Download Inspect

Health Assessment
Head, Eyes, Ears, Nose,
Mouth, & Neck
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
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.
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.

Palpate
TMJ
– In groove in front of ears

ROM
– 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.
Anatomy
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

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?
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
RN Chart Symptoms
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Burning
Discharge
Discomfort
Dryness
Ecchymosis
Edema
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Itching
Pressure
Redness
Sclera hemorrhage
Stye
Tearing
Visual field loss
Vision Exam CN II

……….
Snellen Chart
– 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
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.
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.
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.
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.
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.
Inspection

Pupils
– Size, shape and symmetry
• 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.
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)
Inspection

Cornea and lens
– Inspect for opacities (cataracts)
• with oblique lighting
Smooth without opacities.
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
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.
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
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.
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
Ophthalmoscopic Exam

Vessels
– 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.
Ear Anatomy
Anatomy
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

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
The Aging Adult
– 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.
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
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.
Examining the Ear Canal and Drum

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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
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.
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.
Abnormal TM

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.
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
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
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)?
Nose and Paranasal Sinuses

Allergic Rhinitis
– Itching
– Swelling
– Rhinorrhea
– Sneezing
– Tearing eyes
– Later- stuffy nose, coughing, decreased
smell, sore throat, dark circles under eyes
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.
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.
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
Mouth and Pharynx

ROS
– Sore throat
– Sore tongue
– Bleeding from the gums
– Tooth pain
– Hoarseness
Mouth and Pharynx

Inspect lips
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–
–
–
–
–
–
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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.
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.
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.
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.
Neck

ROS
– Neck pain?
– Lumps or swelling?
– History of neck surgery?
– History of neck trauma?
Neck Inspection & Palpation
 Inspect
for:
Head position
Neck muscle symmetry
Masses or scars
Abnormal pulsations
Neck supple & symmetrical
Without masses, scars, or
abnormal pulsations
Trachea

Inspect
 Should be midline

Palpate
 For tracheal shift
• Place finger in sternal
notch and slip to each
side.
Trachea midline.
Cervical Lymph Nodes

Palpate the lymph nodes

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
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.
Thyroid Gland
 Inspect
first then
palpate
 Assess for:
Enlargement
• Goiter
Consistency
Symmetry
Nodules
Movement
Thyroid nonpalpable