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 expressionsSymmetry

• 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

appearanceNormocephalic without masses, lesions, or tenderness.

TMJ Palpate

– 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

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

Basics of Vision

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

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

Burning Discharge Discomfort Dryness Ecchymosis Edema

Itching Pressure Redness Sclera hemorrhage Stye Tearing Visual field loss

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

Vision Exam CN II ……….

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.

Confrontation tests/Peripheral Visual Fields

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.

Extraocular Muscles

Position and alignment of the eyes– Abnormal protrusion in Graves’ disease,

orbital tumors or inflammation– Crossing of eyes (strabismus) with neuromuscular injury or

inherited abnormalitiesEyes without protrusion or sunken appearance.

Eyebrows: quantity and distribution and scaliness of underlying skin– Sparseness noted in hypothyroidism or elderlyEyebrows 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 eyePERRLA (only if perform accommodation). Pupils R 4/2 = L 4/2.

Inspection

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)

Pupils

Cornea and lens– Inspect for opacities (cataracts)

• with oblique lighting

Smooth without opacities.

Inspection

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

Ophthalmoscopic Exam

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.

Light Reflex

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

Examining the Optic Disc and Retina

Inspect for:– General background of fundus

• Color, lesionsFundus 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 retinaOptic disc creamy yellow, round, with sharply demarcated

margins.

Ophthalmoscopic Exam

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

Abnormal Optic Disc

Vessels– Arterioles brighter than veins,

25% smaller– A:V ratio 2:3– Arterioles and veins cross each other without

changing in diameterObserved 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 reflexMacular dark red, even, and homogenous.

Ophthalmoscopic Exam

Ear Anatomy

Anatomy

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

Physiology

The Aging Adult

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.

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

ROS: Ear

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.

Inspection and Palpation

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.

Examining the Ear Canal and Drum

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.

Inspect the Eardrum

Abnormal TM

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

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

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

Nose and Paranasal Sinuses

Allergic Rhinitis– Itching– Swelling– Rhinorrhea– Sneezing– Tearing eyes

– Later- stuffy nose, coughing, decreased smell, sore throat, dark circles under eyes

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 tendernessNose 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, polypsNormally no swelling, mucoid drainage; redder than

oral mucosaSeptum 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

Nose and Sinuses

ROS– Sore throat– Sore tongue– Bleeding from the gums– Tooth pain– Hoarseness

Mouth and Pharynx

Inspect lips– 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 bleedingTeeth 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.

Mouth and Pharynx …

Neck

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

Neck Inspection & Palpation

Inspect for:Head positionNeck muscle symmetryMasses or scarsAbnormal pulsations

Neck supple & symmetricalWithout masses, scars, or

abnormal pulsations

Trachea

InspectShould be midline

PalpateFor tracheal shift

• Place finger in sternal notch and slip to each side.

Trachea midline.

Cervical Lymph Nodes

Palpate the lymph nodes Use the pads of your index and middle

fingers with a gentle rotary motion.

1. Preauricular2. Posterior auricular3. Occipital4. Tonsilar5. Submandibular6. Submental7. Superficial cervical8. Posterior cervical9. Deep cervical chain10. 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 SymmetryNodulesMovementThyroid nonpalpable