Head-to-Toe Physical Inspection (Clinical Examination)

General Appearance (Before Touching the Patient)

• Level of consciousness / alertness — awake, alert, oriented, confused, drowsy
• Apparent age vs. stated age — looking older may suggest chronic illness, substance use, or prolonged stress
• Body habitus — obese, cachectic, muscular, dysmorphic
• Nutritional status — wasting, temporal wasting, loss of subcutaneous fat
• Posture & positioning — tripod position (respiratory distress), guarding, inability to lie flat
• Gait (if ambulatory) — antalgic, ataxic, hemiplegic, parkinsonian
• Distress — pain, dyspnea, anxiety (none, mild, moderate, severe)
• Skin color globally — pallor, jaundice, cyanosis, flushing, bronzing
• Obvious deformities or asymmetries

Head

• Shape & symmetry — normocephalic, macrocephaly, microcephaly, bossing (frontal bossing in rickets/acromegaly)
• Hair — distribution, texture, alopecia (patchy vs. diffuse), hair loss patterns (androgenic, discoid lupus, tinea capitis)
• Scalp — erythema, scaling (psoriasis, seborrheic dermatitis), lesions, tenderness
• Face — symmetry, ptosis, facial palsy (CN VII), facies (moon face, coarse features of hypothyroidism, narrow face of myotonic dystrophy)

Eyes

• Eyelids — ptosis, lid lag, entropion, ectropion, xanthelasma (lipid deposits, associated with hyperlipidemia), periorbital edema
• Periorbital area — "raccoon eyes" (orbital ecchymosis — basal skull fracture), periorbital puffiness (nephrotic syndrome, hypothyroidism)
• Conjunctiva — pallor of palpebral conjunctiva (anemia), injection (conjunctivitis — individually visible vessels branching from sclera), ciliary injection (ring around cornea — suggests deeper inflammation: iritis, keratitis)
• Sclera — icterus (jaundice), blue sclera (osteogenesis imperfecta), episcleritis, pinguecula, pterygium
• Cornea — clarity (haze suggests corneal edema, glaucoma), arcus senilis (lipid ring — normal in elderly, significant <50 yrs)
• Pupils — size, equality (PERRL), shape (irregular in synechiae), Anisocoria, Horner syndrome, CN III palsy
• Iris — Kayser-Fleischer rings (Wilson's disease), heterochromia
• Eye position — exophthalmos/proptosis (Graves' disease, orbital tumor), enophthalmos, strabismus

Ears

• Auricle (pinna) — shape, tophi (urate crystals on helix — gout), lesions, Darwin's tubercle
• Pre/post-auricular area — lymphadenopathy, sinuses, skin tags
• External auditory canal — cerumen, discharge (otorrhea — otitis externa/media), foreign body
• Battle's sign — mastoid ecchymosis (basal skull fracture, appears 24–48 hrs post-injury)

Nose

• External — shape, deviation, saddle-nose deformity (syphilis, Wegener's/GPA, trauma), skin lesions
• Nares — flaring (respiratory distress, especially in infants), symmetry
• Nasal mucosa — color, edema (pale/boggy in allergic rhinitis, erythematous in viral), polyps, septal deviation, septal perforation (cocaine use, GPA)
• Discharge — clear (allergic/viral), purulent (bacterial sinusitis), bloody (epistaxis)

Mouth & Throat

• Lips — cyanosis (central, circumoral), angular cheilitis (iron/B-vitamin deficiency), herpes labialis, lip lesions
• Teeth & gums — dental caries, gingival hypertrophy (phenytoin, cyclosporine, nifedipine), gum pallor, lead line (Burton's line at gingival margin)
• Oral mucosa — ulcers (aphthous, Behçet's, SLE), leukoplakia, oral candidiasis (white plaques), Koplik's spots (measles — white spots on buccal mucosa)
• Tongue — macroglossia (hypothyroidism, acromegaly, amyloidosis), smooth/atrophic tongue (B12/iron deficiency), geographic tongue, fasciculations (LMN disease), deviation (CN XII palsy)
• Palate & uvula — petechiae on hard palate (strep, mononucleosis), high-arched palate (Marfan's), bifid uvula (submucous cleft palate)
• Pharynx & tonsils — erythema, exudate (bacterial tonsillitis), tonsillar enlargement (grade 1–4), posterior pharyngeal cobblestoning (post-nasal drip)

Neck

• Symmetry — torticollis, webbing (Turner syndrome)
• Lymph nodes — location, visible enlargement (cervical, supraclavicular — Virchow's node on left is classic for gastric/abdominal malignancy)
• Thyroid — visible goiter, asymmetry, midline position, moves with swallowing
• Trachea — midline vs. deviated (away from tension pneumothorax, toward collapse/fibrosis)
• Jugular veins — JVP elevation (heart failure, cardiac tamponade, SVC syndrome), visible pulsations
• Skin — acanthosis nigricans at posterior neck (insulin resistance), café-au-lait spots

Chest & Thorax

Inspection from Front and Back

• Shape — barrel chest (COPD — increased AP diameter), pectus excavatum (funnel chest), pectus carinatum (pigeon chest), kyphosis, scoliosis, kyphoscoliosis
• Symmetry — one side lagging behind (pleural effusion, pneumothorax, consolidation)
• Respiratory pattern:
  • Rate (normal 12–20/min), rhythm
  • Depth and effort
  • Accessory muscle use (sternocleidomastoid, scalenes) — moderate-to-severe obstruction
  • Intercostal / subcostal / supraclavicular retractions — increased work of breathing
  • Paradoxical breathing (abdomen moves inward on inspiration) — diaphragmatic paralysis or severe fatigue
  • Cheyne-Stokes, Kussmaul, Biot's respirations

Breast Inspection (Seated, Arms at Sides → Raised → Pressed on Hips)

• Contour & symmetry — dimpling, retraction, peau d'orange (skin edema with tethered follicles — inflammatory breast cancer)
• Nipples — inversion (new vs. longstanding), discharge, deviation, Paget's disease (eczematous nipple change)
• Skin — erythema, edema, ulceration, prominent veins

Cardiovascular (Precordium)

• Visible pulsations — apical impulse normally in 5th ICS, mid-clavicular line (displaced in cardiomegaly)
• Heaves / lifts — left parasternal heave (RV enlargement), visible forceful apical impulse (LV hypertrophy/volume overload)
• Visible venous distension on anterior chest wall — SVC obstruction

Abdomen

• Contour — flat, scaphoid (concave — malnourishment, dehydration), distended (the "6 Fs": Fat, Fluid, Flatus, Feces, Fetus, Fatal mass)
• Symmetry — visible masses, asymmetric distension
• Skin — striae (obesity, pregnancy, Cushing's — purple striae), caput medusae (dilated periumbilical veins — portal hypertension), spider angiomata, surgical scars
• Umbilicus — Cullen's sign (periumbilical bruising — retroperitoneal hemorrhage, pancreatitis), Sister Mary Joseph nodule (periumbilical metastasis)
• Visible peristalsis — normally absent; visible waves suggest intestinal obstruction or thin abdominal wall
• Flanks — Grey Turner's sign (flank bruising — retroperitoneal bleed, hemorrhagic pancreatitis)
• Aortic pulsations — may be visible in thin patients; prominent pulsation suggests abdominal aortic aneurysm

Genitourinary & Inguinal Region

• Inguinal area — visible hernias (ask patient to cough/strain), lymphadenopathy, skin changes
• External genitalia — inspection varies by sex; assess for lesions, discharge, masses, asymmetry
• Perineum — fissures, fistulas, hemorrhoids, skin tags

Musculoskeletal: Spine & Back

• Alignment — scoliosis (lateral curvature; Adams forward bend test), kyphosis, lordosis, flat back
• Skin over spine — tuft of hair or dimple at lumbosacral region (spina bifida occulta)
• Paravertebral muscles — asymmetric prominence in scoliosis; costovertebral angle fullness (renal pathology)

Upper Extremities

• Skin — lesions, pigmentation, track marks (IV drug use), purpura, petechiae
• Nails — clubbing (chronic hypoxia, IBD, cirrhosis, infective endocarditis), koilonychia (iron deficiency), leukonychia, half-and-half nails (renal failure), Beau's lines (systemic illness), splinter hemorrhages (endocarditis, vasculitis), pitting (psoriasis), onycholysis
• Hands — Dupuytren's contracture, thenar/hypothenar wasting, joint deformities (swan neck, boutonniere — RA; Heberden's/Bouchard's nodes — OA), Janeway lesions (macular, non-tender — infective endocarditis), Osler's nodes (tender — endocarditis)
• Palmar erythema — cirrhosis, pregnancy, RA
• Wrists, elbows — rheumatoid nodules (extensor surface), psoriatic plaques, olecranon bursitis
• Arms — muscle bulk, fasciculations, skin lesions, edema

Lower Extremities

• General — symmetry, muscle wasting, limb length discrepancy
• Skin — erythema (cellulitis), venous stasis changes (lipodermatosclerosis, brownish hemosiderin deposits, varicose eczema), ulcers (venous — irregular, above medial malleolus; arterial — punched-out, over pressure points; neuropathic — plantar surface, painless)
• Varicose veins — tortuous, visible dilated superficial veins
• Edema — distribution (bilateral = systemic; unilateral = local — DVT, lymphedema), pitting vs. non-pitting
• Joints — knee effusion (loss of normal dimples alongside patella), deformity (varus/valgus)
• Feet & toes — clubbing, cyanosis, nail changes, hallux valgus, Charcot joint

Neurological (Inspection Component)

• Facial symmetry at rest and with expression (CN VII)
• Ptosis (CN III, Horner's)
• Muscle bulk — generalized vs. focal wasting, fasciculations (LMN or motor neuron disease)
• Involuntary movements — tremor (rest vs. intention vs. postural), chorea, athetosis, myoclonus, tics, dystonia
• Posture — hemiplegic posture, decorticate/decerebrate posturing
• Gait — (observed during ambulation) hemiplegic, steppage, waddling, scissor, ataxic, shuffling (Parkinson's), high-stepping

Skin (Throughout)

• Lesions — primary (macule, papule, plaque, vesicle, bulla, pustule, nodule, wheal) vs. secondary (scale, crust, erosion, ulcer, lichenification, scar, excoriation)
• Distribution — sun-exposed, flexural, extensor, dermatomal
• Color changes — pallor, jaundice (scleral icterus first), cyanosis (central vs. peripheral), bronze (hemochromatosis), hyperpigmentation (Addison's — buccal mucosa, palmar creases), vitiligo

Key Principles to Remember