FINAL COMPREHENSIVE HEAD-TO-TOE
COMPREHENSIVE HEAD TO TOE I-HUMAN
LAURA WOOD CASE STUDY REAL ONE WEEK 9
LATEST 23RD JULY UPDATE
1: Physical Exam: #1 - ANSWER-General Survey: Documentation should contain a
statement regarding the patient's age, race, sex, orientation to time, place, person;
overall appearance, whether or not they are in distress; the examiner's opinion
regarding the patient's cognitive and emotional status.
1: Physical Exam: #2 - ANSWER-General appearance, skin, hands, fingernails,
toenails, color and pigmentation, temperature, moisture, texture and turgor are
deliberately examined.
1: Physical Exam: #3 - ANSWER-Upper and lower extremities are deliberately palpated
bilaterally using the dorsum of the hand.
2: Head and Face: #1 - ANSWER-Entire head, scalp and hair inspected. Hair should be
separated in at least three areas to assess scalp.
Entire head is deliberately palpated.
2: Head and Face: #2 - ANSWER-Palpate temporal arteries bilaterally
2: Head and Face: #3 - ANSWER-Maxillary and frontal sinuses are palpated (2pts)
2: Head and Face: #4 - ANSWER-Cranial nerve V (CN V) Palpate temporal and
masseter muscles while patient clenches teeth.
2: Head and Face: #5 - ANSWER-Palpate temporomandibular joint while patient
opens/closes mouth
, 2: Head and Face: #6 - ANSWER-CN V Observe and palpate temporomandibular joint
while patient
1) opening and closing jaw widely
2) moving side to side
3) sticking jaw out all maneuversWith and
Without against resistance of examiner's hand (3pts)
2: Head and Face: #7 - ANSWER-CN V Test for light touch on face with wisp of cotton,
comparing sides. Eyes should be closed. May do during neuro part of exam.
2: Head and Face: #8 - ANSWER-Cranial Nerve VII (CN VII) Observe presence and
symmetry of patient's facial muscle movements (7pts)
☐Close Eyes
☐Open Eyes Against Resistance
☐Frown
☐Lift Eye Brows
☐Puff Out Cheeks
☐Show Teeth
☐Smile
3: Eyes: #2 - ANSWER-External Structures of the Right and Left Eye are inspected and
verbalized (6pts)
☐Eyebrows
☐Lashes & Lids
☐Lacrimal Gland
☐Conjunctiva
☐Sclera
☐Cornea
3: Eyes: #3 - ANSWER-Anterior Chamber of the Eye Assessed from the side using pen
light (note corneal clarity/shape) ☐Right ☐Left
3: Eyes: #4 - ANSWER-Corneal Light Reflex - Hirschberg Test - (CN III, IV, VI) (does
light shine equally)
3: Eyes: #5 - ANSWER-Pupillary reflexes (CN III, IV, VI) direct/
consensual/accommodation (testing is performed 3x)
DIRECT Assess both eyes separately for pupillary reflexes
☐Right ☐Left
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