Head to Toe Exam
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Indicate wash hands and dons PPE as indicated prior to exams Introduces self as IDMT student Inspect head/hair/scalp Palpate head/hair/scalp
Verbalize step "Good morning I am Sgt/Airman ___, I am an IDMT student performing a physical exam for you today." "Normocephalic with even hair distribution; no masses or swelling." "Hair texture is normal without infestations; scalp has no scaling or lesions. Mastoid is nontender and without discoloration" "TMJ not tender and without swelling; no pain, popping, or locking with ROM" "CN V intact." "CN VII intact."
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Inspect, palpate, and perform ROM of TMJ (open, close, side to side, forward, back) CN V (clench teeth while palpating temporalis/masseter) CN VII (raise eyebrows, frown, close, eyes, and attempt to open with resistance; show teeth, smile, and puff out cheeks) Verbalize visual acuity Inspect eyes, brows, lashes, and lids Inspect conjunctiva and sclera Inspect and palpate lacrimal duct Evaluate visual fields by confrontation
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"Visual acuity checked" "No exophthalmos, ptosis, periorbital discoloration, edema, or skin lesions." "No injection, icterus, lesions, edema, or foreign bodies." "No swelling and no regurgitation." "Visual fields are full and equal to examiner."
Check extraocular movement and lid lad "EOMIs equal without nystagmus, no lid lag." Asses for pupillary reaction to convergence and accommodation (near/far) Evaluate position and alignment of eyes and cover/uncover "Eyes converge equally and pupils constrict with near focus." "No strabismus observed."
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Inspect iris and pupillary reaction to light "Pupils are equal, round, and reactive to light and (direct and consensual) accommodation bilaterally." Anterior chamber depth Inspect for red reflex "No crescent shadow." "Red reflex present."
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Inspect clarity of cornea, anterior chamber, lens, and vitreous Inspect optic disc Inspect retinal vessels
Indicate wash hands and dons PPE as indicated prior to exams Introduces self as IDMT student Inspect head/hair/scalp Palpate head/hair/scalp
Verbalize step "Good morning I am Sgt/Airman ___, I am an IDMT student performing a physical exam for you today." "Normocephalic with even hair distribution; no masses or swelling." "Hair texture is normal without infestations; scalp has no scaling or lesions. Mastoid is nontender and without discoloration" "TMJ not tender and without swelling; no pain, popping, or locking with ROM" "CN V intact." "CN VII intact."
5
Inspect, palpate, and perform ROM of TMJ (open, close, side to side, forward, back) CN V (clench teeth while palpating temporalis/masseter) CN VII (raise eyebrows, frown, close, eyes, and attempt to open with resistance; show teeth, smile, and puff out cheeks) Verbalize visual acuity Inspect eyes, brows, lashes, and lids Inspect conjunctiva and sclera Inspect and palpate lacrimal duct Evaluate visual fields by confrontation
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"Visual acuity checked" "No exophthalmos, ptosis, periorbital discoloration, edema, or skin lesions." "No injection, icterus, lesions, edema, or foreign bodies." "No swelling and no regurgitation." "Visual fields are full and equal to examiner."
Check extraocular movement and lid lad "EOMIs equal without nystagmus, no lid lag." Asses for pupillary reaction to convergence and accommodation (near/far) Evaluate position and alignment of eyes and cover/uncover "Eyes converge equally and pupils constrict with near focus." "No strabismus observed."
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Inspect iris and pupillary reaction to light "Pupils are equal, round, and reactive to light and (direct and consensual) accommodation bilaterally." Anterior chamber depth Inspect for red reflex "No crescent shadow." "Red reflex present."
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Inspect clarity of cornea, anterior chamber, lens, and vitreous Inspect optic disc Inspect retinal vessels