • Complete blood count 3
  • Urinalysis 3
  • Serum electrolytes (including calcium and magnesium) 3
  • Blood urea nitrogen and serum creatinine 3
  • Fasting blood glucose or glycohemoglobin 3
  • Lipid profile 3
  • Liver function tests 3
  • Thyroid-stimulating hormone 3
• Consider 12-lead electrocardiogram and chest radiograph (PA and lateral) when indicated 3
• Consider echocardiography or other cardiac imaging when indicated 3

Special Considerations for Specific Populations

• For diabetic patients:
  • Perform comprehensive foot examination at least annually 3
  • Obtain history of ulceration, amputation, Charcot foot, vascular surgery, smoking, retinopathy, and renal disease 3
  • Screen for peripheral arterial disease with ankle-brachial index if indicated 3
• For older adults:
  • Apply the "Geriatric 5Ms" framework: Mind (cognitive/psychological), Mobility, Medications, what Matters most, and Multicomplexity 3
  • Assess for cognitive impairment, fall risk, and medication appropriateness 3
  • Consider functional assessment for activities of daily living 3

Documentation and Follow-up Planning

• Document all findings systematically 1
• Identify any abnormalities requiring further evaluation or intervention 1
• Develop a follow-up plan based on findings 1
• Provide patient education on self-examination techniques when appropriate (e.g., skin checks, foot care) 3