HEAD & FACE (5)

Inspect the head (inspect for size, shape, and configuration) and palpate the head
Inspect the face - inspect for symmetry, features, movement, expression, and skin condition
(inspection)
Palpate the temporal artery - use 2 fingers
Palpate the temporomandibular joint (TMJ) - use 2 fingers

Findings: Upon assessment, her head is symmetric, round, erect, and in midline which is
appropriate in relation to her body size (normocephalic). The head size and shape vary, but this
is normal according to her ethnicity which is Asian. Furthermore, it is hard and smooth, without
lesions. Moving on to her face, it is symmetric with a round appearance and no abnormal
movements noted. Her temporal artery is elastic and not tender. When it comes to her
temporomandibular joint, there is no swelling, tenderness, or crepitation with movement. Mouth
opens and closes fully within 3 to 6 cm between upper and lower teeth. Lower jaw moves
laterally 1 to 2 cm in each direction.

Now, we will move on the assessment of your neck.

NECK (7)
Inspect the neck - slightly extend the neck
Inspect movement of the neck structures - swallow 2x
Inspect the cervical vertebrae - chin to chest
Inspect range of motion - turn right, left, chin touches chest, chin to the ceiling
Palpate the trachea - slightly extend the neck (use index and thumb). Place your finger in the
sternal notch. Feel each side of the notch and palpate the tracheal rings.
Palpate the thyroid gland - position at the back of the patient.
Auscultate the thyroid only if you find an enlarged thyroid gland during inspection or palpation.
Palpate the lymph nodes (10) - use index finger only in submental, submandibular, and tonsils.
Use 2 in the rest.

Findings: Upon inspection, the neck of the patient is symmetric, with head centered and without
bulging masses. Her cricoid cartilage moves upward symmetrically as she swallows. Her C7
(vertebrae prominens) is visible and palpable but I didn’t palpate it since it is visible. Her neck
movement is smooth and controlled with 45-degree flexion, 55-degree extension, 40-degree
lateral abduction, and 70- degree rotation. Her trachea is midline. In her thyroid gland, the
landmarks are positioned midline. Since it is normal and not enlarged, I did not auscultate her
thyroid. When it comes to her lymph nodes, there is no swelling or enlargement and no
tenderness.
We will now proceed to the assessment of your eyes.
EYES
1. Test distant visual acuity - cover one eye first then test with both eyes. Once stated
incorrectly, that would be the score
20/20 - one can read at 20 feet what a normal eye can see at 20 feet
20/25 - one can read at 20 feet what a normal eye can see at 25 feet
2. Test near visual acuity - cover one eye first then test with both eyes. Once stated incorrectly,
that would be the score
14/14 - one can read at 14 inch what a normal eye can see at 14 inch
3. Test visual fields for gross peripheral vision - cover one eye of the patient and nurse. Place
upper and lower right and left. Raise one to 5 fingers.
4. Perform Corneal Light reflex test - Hold a penlight approximately 12 inches from the client’s
face. Shine the light toward the bridge of the nose while the client stares straight ahead. Note
the light reflected on the corneas.
5. Perform cover test - Ask the client to stare straight ahead and focus on a distant object.
Cover one of the client’s eyes with an opaque card. As you cover the eye, observe the
uncovered eye for movement. Now remove the opaque card and observe the previously
covered eye for any movement. Repeat test on the opposite eye.
6. Perform Positions Test - Instruct the client to focus on an object you are holding
approximately 12 inches from the client’s face. Move the object through the six cardinal
positions of gaze in a clockwise direction, and observe the client’s eye movements
Move the object diagonally, right, and left. There are 6 movements and always go back to the
center. Start from the right of the patient (your left).
7. Inspect the eyelids and eyelashes
8. Assess ability of eyelids to close
9. Note the position of the eyelids in comparison with the eyeballs
10. Observe eyelids for redness, swelling, discharge or lesions.
11. Observe eyelids for the position and alignment of the eyeball in the eye socket.
12. Inspect the bulbar conjunctiva and sclera - Have the client keep the head straight while
looking from side to side then up toward the ceiling.
13. Inspect the palpebral conjunctiva
14. Evert the upper eyelid - no need to stay
15. Inspect the lacrimal apparatus.
16. Palpate the lacrimal apparatus - use both index finger below it and be gentle
17. Inspect the cornea and lens - in both eyes, check the side view. Stand up, bend near the
patient, and shine a light.
18. Inspect the iris and pupil - in both eyes, check the front view. Stand up, bend near the
patient, and shine a light.
19. Test pupillary reaction to light (Pupillary Light Reflex) - Stand up, bend near the patient, and
shine a light from side to center slowly to see the action of the pupil constricting.
20. Assess Consensual Response - place a paper in the nose bridge of the patient, completely
blocking the view on each side. Shine a light obliquely into one eye and observe the pupillary
reaction in the opposite eye.
21. Test accommodation of pupils - Hold your finger or a pencil about 12 to 15 inches from the
client. Ask the client to focus on your finger or pencil and to remain focused on it as you move it
closer in toward the eyes

Findings:
● Upon assessment of the eye of the patient, her right eye distant visual acuity is __ with
corrective lenses and with __ mistakes. On the other hand, her left eye's distant visual
acuity is __ with corrective lenses and with ____ mistake. Her eyes' distant visual acuity
is ___ with corrective lenses. This means that the client can distinguish what the person
with normal vision can distinguish from 20 feet away.
● Moving to her near visual acuity, her right eye is __ with corrective lenses and with __
mistake. On the other hand, her left eye is ____ with corrective lenses and with ___
mistake. Her near visual acuity is __ with and __ mistake. This means that she can read
what the normal eye can read from a distance of 14 inches. (14/14).
● When it comes to her gross peripheral vision, she saw my finger at the same time that I
saw it. Approximately, her inferior visual field is 70 degrees, superior is 50 degrees,
temporal is 90 degrees, and nasal is 60 degrees.
● Proceeding to her corneas, the reflection of light on it is in the exact same spot on each
eye, which indicates parallel alignment.
● During the cover test, her uncovered eye remains fixed straight ahead. And her covered
eye as well after being uncovered.
● During the positions test, her eye movement is smooth and symmetric throughout all six
directions.
● Proceeding to her eyelids and eyelashes, her upper lid margin is between the upper
margin of the iris and the upper margin of the pupil. The lower lid margin rests on the
lower border of the iris. No white sclera is seen above or below the iris. Palpebral
fissures may be horizontal.
● Furthermore, her upper and lower lids close easily and meet completely when closed.
● Her lower eyelid is upright with no inward or outward turning. Eyelashes are evenly
distributed and curve outward along the lid margins.
● Upon inspection, the skin on both of her eyelids is without redness, swelling, or lesions.
● When it comes to her eyeballs, they are symmetrically aligned in sockets without
protruding or sinking.
 ● The bulbar conjunctiva is clear, moist, and smooth. Underlying structures are clearly
visible. Sclera is white.
● (2) Meanwhile, the lower and upper palpebral conjunctivae are clear and free of swelling
or lesions, foreign bodies, or trauma.
● Moving on to the lacrimal apparatus, no swelling or redness present over areas of the
lacrimal gland. The puncta (red sa gilid) is visible without swelling or redness and is
turned slightly toward the eye.
● No drainage is noted from the puncta when palpating the nasolacrimal duct.
● When it comes to cornea and lens, the cornea of the client is transparent, with no
opacities. The oblique view shows a smooth and overall moist surface; the lens is free of
opacities.
● The iris of the client is round, flat, and evenly colored. The pupil, round with a regular
border, is centered in the iris. Her pupils are equal in size (3 to 5 mm).
● During the assessment for pupillary light reflex, consensual response, and
accommodation of pupils, her direct pupillary response is constriction which is normal
but in accommodation of pupils there is also the convergence of the eyes when focusing
on a near object.

EARS (7)
1. Inspect the auricle, tragus, and lobule - ikutan yung patient and compare both ears.
2. Inspect the external auditory canal - hold the auricle then bring it up and back then shine a
light. Position at the back of the patient
3. Palpate the auricle and mastoid process - both hands must palpate the mastoid process,
staying in one position with circular motion
4. Perform the whisper test - ask the patient to cover one ear and move to the side of the
uncovered ear 2 feet away. Then, lean slightly forward and whisper 3 words with 2 syllable. With
your head 2 feet behind the client (so that the client cannot see your lips move), whisper a two
syllable word such as “popcorn” or “football.” Ask the client to repeat it back to you. If the
response is incorrect the first time, whisper the word one more time. Identifying three out of six
whispered words is considered passing the test.
5. Perform Weber’s test if the client reports diminished or lost hearing in one ear - after tapping
the tuning fork, immediately place it at the top of the forehead of the patient.
6. Perform the Rinne’s test - ask the client to raise her hand if no sounds are being heard
anymore. Strike a tuning fork and place it on the client’s mastoid process. Then, move the
prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the
sound is audible after the fork is moved. Count the seconds.
7. Perform the Romberg test. This tests the client’s equilibrium. Ask the client to stand with feet
together, arms at sides with the eyes closed

Findings: After inspecting the ears of the patient, it is equal in size bilaterally (normally 4–10
cm). The auricle aligns with the corner of each eye and within a 10-degree angle of the vertical
position and her earlobes are free.
Findings: A small amount of odorless cerumen (earwax) is the only discharge normally present.
Cerumen color may be yellow, orange, red, brown, gray, or black. Consistency may be soft,
moist, dry, flaky, or even hard.
Findings: The auricle, tragus, and mastoid process are not tender. During the whisper test, she
was able to correctly repeat the two-syllable word as whispered. During the weber’s test,
vibrations are heard equally well in both ears. No lateralization of sound to either ear. Air
conduction sound is normally heard longer than bone conduction sound (AC > BC). Client
maintains position for 20 seconds without swaying or with minimal swaying.
NOSE (3)
Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness.
Check patency of air flow through the nostrils by occluding one nostril at a time and asking client
to sniff. One sniff per side nose
Inspect the internal nose - tingala ng konti then tignan talaga yung nose.

Findings: Upon assessment of the nose, the color is the same as the rest of the face; the nasal
structure is smooth and symmetric; the client reports no tenderness. Furthermore, she was able
to sniff through each nostril while the other is occluded. Moving on to her nasal mucosa, it is
dark pink, moist, and free of exudate. The nasal septum is intact and free of ulcers or
perforations. Turbinates are dark pink (redder than oral mucosa), moist, and free of lesions.

Sinuses (2)
Palpate the sinuses - Palpate the frontal sinuses by using your thumbs to press up on the brow
on each side of nose and the maxillary sinuses on each side of the nose
Percuss the sinuses. Lightly tap (percuss) over the frontal sinuses and over the maxillary
sinuses for tenderness

Findings: Upon palpation and percussion, her frontal and maxillary sinuses are nontender and
no crepitus is evident.

MOUTH AND THROAT

● Put gloves, hold a tongue depressor
1. Inspect the lips. Observe lip consistency and color
2. Inspect the teeth and gums - say aaa check upper and lower
3. Inspect the buccal mucosa - hold a penlight and tongue depressor, say aaa. Check the sides
of the mouth
4. Assess the ventral surface of the tongue - taas dila
5. Inspect for Wharton’s ducts— check ilalim
7. Assess the uvula - labas dila, use tongue depressor para mahold dila
6. Inspect the tonsils.
8. Inspect the hard (anterior) and soft (posterior) palates and uvula - hard muna then soft
9. Inspect the posterior pharyngeal wall - likod ng uvula, kapag naduwal, means nakita
pharyngeal wall
10. Inspect and palpate the tongue.
11. Observe the sides of the tongue - ipatagilid, use yung index
12. Check the strength of the tongue.
13. Note odor.

Findings:
● Lips are smooth and moist without lesions or swelling.
● Thirty-two pearly whitish teeth with smooth surfaces and edges. Upper molars should
rest directly on the lower molars and the front upper incisors should slightly override the
lower incisors. Some clients normally have only 28 teeth if the four wisdom teeth do not
erupt.
● The buccal mucosa should appear pink in light-skinned clients; tissue pigmentation
typically increases in dark skinned clients.
● The tongue’s ventral surface is smooth, shiny, pink, or slightly pale, with visible veins and
no lesions.
● The frenulum is midline; Wharton’s ducts are visible, with salivary flow or moistness in
the area. The client has no swelling, redness, or pain.
● No redness of or exudate from uvula or soft palate. Midline elevation of uvula and
symmetric elevation of the soft palate.
● Tonsils may be present or absent. They are normally pink and symmetric and may be
enlarged to 1+ in healthy clients. No exudate, swelling, or lesions should be present.
● The hard palate is pale or whitish with firm, transverse rugae (wrinkle-like folds). Palatine
tissues are intact; the soft palate should be pinkish, movable, spongy, and smooth
● After inspecting the posterior pharyngeal wall, the throat is normally pink, without
exudate or lesions
● Tongue should be pink, moist, a moderate size with papillae (little protuberances)
present. A common variation is a fissured, topographic map–like tongue, which is not
unusual in older clients. No lesions are present.
● In the side of the tongue, no lesions, ulcers, or nodules are apparent.
● The tongue offers strong resistance
● No unusual or foul odor is noted