The medical Head-to-Toe assessment:
Just as the trauma patient should receive a rapid body survey, we should be performing a head-to-toe assessment on our medical patients as well. The key difference being that the RTS is designed to rapidly identify life threats, whereas the medical assessment is intended to assist in narrowing our differential diagnosis. As there is less of a time constraint in most medical scenarios, we are able to work through our assessment in a more thorough fashion. That being said, we will not always perform the entire medical assessment, and may choose to focus on areas that pertain directly to patient complaint. The following format allows for general understanding of the head-to-toe exam for medical patients.
Following the primary assessment, and the correction of life threats, the head-to-toe exam can be done concurrently with obtaining the patient history, or it can be performed afterward, depending on scene and patient variables. Allow yourself flexibility and don't feel that there has to be a rigid format here.
Head and Neck:
Pupils for equality and reactivity, as well as visual field test for nystagmus.
Face for symmetry, or evidence of droop.
Speech for slurring or unusual responses.
Neck for tenderness, stiffness, or palpable lymph nodes/masses.
Chest:
Auscultate for air entry, noting any adventitious sounds.
Observe for symmetrical chest expansion, noting any increased A-P diameter.
Look for Patches, Pacemaker, or Scars.
Ask about pain, or dyspnea.
Back:
Ask about any pain (NOPQRST).
Palpate for tenderness or deformity.
Note any medication patches, or surgical scars.
Abdomen:
Palpate for tenderness, masses, distension, or rigidity in all 4 quadrants.
Observe for pulsation, discolouration, asymmetry, or scars.
Ask about nausea, constipation, urinary and bowel habits.
Upper limbs:
Look for medical bracelets, scars, track marks, or trauma.
Assess grip strength and drift.
Test CSM
Lower limbs:
Assess for edema.
Test pedal strength.
Observe for ataxia.
Test CSM
As I said before; you may perform the entire exam, or focus on only the affected region/system. This is a flexible exam.
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