1. Head, Eyes, Ears, Nose, Mouth, & Neck
Health Assessment
Head, Eyes, Ears, Nose, Mouth, & Neck

2. ROS: Head Recent head trauma? Loss of consciousness? Headaches?
Sinus, migraine, neurological
Use of helmet when appropriate?
Occupation, contact sports or cycling, rollerblading, and skateboarding

3. Face Inspection Inspect the face for: Facial expressions Symmetry
Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth.
Facial expressions appropriate to situation. Face symmetrical without drooping or involuntary movements.

4. Skull Inspection/Palpation
Normocephalic-round, symmetric skull that is appropriately related to body size
Cranial bones with normal protrusions: forehead, lateral angle of parietal bone, occipital bones, mastoid process
Palpate for masses or nodules
Assess infant sutures for bulging or depressed/sunken appearance
Normocephalic without masses, lesions, or tenderness.

5. TMJ Palpate ROM Muscle Strength In groove in front of ears
Open and close
Protrusion and retraction
Lateral side-to-side motion
Muscle Strength
Bite down while palpating the masseter muscles
Clench teeth while placing downward pressure on the chin
TMJ with full ROM and 5/5 muscle strength. No popping, clicking, or tenderness noted.

6. Anatomy

8. Basics of Vision Light reflected from image
Light passess through pupil and cornea bends incoming light rays so they will be focus on the inner retina
Retina with sensory neurons
Nerve impulses sent through optic disc

9. ROS: Eyes Any visual or eye complaints?
Pain, photophobia, burning, itching, excess tearing or crusting, diplopia, blurred vision, “curtain over eye,” floaters, flashing lights, or halos
Any personal or family history of eye disease?
Glaucoma, retinopathy, cataracts, macular degeneration (Box 33-13)
Closed angle (acute) is ocular emergency
sudden ocular pain, halos, red eye, very high pressure in eye, n/v, decreased vision, fixed mid-dilated pupil
Any history of eye trauma, diabetes, hypertension, or eye surgery?

10. ROS: Eyes Wear glasses or contacts?
When was last exam by ophthalmologist or optometrist?
<40 y/o every 3-5 years
>40 y/o every 2 years
>65 y/o, presence of eye disorder, or at risk for eye disease annually or more often if indicated
Use of eye protection when appropriate
Use of chemicals, welding, sawing, fencing, motorcycling

11. RN Chart Symptoms Burning Discharge Discomfort Dryness Ecchymosis
Edema
Itching
Pressure
Redness
Sclera hemorrhage
Stye
Tearing
Visual field loss

12. Vision Exam CN II ………. Snellen Chart Abnormal vision: Normal 20/20
Abnormal 20/30 or above
Legally blind 20/200 with correction
Abnormal vision:
Hyperopia: farsighted
Myopia: nearsighted
Presbiopia: inability to accommodate due to weak ciliary muscles, and inability to bulge with near vision (leads to hyperopia)
Diplopia: double vision due to weakness of extraocular muscles
Vision by Snellen chart: O.D. 20/20, O.S. 20/30, O.U. 20/20

13. Confrontation tests/Peripheral Visual Fields
Gross measure of a patient’s peripheral vision compared to that of your own
Have your patient look at you in the eyes 2 ft away
Move your fingers into the vision field and have the patient state “now” when they can see your fingers.
Normal=when you can see your own fingers at the same time that the patient does
If you find a defect, test each eye separate and establish the boundaries.
Enlarged blind spots occur in glaucoma, optic neuritis and papilledema
Peripheral visual fields intact by confrontation test.

14. Extraocular Muscles Six muscles attaching eyeball to orbit
Extraocular muscles are stimulated by three cranial nerves
CN VI (abducens) innervates the lateral rectus muscle (abducts the eye)
CN IV (trochlear) innervated the superior oblique muscles (moves eye down and in)
CN III (oculomotor) innervates all the rest: superior, inferior, medial rectus and the inferior oblique muscles.

15. Extraocular Muscles
Extraocular Muscle function: test function of each muscle by asking the patient to move eyes (keep head still) through six cardinal positions of gaze.
Normal: Eyes parallel without nystagmus.
EOMs intact without nystagmus or lid lag.

16. Inspection Position and alignment of the eyes
Abnormal protrusion in Graves’ disease,
orbital tumors or inflammation
Crossing of eyes (strabismus) with neuromuscular injury or inherited abnormalities
Eyes without protrusion or sunken appearance.
Eyebrows: quantity and distribution and scaliness of underlying skin
Sparseness noted in hypothyroidism or elderly
Eyebrows present bilaterally and move symmetrically. No scaling or lesions.
Eyelids: Inspect
Width of palpebral fissures, ptosis, edema of the lids, color of the lids, lesions, condition and direction of eyelashes, adequacy of eye closure
Eyelids intact without redness, swelling, dc, or lesions.Eyelashes evenly distributed and curve outward.

17. Inspection Lacrimal apparatus:
Inspect lacrimal gland and sac for redness & swelling
Assess for excessive tearing or dryness
No swelling of lacrimal apparateus noted. Puncta patent, without erythema, or tenderness.
Conjunctiva and sclera: depress both lower lids with your thumbs, exposing the sclera and conjunctiva, ask the patient to look up/down and side/side to get a good view
Assess color, vascular patterns, nodules or swelling.
Conjunctiva clear, sclera white. No lesions or foreign bodies noted.

20. Inspection Pupils Size, shape and symmetry Pupillary reaction to light
If pupils are large, small or unequal, measure them
Pupillary reaction to light
In a darkened room, have a patient look into the distance
Shine a bright light obliquely into each pupil
Direct reaction: pupillary constriction in the same eye
Consensual reaction: pupillary constriction of the opposite eye
PERRLA (only if perform accommodation). Pupils R 4/2 = L 4/2.

21. Pupils
Accommodation: convergence of eyes, constriction of pupil as patient shifts gaze from a distance to a near object
Documentation: PERRLA (Pupils Equal Round, Reactive to Light & Accommodating)

22. Inspection Cornea and lens Inspect for opacities (cataracts)
with oblique lighting
Smooth without opacities.

23. Ophthalmoscopic Exam Getting Started Start at the “0” diopters
Use large, round beam of light
Use your right hand and right eye for patient’s right eye, and your left eye for patient’s left eye
Get close
Darken room
Have patient gaze at a distant object

24. Light Reflex
Stand 15 inches away from the patient and off to the side of the patient, shine the light beam on the pupil and look for the orange glow in the pupil. Normally: light reflex. Abnormal: absent light reflex (may be due to opacity of the lens, i.e. cataract)
Red reflex present bilaterally.

25. Examining the Optic Disc and Retina
First, locate the optic disc (you can follow a blood vessel centrally to find it)
Focus by adjusting the lens of your ophthalmoscope
If the patient is nearsighted (myopic), rotate the lens disc counterclockwise to the minus diopters
If the patient is farsighted (hyperopic), move the disc clockwise to the plus diopters
You can correct your own refractive error in the same way

26. Ophthalmoscopic Exam Inspect for: General background of fundus
Color, lesions
Fundus red without lesions
Optic Disc
Sharpness or clarity of the disc outline
Color of the disc, normally yellowish orange to creamy pink
Size of the central physiologic cup (if present), usually yellowish white. The horizontal diameter is usually less than half the horizontal diameter of the disc.
Normal Optic disc findings
1.5mm in size, round
Margins sharp
Demarcated from retina
Optic disc creamy yellow, round, with sharply demarcated margins.

27. Abnormal Optic Disc
Papilledema: swelling of the optic disc and anterior bulging of the physiologic cup. Related from increased intracranial pressure
May be related to meningitis, trauma, mass, lesions

28. Ophthalmoscopic Exam Vessels Macula Arterioles brighter than veins,
25% smaller
A:V ratio 2:3
Arterioles and veins cross each other without changing in diameter
Observed vessels were without nicking. AV ratio 2:3
Macula
Located 2 DD temporal to disc
Color even and darker than rest of fundus
May see fovea light reflex
Macular dark red, even, and homogenous.

29. Ear Anatomy

30. Anatomy

31. Physiology Sound waves strike the tympanic membrane
Vibrations transmit through the auditory ossicles (malleus, incus, stapes) to oval window
Vibrations travel to cochlea and then to the round window
CN VIII (acoustic)
Nerve sends message to brain

32. The Aging Adult Decreased hearing because: Presbycusis
Gradual sensorineural hearing loss caused by nerve degeneration in inner ear or auditory nerve
Onset around 50 years old
First notices a high-frequency tone loss
Harder to hear consonants than vowels
Words sound garbled
Accentuated by background noise
Music, dishes clattering, large party noise

33. The Aging Adult Auditory reaction time increases after age 70.
Cilia lining the ear canal becomes coarse and stiff
Decreased hearing as impedes sound waves
Causes cerumen to accumulate and oxidize
Cerumen drier due to atrophy of apocrine gland
Auditory reaction time increases after age 70.
Takes longer for the older adult to process sensory input and respond to it.

34. ROS: Ear How is your hearing?
Use of hearing aid?
Taking ototoxic drugs?
Have you had any trouble with your ears or balance?
Are you having any vertigo? (feeling as if the room is spinning, different from dizzy)
Are you having any tinnitus? (musical ringing in the ear)
Does anyone smoke in your household?
Increased risk of otitis media in children

35. Inspection and Palpation
Outer Ear: Auricles (pinna)
Helix should be in a line extending from the eye the occipital area
Symmetrical
No masses, lesions, or tenderness
Manipulate the pinna & tragus to assess for external otitis
Ears equal bilaterally. No
Swelling or thickening of
cartilage. Skin intact without
massess or lesions.
No tenderness noted.

36. Examining the Ear Canal and Drum
Use an otoscope with the largest ear speculum that the canal will accommodate
Position the patient’s head so that you can see through the scope
Straighten the ear canal be grasping the auricle firmly and pull it upward, backward and slightly away from the head
Brace your hand against the patient’s face
Insert the speculum gently into the ear canal, directing it somewhat down and forward

37. Examining the Ear Canal and Drum
Inspect the ear canal
Discharge, foreign bodies, redness of the skin and swelling
Cerumen (wax) can be yellow to brown, soft or hard, may obscure your view
External canal without erythema, edema, foreign bodies, lesions, or dc.

38. Inspect the Eardrum Identify the handle of the malleus
Identify the short process of the malleus
Inspect the pars flaccida and Pars tensa
Normal
Shiny, transparent, pearly gray, slight concave, non-bulging, no perforation
TM gray and intact bilaterally
without erythema, bulging,
or retraction.

39. Abnormal TM

40. Auditory Acuity Estimating Hearing Occlude one ear of your patient
Stand 1-2 feet behind patient
Whisper a word (i.e. 88)
Repeat with other ear
Gross hearing intact by whisper test.

41. Auditory Acuity Weber Test
Tap against palm and place midline vertex of head
Normal: Hears equally in both ears
Conductive hearing loss- best in impaired ear
Sensorineural hearing loss- only in normal ear

42. Auditory Acuity Rinne Test
Tap against palm and place on mastoid process. When no longer hears place 1-2 cm from ear until no longer hears
Normal: AC>BC (2:1 ratio)
Conductive hearing loss- BC=AC or BC>AC
Sensorineural hearing loss- heard longer thru air, but less than 2:1 ratio

43. Nose and Paranasal Sinuses
ROS
Nasal congestion or runny nose (rhinorrhea)?
Sneezing?
Medications that may cause stuffiness?
Pain, tenderness in the face over the sinuses?
Is the pain limited to one side?
Trauma or bleeding from the nose (epistaxis)?

44. Nose and Paranasal Sinuses
Allergic Rhinitis
Itching
Swelling
Rhinorrhea
Sneezing
Tearing eyes
Later- stuffy nose, coughing, decreased smell, sore throat, dark circles under eyes

45. Nose and Sinuses
Inspect the anterior and inferior surfaces of the nose
Note any asymmetry or deformity
Inspect for discharge
Test patency
Press on each nostril one at a time and have the patient breath in
Palpate for any masses, lesions or tenderness
Nose symmetrical midline. No deformities or skin lesions. Nares patent bilaterally.

46. Nose and Sinuses ……… Inspect the inside of the nose
Inspect vestibule, septum and turbinates
Color of nasal mucosa
Foreign body
Discharge (note color: clear, yellow, green, bloody)
Masses, lesions, polyps
Septum: deviation, perforation, bleeding
Turbinates: color, swelling, exudate, polyps
Normally no swelling, mucoid drainage; redder than oral mucosa
Septum without deviation, perforation, or bleeding. Turbinates pink, without dc, edema, exudate, or polyp.

47. Nose and Sinuses Palpate for sinus tenderness
Press up on the frontal sinuses from under the bony brows (avoid pressure on the eyes)
Press up on the maxillary sinuses
Normal: pt will feel pressure but no pain with palpation
Frontal and maxillary
sinuses nontender
to palpation

48. Mouth and Pharynx ROS Sore throat Sore tongue Bleeding from the gums
Tooth pain
Hoarseness

49. Mouth and Pharynx Inspect lips Inspect oral mucosa (inside of mouth)
Color
Moisture
Lumps
Ulcers
Cracking
Symmetry
Swelling (edema)
Inspect oral mucosa (inside of mouth)
With good light and a tongue blade, inspect for color, ulcers, white patches, and nodules.
Lips pink and moist without cracking or lesions. Buccal mucosa pink without nodules or lesions.

50. Mouth and Pharynx Teeth/Gums
Inspect for missing teeth, caries, conditions, discoloration
Note the color of the gums
Normal
Pink
Margins without swelling
No bleeding
Teeth white, straight, evenly spaced, clean and free of decay. Gums pink without swelling or bleeding.

51. Mouth and Pharynx Tongue Ask the patient to stick out his tongue
Inspect for symmetry (CN XII)
Note the color and texture of the dorsum of the tongue
Deep fissures with dry mucosa could indicate dehydration
Inspect the sides and undersurface of the tongue
Inspect the floor of the mouth (these are the areas where cancer most often develops)
Note any white or reddened areas, nodules, or ulcerations.
Tongue pink, moist, without lesions.

52. Mouth and Pharynx … Pharynx
With the patient’s mouth open, have the patient say “ah”
As the patient says “ah” check the rise of the soft palate (CN X)
Gag reflex (CN IX , X)
If needed press a tongue blade firmly down upon the midpoint of the arched tongue
Inspect the soft palate, anterior and posterior pillars, uvula, tonsils and pharynx
Note color, swelling, ulceration
Tonsillar enlargement
Exudate
Breath odor (halitosis)
Soft palpate pink, rises midline. Tonsils pink without enlargement or exudate. Pharyngeal wall pink without exudate or lesions. No halitosis noted.

54. Neck ROS Neck pain? Lumps or swelling? History of neck surgery?
History of neck trauma?

55. Neck Inspection & Palpation
Inspect for:
Head position
Neck muscle symmetry
Masses or scars
Abnormal pulsations
Neck supple & symmetrical
Without masses, scars, or abnormal pulsations

56. Trachea Inspect Palpate Should be midline For tracheal shift
Place finger in sternal notch and slip to each side.
Trachea midline.

57. Cervical Lymph Nodes Palpate the lymph nodes Preauricular
Use the pads of your index and middle fingers with a gentle rotary motion.
Preauricular
Posterior auricular
Occipital
Tonsilar
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical chain
supraclavicular

58. Cervical Lymph Nodes
Note location, size, shape, delimitation, mobility, consistency and tenderness.
Lymph nodes normally nonpalpable in healthy adults
Small, soft, mobile, discrete, non-tender nodes (shotty) may be found in normal persons.
Enlarged (>1cm) firm, tender, and freely moveable often indicates infection.
Hard, non-tender, and fixed often indicates malignancy.
Enlarged supraclavicular node, especially on left, suggests possible metastasis from thorax or abdomen
No lymphadenopathy noted or lymph nodes nonpalpable.

59. Thyroid Gland Inspect first then palpate Assess for: Enlargement
Goiter
Consistency
Symmetry
Nodules
Movement
Thyroid nonpalpable