VISION TEST NORMAL ABNORMAL

20/20 with or
Distant visual without MYOPIA
acuity corrective
lenses
HYPEROPIA
Near Visual PRESBYOPIA
14/14
Acuity (common for 45
y/o and above)
EOM FUNCTION NORMAL ABNORMAL
Position test Eye movement Failure to follow
should be movements
smooth and symmetrically
symmetric
throughout all six NYSTAGMUS
directions
Muscle Cranial Nerve

Superior rectus Oculomotor

Superior oblique Trochlear

Lateral rectus Abducens

Inferior oblique Oculomotor

Inferior rectus Oculomotor

Medial rectus Oculomotor

EOM FUNCTION NORMAL ABNORMAL
Peripheral vision Inferior: 70deg Delayed or
Superior: 50deg absent
Temporal: 90deg perception
Nasal: 60deg

Corneal light Reflection of light STRABISMUS

reflex on the corneas
should be in the
same spot
INSPECTION NORMAL ABNORMAL
Internal eye Red reflex should Papilledema
be easily visible Glaucoma

Optic disc should

be round with
sharp, well-
defined borders
INSPECTION NORMAL ABNORMAL

Width and position Upper lid margin PTOSIS

of palpebral should be between EXOPHTHALMOS
fissures the upper margin of
the iris and the
upper margin of the
pupil
Lower lid margin
rest on the lower
border of the iris

Assess ability of Close completely Failure of lids to

eyelids to close close completely
INSPECTION NORMAL ABNORMAL
EYELIDS AND Lower lid is upright with no ENTROPION
LASHES inward or outward turning ECTROPION

Position Eyelashes are evenly

distributed and curve
outward along the lid
margins

XANTHELASMA

Redness, swelling, Without redness, swelling or Redness and crusting

discharge, lesions lesions suggests seborrhea or
blepharitis
STYE (hordeolum)
INSPECTION NORMAL ABNORMAL

BULBAR Clear, moist, and CONJUNCTIVITIS

CONJUNCTIVA smooth
Underlying structures
are visible

PALPEBRAL Lower and upper Cyanosis of the

CONJUNCTIVA palpebral conjunctiva lower lid
are pink free of
swelling and trauma

SCLERA Sclera is white Jaundice

INSPECTION NORMAL ABNORMAL
LACRIMAL DUCT No swelling or Swelling or redness
redness Excessive tearing
CORNEA AND LENS Cornea is CATARACTS
transparent with no
opacities

ARCUS SENILIS
IRIS AND PUPILS Iris is round, flat, ANISOCORIA
and evenly colored MIOSIS
PERRLA MYDRIASIS
PALPATION NORMAL ABNORMAL
LACRIMAL SACS, No swelling or Swelling 
EYEKIDS, EYEBALLS tenderness infection
Eyeball is firm cardiovascular
problems, renal
problems

Less than firm

eyeballs DHN
• Watch with second hand for Romberg test
• Tuning fork (512 or 1, 024 Hz)
• Otoscope
INSPECTION NORMAL ABNORMAL
AURICLE, TRAGUS, Equal in size Ears are smaller than
LOBULE bilaterally (4-10cm). 4 cm or larger than
Size, shape, position Auricle aligns with the 10 cm
corner of each eye
and within a 10- Malaligned or low-
degree angle of the set ears may be seen
vertical position with genitourinary
dso. or chromosomal
defects
INSPECTION NORMAL ABNORMAL
AURICLE, TRAGUS, No lesions, lumps, -Enlarged preauricular
LOBULE nodules, discharge. and postauricular
lymph nodes
Lesions, discoloration Color is consistent with -Tophi
and discharge facial color. -Blocked sebaceous
glands
Darwin’s tubercle -Ulcerated, crusted
nodules that bleed
-Redness, swelling,
scaling, or itching
-Pale blue ear color
INSPECTION NORMAL ABNORMAL
EXTERNAL AUDITORY Small amount of Foul-smelling, sticky,
CANAL odorless cerumen yellow discharge
Color and consistency
of cerumen Bloody, purulent
discharge

Blood or watery
drainage

Impacted cerumen
Color and consistency Pink and smooth and Reddened, swollen
of the ear canal walls without nodules canals
Exotoses
Polyps
INSPECTION NORMAL ABNORMAL
TYMPANIC MEMBRANE Pearly gray, shiny, and Red, bulging, eardrum,
translucent with no and distorted,
bulging or retraction diminished and absent
Slightly concave, light reflex.
smooth and intact
Yellowish, bulging
membrane with
bubbles behind.

Bluish or dark red

color.
White spots.
Perforations.
Prominent or absent
landmarks.
 NORMAL ABNORMAL
WHISPER TEST At 1-2 ft, the client will Inability to repeat the
be able to repeat the phrases  inability to
phrase hear ↑frequency sound
WEBER’S TEST Vibrations are heard Conductive hearing loss
(conduction of sound equally well in both (lateralization of sound
waves through BONE to ears. to the POOR EAR)
help distinguish
between CONDUCTIVE No lateralization of Sensorineural hearing
HEARING LOSS and sound to either ear loss
SENSORINEURAL (lateralization of sound
HEARING LOSS) to the GOOD EAR)
RINNE TEST AC > BC CHL: BC>AC
(compares air and bone SHL: AC>BC
conduction sounds)
SHL: results when the damage is located in the
inner ear  normal conduction of sound waves
occur but the impaired inner ear cannot make the
conversion  prolonged exposure to loud noises,
ototoxic medications

CHL: when something blocks or impairs the passage

of vibrations from getting to the inner ear 
cerumen buildup fluid  common older client
 NORMAL ABNORMAL
ROMBERG’S TEST Maintains position for Moves feet apart to
20 seconds without prevent fall or start to
swaying or with fall
minimal swaying
N OSE A SSESSMENT
 NORMAL ABNORMAL
Inspect and palpate Color is the same as the Nasal tenderness on
external nose rest of the face palpation indicates
Nasal structure is infection
smooth and symmetric
No tenderness
Patency of air flow Able to sniff through Rhinitis
each nose while the Swelling
other is occluded FB obstruction
 NORMAL ABNORMAL
Inspect internal nose Nasal mucosa is dark Swollen and pale pink
pink, moist and free or bluish gray
from exudate
Red and swollen
Nasal septum is intact
and free of ulcers and Exudates
perforation
Purulent nasal
Turbinates are dark pin, discharge
moist, free of lesions
Bleeding

Ulceration
 NORMAL ABNORMAL
Palpate the sinuses No tenderness, no Tender
crepitus With crepitation

Percuss the sinuses Not tender Tender

Transilluminate the With red glow Without red glow

sinuse
INSPECTION NORMAL ABNORMAL
Color and Smooth and moist PALLOR
consistency of the without lesions or CYANOSIS
lips swelling REDDISH
SWELLING
Pink lips
Number, color, 32 pearly white teeth Yellow or brownish
condition and with smooth surfaces teeth
alignment of the and edges
teeth Tooth decay
No repaired or
decayed areas, no Chalky white teeth
missing teeth
INSPECTION NORMAL ABNORMAL
Color and Pink, moist, and firm Red, swollen gums
consistency of the with tight margins to Enlarged reddened
gums the tooth. No lesions gums
or masses. Bluish-black or grey
white line
Color of the buccal Pink, smooth without Leukoplakia
mucosa lesions (precancerous
lesions)
Oral thrush
Koplik’s spots
Canker sores
INSPECTION NORMAL ABNORMAL
Color and integrity Soft palate is pinkish, Thick, white plaques
of soft and hard movable, spongy and Deep purple, raised
palate smooth or flat lesions
Yellowish tint
Hard palate is pale or
whitish with firm
transverse rugae
Uvula’s position Fleshy, solid Bifid uvula
structure, that hangs
freely in the midline
No redness
With midline and
symmetric elevation
INSPECTION NORMAL ABNORMAL
Color, size, and May be present or Hyperemic with
presence of lesions absent exudates
and exudates on the Normally pink and
tonsils may be enlarged to
+1
No swelling, lesions
and exudates
Pharynx’ color Normally pink Bright red throat
with white or yellow
exudates 
pharyngitis
Yellow mucus 
PND
INSPECTION NORMAL ABNORMAL
TONGUE Pink, moist, a Deep longitudinal
moderate size with fissures
Color, moisture, size papillae
and texture Black hairy
Fissured tongue tongue

No lesions Red, beefy tongue

Enlarged or very
small tongue
INSPECTION NORMAL ABNORMAL
Ventral surface of Smooth, shiny, pink or Lesions, ulcers,
the tongue, slightly pale, with nodules
frenulum visible veins and no
lesions

Frenulum is midline

CN assessment Normal CN function deficit

 NAME TYPE FUNCTION

I OLFACTORY S SMELL

II OPTIC S SIGHT

EXTRAOCULAR EYE
III OCULOMOTOR M
MOVEMENT

EXTRAOCULAR EYE
IV TROCHLEAR M
MOVEMENT
 NAME TYPE FUNCTION
V TRIGEMINAL B S- FACIAL SENSATION
M- CHEWING
VI ABDUCENS M EXTRAOCULAR EYE
MOVEMENT
VII FACIAL B S- TASTE OF
ANTERIOR 2/3 OF
THE TONGUE
M- FACIAL MOVEMENT
VII ACOUSTIC S HEARING AND SENSE
(VESTIBULOCO OF BALANCE
CHLEAR)
MNEMONICS FOR 12 CRANIAL
NERVES: Oh, Oh, Oh, To Touch
And Feel a Girl’s V (whatever that
starts with V) feel So Heaven

FOR ITS TYPE: Some Says Marry

Money But My Brother Says Bad
Business Marry Money