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Adventist University of the Philippines

College of Nursing
MNHA 510 – Advanced Physical Assessment

Head/Neck, Eyes, Ears, Nose and Throat

Equipments: a tape measure, stethoscope, cup of water, transilluminator, a Snellen chart,
Rosenbaum chart, penlight, cotton wisp, ophthalmoscope, eye cover, otoscope, nasal speculum,
tongue blades, tuning fork, gauze, gloves, and vials with different odors.

Physical Examination Findings

Inspection of the Head, Face and Neck
Head/Face: Head position is in the midline.
First, observe the head position

Second, inspect the skull for size, shape, and
symmetry.
Third, examine the scalp by systematically parting the
hair from the frontal to the occipital region. Note any
lesions, tenderness, parasites, nits, scaliness, or hair
loss pattern.
Normocephalic, a round symmetric
skull appropriate with the body size.
Skull is smooth.
The scalp was clean and free of any
lesions or pest inhabitants. Noted with
moderate seborrhea (dandruff).

Fourth, inspect the facial features, noting shape and
symmetry at rest and with movement and expression.
Watch for tics.
Fifth, inspect the frontal and maxillary sinuses.
*Note: If a sinus infection is suspected,
transilluminate the maxillary and frontal sinuses in a
darkened room.
No involuntary movements upon rest.
No abnormalities on face such as coarse
facial features, exophthalmos, changes
in skin color or pigmentation. No
abnormal swelling.
No signs of sinus infection.

Neck: Observed bilateral symmetry of the

First, observe for bilateral symmetry of the sternocleidomastoid and trapezius
sternocleidomastoid and trapezius muscles. muscles.

Second, check for alignment of the trachea. Trachea is in midline.

Third, observe the landmarks of the anterior and Seen and observed.
posterior triangles.

Fourth, note any fullness at the base of the neck. Negative fullness at the back of the
neck.
Fifth, look for such abnormalities as masses, webbing, No abnormalities found and noted.
excess skinfolds, unusual shortness, or asymmetry.
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Physical Examination Findings

Sixth, observe for jugular vein distention and carotid None noted and observed.
artery prominence. *Note: JVD measurement will be
reviewed during the CV lab.

Seventh, evaluate range of motion by having the Upon movement all motion is smooth
patient flex, extend, rotate, and laterally turn the head and controlled.
and neck.

Eighth, test muscle strength by placing one hand on
the cheek and jaw and asking the patient to turn
toward your hand while you apply resistance. Also
have the patient shrug the shoulders while you apply
resistance.
Muscle strength was strong even with
resistance applied on the check, jaw,
and shoulders.

Palpation of the Head, Face and Neck

Head/Face: The skull feels symmetric and smooth.
First, gently and systematically palpate the skull from There is no tenderness to palpation.
front to back.

Second, palpate the hair, noting its texture, color, and
distribution.
Third, assess the temporal arteries for ant thickening,
hardness, or tenderness. *Note: This is especially
important in the older adult population.
The scalp was clean and free of any
lesions or pest inhabitants. Hair was
distributed evenly to all parts of the
head. Hair color was black. Scalp hair
texture was fine, straight, and shiny.
No ant thickening, hardness, or
tenderness noted and palpated.

Fourth, palpate the frontal sinuses by pressing your No sinus pain noted. Nose is patent
thumbs up under the bones on each side of the nose. with good airflow.
Palpate the maxillary sinuses by pressing up under the
zygomatic processes.

Fifth, palpate both temporomandibular joint spaces to No pain, crepitus, locking or popping
detect pain, crepitus, locking, or popping. detected.

Sixth, if the salivary glands appear asymmetrical or The salivary glands is soft and mobile.
enlarged, palpate to determine the discreteness, No tenderness noted upon palpation.
mobility, texture, and tenderness of the enlargement.
With the patient’s mouth open, press on the gland to
try to express material through the salivary duct.

Neck:
First, palpate the trachea by placing a thumb along
each side of the trachea and comparing the space
between it and the stenorcleidomastoid muscles.
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Physical Examination Findings

Second, palpate the thyroid gland while in front of ----
or behind ---- the patient. With either approach, use
the following two examination tips:

-Flex the patient’s head hold slightly forward and -Noted relaxation of the neck muscles
toward the side being examined. on the right side. Thyroid gland was
soft, smooth, symmetrical, and non-
-Have the patient hold a sip of water in the mouth until tender, and slides upward slightly when
your hands are in place and you tell the patient to swallowing.
swallow.

For the approach from behind, stand behind the

patient who is seated in a chair. Then follow the
following four steps:

-Place two fingers of each hand on the sides of the

trachea just beneath the cricoid cartilage.

-Feel for the isthmus of the gland as the patient

swallows.

-Palpate the left lobe by displacing the trachea to the

left with your right fingers and placing the first three
fingers of your left hand medial to the left
sternocleidomastoid muscle. When the patient
swallows, feel for the gland to move.

-Palpate the right lobe by moving your hands to the

opposite corresponding positions.

Palpate the thyroid gland’s size, shape, configuration,

and consistency and note any tenderness or nodules.

Third, feel for the hyoid bone and the thyroid and Hyoid bone, thyroid and cricoid was
cricoid cartilages. palpated.

Fourth, check for a tracheal tug. With the patient’s No tracheal tug noted or detected.
neck extended, place your index finger and thumb on
each side of the trachea below the thyroid isthmus.

Fifth, inspect and palpate the lymph nodes of the head No lymph nodes palpated.
and neck (occipital, postauricular, preauricular, parotid
and retropharyngeal nodes, submandibular, submental,
superficial cervical, posterior cervical, deep cervical
and supraclavicular areas).

Auscultation of the Head and Neck

First, auscultate the temporal arteries. * Note: This is No anomaly suspected
not routinely performed unless an anomaly is
suspected.
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Second, auscultate the carotid arteries. * Note: This Pulse was heard. But no bruit sounds
will be discussed further in the CV lab. noted.

Vision assessment
To test distance vision, have the patient cover one eye No squinting, hesitancy, leaning
and read the smallest line on the Snellen chart in forward, or misreading of letters noted.
which he or she can identify all the letters. Then have With 20/20 visual acuity.
the patient cover the other eye and read the line from
right to left. Then have the patient read the smallest
line on the Snellen chart with both eyes. Record the
visual acuity for both eyes, the right eye and the left
eye.

To test near vision, have the patient hold the near- Can read without hesitancy and without
vision screener card about 35 centimeters from the moving the card closer or farther away.
eyes and read the smallest line possible. Record the
visual acuity designated by that line.

To test peripheral vision, use the confrontation test. The patient can see the same time I can
While positioned about 1 meter away at eye level, see it.
have the patient cover the right eye while you cover
your left. Look at each other. Move your wiggling
fingers into the center from the side. Have the patient
say when the fingers are first seen. Both of you should
see them at the same time. Test the nasal, temporal,
superior, and inferior fields.

External Inspection of the Eye

First assess the two major surrounding structures.
-Inspect the eyebrows for size, extension - Eyebrows are present
beyond the eye, and hair texture. bilaterally. It moves
symmetrical as the facial
expression changes.
-Inspect the orbital area for edema, lesions, - No edema, lesions, puffiness, or
puffiness and sagging tissue below the sagging tissue noted on the
orbit orbital area.

Second, examine the eyelids for the following:

- Inspect the lightly closed eyelids for - No tremors or fasciculations
fasciculation’s or tremors. noted.

- Observe the ability to open the lids wide and - Can open the lids wide and
close them completely. close the completely.

- Check the eyelid margins for flakiness, - No flakiness, redness, or

redness, and swelling. swelling on the eyelid margins.

- Look for the eyelashes to curve away from the - The eyelashes are evenly
globe. distributed along the lid margins
and curve outward.

- Note the upper eyelid position with the eyes
open.
- Note eyelid eversion or inversion.
- Observe for a stye or crusting.
- Note whether the eyelids meet completely and
cover the globe when the eyes are closed.
- Palpate the eyelids for nodules.
Third, inspect the conjunctivae and note appearance.
- To assess the lower conjunctiva, have the
patient look up while you pull down the lower
lid.
- To assess the lower conjunctiva, have the
patient look down while you pull the eyelashes
down and forward. Evert the lid on a cotton-
tipped applicator.
Internal Inspection of the Eyes
First, examine the cornea in two ways:
- Check the cornea for clarity by shining a light
tangentially on it.
- Check corneal sensitivity by touching a cotton
wisp to the cornea.
Second, assess the iris and pupil, noting five
characteristics.
- Inspect the iris, which should be clearly
visible.
- Observe the pupils’ size and shape.
- Test the pupils’ response to light directly and
consensually.
- Perform the swinging flashlight test. Shine the
light in one eye and then rapidly swing it to the
other eye.
- Test for accommodation. After looking at a
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- Upper lids overlaps superior
part or the iris, and approximate
completely when closed.
- No eversion or inversion noted.
- No stye was present.
- Eyelids met completely and
cover the globe when the eyes
are closed.
- No nodules noted.
- The eyeball looks moist and
glossy.
- Conjunctiva are clear and with
normal color (pink over the
lower lids and white over the
sclera).
- No color change, swelling, or
lesions noted.
- No cloudiness in the cornea
noted.
- Haven’t done this.
- Iris is clearly visible. Round,
and even coloration.
- Pupil’s size are equal size.
- Constriction of the pupil on the
same side (a direct light reflex),
and simultaneous constriction of
the other pupil.
- Haven’t done this.
- Pupillary constriction noted.
- Convergence of the axes of the
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distant object and then focusing on an object eyes.

10 centimeters from the nose, the pupils should
constrict.

Third, observe the sclera. - Haven’t done this.

Fourth, inspect the lens. - Haven’t done this.

Fifth, inspect and palpate the lacrimal apparatus. - No tenderness upon palpation.

Sixth, test extraocular movements:

To evaluate eye movement, use three techniques.
- Have the patient watch your finger move
through the six cardinal fields of gaze. - Parallel tracking of the object
with both eyes noted.
- Have the patient follow your finger vertically - The globes and upper lids
from the ceiling to the floor. moved smoothly, without lid lag
The globes and upper lids should move or exposure of the sclera.
smoothly, without lid lag or exposure of the
sclera.

- Test extraocular muscle balance using the

corneal light reflex. With the patient looking at
a nearby object, shine a light on the nasal
bridge. *Note: If abnormal, perform the cover-
uncover test.

Seventh, perform an ophthalmoscopic examination:

- To promote pupil dilation, dim the lights.
-No pallor, hyperemia, irregular or
- To examine the patient’s right eye, use your blurred margins noted.
right eye and hold the ophthalmoscope in your
right hand.
For the patient’s left eye, use your left eye and
hold the ophthalmoscope in your left hand.

- For the stability, put your free hand on the

patient’s shoulder or head.

- To change the ophthalmoscope lens, use your

index finger. Start with the lens set at zero and
adjust as needed.

- To avoid tiring the patient, give short breaks

from the bright light.

Perform an ophthalmoscopic exam by visualizing

each structure.
Haven’t done this. No Opthalmoscopic
- Aiming the ophthalmoscope light at the pupil instrument.
from 30 centimeters away, visualize the red
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reflex.

- Next, move in to visualize the fundus (or

retina).

- Then observe the retinal vessels, noting venous

pulsations and any abnormalities at the sites
where arterioles and venules cross.

- Next, examine the optic disc itself.

- Inspect the macula.

Hearing Assessment
Simply note how the patient responds to questions and - Done this.
directions.

Check the patient’s response to your whispered voice. - Can hear the words clearly even
In each ear, the patient should hear at least three out of if whispered.
six whispered words correctly.

Perform the weber test by placing the stem of a - Equal sound on both ears noted.
vibrating tuning fork on the midline of the head.

Perform the Rinne test by placing the stem of a - Can hear sound of the tuning
vibrating tuning fork on the mastoid bone to test bone fork adjacent to their ear.
conduction. Time how long the sound is heard. When
the patient no longer hears it, move the tuning fork 1
to 2 centimeters from the auditory canal to test air
conduction. Again, time how long the sound is heard.

External Inspection of the Ears

First, inspect the auricles for size, shape, symmetry, - Ears are equal size bilaterally
landmarks, and color. with no swelling or thickening.

Second, assess the position of the auricles. - Ear lobes are bean shaped,
parallel, and symmetrical.
Third, inspect the external auditory canal for discharge - No discharges and changes in
or odor. odor noted.

Palpation of the Ears

Palpate the auricles and mastoid area for tenderness, - No tenderness and swelling or
swelling and nodules. nodules noted.

Internal Inspection of the Ears

Otoscope examination: Haven’t done this. No Otoscope.
- With the patient’s head tilted to the opposite
shoulder, gently pull the auricle up and back
while inserting the speculum.

- Inspect the auditory canal, noting any

discharge, scaling, redness, lesions, foreign
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bodies, or cerumen. Expect to see minimal

cerumen, uniform pinkness, and hairs in the
outer third of the canal.

- Inspect the tympanic membrane for landmarks

(umbo, handle of malleus and cone light),
color, contour, and perforations.

External Inspection of the Nose

First, inspect the nose for deviations in shape, size, and - The nose is symmetric, in the
color. midline, and in proportion to
other facial features.

Second, observe the nares for discharge and flaring or - No discharges noted. No flaring
narrowing. If discharge is present, describe its or narrowing of the nares.
character, amount, and color and note whether it is
unilateral or bilateral.

Third, palpate the bridges and soft tissues of the nose - No nose tenderness, masses, or
for tenderness, masses, or displacement of cartilage or displacement of cartilage or
bone. bone.

Fourth, evaluate nasal patency by blocking one naris at - No obstruction of the nostrils.
a time as the patient breathes. Patent.

Internal Inspection of the Nose

First, inspect the nasal mucosa for color and any - Pink nasal mucosa. No any
discharge, masses, lesions or swelling of the turbinate. discharge, masses, lesions or
swelling of the turbinate.

Second, inspect the nasal septum for alignment and -Nasal septum is midline. No
any perforation, bleeding, or crusting. perforation, bleeding, or
crusting noted.
Third, test sense of smell only if the patient voices a - Can smell really well. No
concern or abnormalities are found. abnormalities found.
Inspection and Palpation of the Mouth, Oral Cavity and Oropharynx
First, Inspect and palpate the lips for color, symmetry, - The lips are pink, symmetrical,
edema, and Lesions. The lips should be pink, smooth, and free of lesions.
symmetrical, smooth, and free of lesions.

Second, with a tongue blade and bright light, examine

the buccal mucosa, gums, and teeth, using four key
assessments.
- Observe the mucous membrane for color, - Pink mucous membrane, soft,
texture and moisture and lesions. no swelling or bleeding.

- Inspect the gums for tooth adherence, color, - No tooth adherence, color,
inflammation, swelling and bleeding. inflammation, swelling and
bleeding of gums.
- Palpate the gums for any lesions, induration,
thickening, or masses. - No tenderness. No gum lesions,
Palpation should not cause tenderness. thickening, or masses.
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- Have two oral cavities for pasta

- Inspect the teeth, noting wear, notches, caries, to the dentist. With one missing
and loose or missing teeth. teeth.

Third, examine the oral cavity in seven ways.

- Inspect the dorsum of the tongue. Note any - No coating or ulcerations noted.
coating, ulcerations, or variation in the size or
color.

- Have the patient stick out the tongue while you - No deviation, tremor, or limited
observe for deviation, tremor, and limited movement noted.
movement.

- Have the patient touch the tip of the tongue to - Haven’t done this.
the palate behind the upper incisors while you
inspect the floor of the mouth and ventral
surface of the tongue. - Haven’t done this.
- Inspect the lateral borders of the tongue,
staying alert for white or red margins.
- Haven’t done this.
- Palpate the tongue and the floor of the mouth
for lumps, nodules, induration, or ulcerations.
- Haven’t done this.
- Inspect the palate and uvula with the patient’s
head tilted back.

Fourth, using a tongue blade, assess the oropharynx in - Haven’t done this. No tongue
three ways. blade.

- Inspect the oropharynx for color and texture.

Note the size and color of the tonsils.

- Observe the posterior wall of pharynx for color

and texture.

- Touch the posterior wall of pharynx on each

side to elicit the gag reflex.