What is the proper procedure for a complete, full-guided head-to-toe exam?

Complete Head-to-Toe Physical Examination Protocol

Begin with vital signs measurement including blood pressure in both arms, temperature, pulse rate, respiratory rate, and oxygen saturation, followed by systematic examination from head to feet with particular attention to neurological, vascular, and skin assessments. 1

Initial Preparation and Vital Signs

• Measure blood pressure in both arms to identify potential subclavian artery stenosis 1
• Record temperature, pulse rate, respiratory rate, and oxygen saturation 1, 2
• Calculate BMI by measuring height and weight 1, 3
• Assess orthostatic blood pressure changes (measure supine, then after standing 1-3 minutes) when evaluating dizziness, falls, or autonomic dysfunction 1

Clinical Pearl: Blood pressure should be measured with the arm resting at heart level using appropriately sized cuff—narrow cuffs overestimate and wide cuffs underestimate pressure 2

General Appearance Assessment

• Evaluate overall appearance, level of consciousness, and signs of acute distress 1
• Assess body habitus for wasting, obesity, or lipodystrophy 1
• Note gait and mobility if patient ambulates 1

Head and Neck Examination

Head

• Inspect for deformities, lesions, and symmetry 1
• Palpate skull for tenderness or masses 1

Eyes

• Test visual acuity using Snellen chart or near card 1, 3
• Assess pupillary response to light and accommodation 1
• Evaluate extraocular movements in all six cardinal directions 1
• Perform fundoscopic examination to visualize optic disc, vessels, macula, and retina 1, 3

Ears, Nose, Throat

• Inspect external auditory canals and tympanic membranes 3
• Examine nasal mucosa and septum 3
• Inspect oral cavity including teeth, gums, tongue, and pharynx 3

Neck

• Palpate thyroid gland for size, nodules, and tenderness 1
• Examine lymph nodes (cervical, supraclavicular, submandibular) for enlargement 1
• Assess jugular venous pressure 3
• Auscultate carotid arteries for bruits 3

Cardiovascular Examination

• Inspect chest for visible pulsations or deformities 3
• Palpate point of maximal impulse 3
• Auscultate heart in all four valve areas (aortic, pulmonic, tricuspid, mitral) for murmurs, gallops, or rubs 3
• Assess peripheral pulses: femoral, popliteal, dorsalis pedis, and posterior tibial 4, 1

Respiratory Examination

• Inspect chest wall movement and respiratory pattern 3
• Palpate for tactile fremitus 3
• Percuss lung fields 3
• Auscultate all lung fields for abnormal breath sounds (wheezes, crackles, rhonchi) 3

Abdominal Examination

• Inspect abdomen for distension, scars, or visible masses 3
• Auscultate bowel sounds in all four quadrants 3
• Palpate lightly then deeply for tenderness, masses, or organomegaly 1, 3
• Assess specifically for hepatomegaly and splenomegaly 1
• Percuss for ascites if indicated 3

Neurological Examination

Mental Status and Cognition

• Evaluate orientation to person, place, time, and situation 1, 3
• Assess memory, attention, and executive function 1, 3

Sensory Function

• Perform 10-g monofilament testing on plantar surfaces of feet (test at least 4 sites per foot including first toe and metatarsal heads) 4, 1
• Test pinprick or temperature sensation using disposable pin or tuning fork 4, 1
• Assess vibration using 128-Hz tuning fork on bony prominences (great toe, malleoli) 4, 1
• Evaluate proprioception at toes and fingers 3

Motor Function

• Test muscle strength in all major muscle groups using 0-5 scale 3
• Assess deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles) 3
• Evaluate ankle reflexes specifically as part of neuropathy screening 4

Coordination and Gait

• Observe gait pattern and balance 3
• Perform finger-to-nose and heel-to-shin testing 3

Vascular Assessment

• Palpate all peripheral pulses bilaterally and grade intensity 4, 1
• Assess capillary refill time (normal <2 seconds) 4, 1
• Check for rubor on dependency and pallor on elevation 4, 1
• Measure venous filling time 4, 1
• Refer patients with claudication symptoms or absent/decreased pedal pulses for ankle-brachial index 4

Comprehensive Skin and Foot Examination

Skin Assessment

• Perform systematic inspection of entire skin surface for lesions, ulcerations, rashes, or suspicious changes 1, 3
• Note color, texture, turgor, and temperature 1
• Pay particular attention to pressure points and dependent areas 1

Detailed Foot Examination (Annual Minimum for All Adults, Every Visit for High-Risk Patients)

Inspection: 4

• Examine skin integrity for ulcers, fissures, calluses, or corns
• Assess for foot deformities (bunions, hammertoes, Charcot changes)
• Check between toes for maceration or fungal infection
• Inspect nails for ingrown edges, thickening, or fungal changes

Neurological Testing: 4, 1

• 10-g monofilament test (as described above)
• Plus at least one additional test: pinprick, temperature, or vibration
• Absent monofilament sensation indicates loss of protective sensation

Vascular Assessment: 4, 1

• Palpate dorsalis pedis and posterior tibial pulses bilaterally
• Assess capillary refill, rubor on dependency, pallor on elevation
• Evaluate for hair loss, skin atrophy, or nail changes suggesting ischemia

Musculoskeletal Examination

• Inspect joints for swelling, erythema, or deformity 3
• Assess range of motion in major joints 3
• Palpate for tenderness or crepitus 3
• Evaluate spine alignment and mobility 3

Genitourinary Examination (When Indicated)

• Perform gender-appropriate examination based on symptoms and screening needs 3
• Document findings systematically 1

Documentation Requirements

• Record all findings systematically by body system 1
• Note both normal and abnormal findings 1
• Document specific measurements (vital signs, BMI, visual acuity) 1, 3
• Create problem list of active and chronic conditions 3

Patient Education Components

• Provide instruction on relevant self-examination techniques 1
• For diabetic or high-risk patients: teach daily foot inspection and proper footwear selection 4
• Educate on skin self-checks for suspicious lesions 1
• Discuss preventive care recommendations based on findings 3

Critical Pitfall: Many healthcare workers measure blood pressure incorrectly—ensure proper technique with appropriate cuff size, arm position at heart level, and patient seated quietly for 5 minutes before measurement 2