COURSE MODULE

N101a – Health Assessment Skills

Module 2 Physical Assessment

2. 1. Integumentary
2. 2. Head and Neck
2. 3. Eyes
2. 4. Ears
2. 5. Nose
2. 6. Sinuses

At the end of this module, the student is expected to:

1. Demonstrate knowledge, skills, and proper attitude in performing Assessment of:
* Integumentary,
* Head and Neck,
* Eyes,
* Ears,
* Nose, and
* Sinuses using the Techniques of Physical assessment
2. Recognize normal and abnormal assessment findings
3. Employ accurate documentation of assessment findings.

Activate prior knowledge:

 Pretest – Simple recall on Anatomy and Physiology

Acquire new knowledge:

 Discussion, power point presentation, videos
 Demonstration / Return Demonstration

DISCUSSION:

I. Examination of the Head and Neck

Equipment Needed
1. Otoscope
2. Tongue blades
3. Cotton tipped applicators
4. Non-latex exam gloves

General Considerations The head and neck exam is not a single, fixed sequence. The assessment varies
depending on the examiner and the situation.
Head
1. Look for scars, lumps, rashes, hair loss, or other lesions.
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.

Fontanels in a newborn - toddler:

1. Posterior fontanel – triangle shaped; closes 1-2 months
2. Anterior fontanel – diamond shaped; closes at 9 months – 2 years

Neck
1. Inspect the neck for asymmetry, scars, or other lesions. 2. Palpate the neck to detect areas of
tenderness, deformity, or masses.

Lymph Nodes
1. Systematically palpate with the pads of your index and middle fingers for the various lymph node
groups.
2. Preauricular - In front of the ear
3. Post auricular - Behind the ear
4. Occipital - At the base of the skull
5. Tonsillar - At the angle of the jaw
6. Submandibular - Under the jaw on the side
7. Submental - Under the jaw in the midline
8. Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
9. Supraclavicular - In the angle of the sternomastoid and the clavicle
10. The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without
getting underneath the muscle. Inform the patient that this procedure will cause some discomfort.
11. Hook your fingers under the anterior edge of the sternomastoid muscle.
12. Ask the patient to bend their neck toward the side you are examining.
13. Move the muscle backward and palpate for the deep nodes underneath.
14. Note the size and location of any palpable nodes and whether they were soft or hard, nontender or
tender, and mobile or fixed
Thyroid Gland
1. Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly
enlarged thyroid gland is called a goiter.
2. one way to look is to have person swallow sip of water; the thyroid gland will move upward with a
swallow.
3. Move to a position behind the patient. Have the patient tilt head slightly to right.
4. Identify the cricoid cartilage with the fingers of both hands.
5. Move downward two or three tracheal rings while palpating for the isthmus.
6. Move laterally from the midline while palpating for the lobes of the thyroid.
7. Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal
gland is often not palpable
Special Tests
A. Facial Tenderness
1. Ask the patient to tell you if these maneuvers cause excessive discomfort or pain.
2. Press upward under both eyebrows with your thumbs. (Frontal sinus)
3. Press upward under both maxilla with your thumbs. (Maxillary sinus)
4. Excessive discomfort on one side or significant pain suggests sinusitis.

B. Sinus Transillumination
1. Darken the room as much as possible.
2. Place a bright otoscope or other point light source on the maxilla.
3. Ask the patient to open their mouth and look for an orange glow on the hard palate. 4. A decreased or
absent glow suggests that the sinus is filled with something other than air.
5. Not always definitive of disease process.

C. Temporomandibular Joint
1. Place the tips of your index fingers directly in front of the tragus of each ear.
2. Ask the patient to open and close their mouth.
3. Note any decreased range of motion, tenderness, or swelling

II.Ears - See also notes under Cranial Nerves for other assessments related to ears and hearing
1. Inspect the auricles and move them around gently. Ask the patient if this is painful.
2. Palpate the mastoid process for tenderness or deformity.
 3. Assess ears using otoscope:
a) Hold the otoscope upside down with your thumb and fingers so that the ulnar aspect of your
hand makes contact with the patient.
b) For adults, pull the ear upwards and backwards to straighten the canal.
c) PEDIATRICS: For children pull the ear down and back.
d) Use the largest speculum that will fit comfortably.
e) Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.
f) Insufflate the ear and watch for movement of the tympanic membrane.
g) Repeat for the other ear.
4. Normal color of eardrum: shiny translucent, pearly gray.
5. Abnormal findings:
a) erythema – suppurative Otitis Media. purulent drainage.
b) Dull, nontransparent gray – serous otitis media with effusion
6. Conductive hearing loss is due to mechanical dysfunction of inner or middle ear.
7. Sensory-neural loss is due to pathological problem of inner ear, CNS or cerebral cortex.
8. In older adults, there may be some normal high-tone hearing loss.

III.Mouth and Throat

It is often convenient to examine the throat using the otoscope with the speculum removed.
1. Ask the patient to open their mouth.
2. Using a wooden tongue blade and a good light source, inspect the inside of the patient’s mouth
including the buccal folds and under the tongue. Note any ulcers, white patches (leukoplakia), or other
lesions.
3. If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the
mouth.
4. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any
tonsillar enlargement, redness, or discharge.
5. Hard palate is located in the anterior part of the mouth. It is made of bone and is pale or whitish.
6. Soft plate is located in the posterior part of the mouth. It is softer, more mobile and pink in color.

III. Examination of the Eye - see also Cranial Nerve II, III, IV, V

Equipment Needed
• Snellen Eye Chart or Rosenbaum Pocket Vision Card
• Ophthalmoscope

Visual Acuity
In cases of eye pain, injury, or visual loss, always check visual acuity before proceeding with the rest of
the exam or putting medications in your patient’s eyes.
1. Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best
corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14
inch "reading" distance).
3. Have the patient cover one eye at a time with an opaque card.
4. Ask the patient to read progressively smaller letters until they can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.)
6. Repeat with the other eye.
Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.
a. Inspection
1. Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry.
2. Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and
sclera.
3. Next spread each eye open with your thumb and index finger. Ask the patient to look to each
side and downward to expose the entire bulbar surface.
4. Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion
cornea.
5. If you suspect the patient has conjunctivitis, be sure to wash your hands immediately. Viral
conjunctivitis is very contagious, so protect yourself!
b. Visual Fields
- Screen Visual Fields by Confrontation
1. Stand two feet in front of the patient and have them look into your eyes.
2. Hold your hands to the side half way between you and the patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate which side they see your fingers move. \
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to
cover the opposite eye with a card.
Extraocular Muscles
A. Corneal Reflections
1. Shine a light from directly in front of the patient.
2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.
B. Extraocular Movement (EOM)
1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with their eyes without moving their head. 3. Check gaze
in the six cardinal directions using a cross or "H" pattern.
4. Check convergence by moving your finger toward the bridge of the patient's nose.
5. Pause during upward and lateral gaze to check for nystagmus (involuntary eye movement
which differs in each eye).
6. Tests CN 3, 4, and 6
C. Pupillary Reactions
1. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and
Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not
specifically check the accommodation reaction use the term PERRL.
2. Look for direct and consensual responses. In a normal response, the eye which the light is
shined has pupillary constriction (direct reflex) AND the other pupil also constricts (indirect or
consensual reflex). An abnormal response (no pupillary constriction) can help to localize the
lesion, particularly when interpreted with the result of vision testing. While observing the
pupillary light response one should also check that the pupils are the same size.
3. Light
a) Dim the room lights as necessary.
b) Ask the patient to look into the distance.
c) Shine a bright light obliquely into each pupil in turn.
d) Look for both the direct (same eye) and consensual (other eye) reactions.
 e) Record pupil size in mm and any asymmetry or irregularity.
4. Accommodation If the pupillary reactions to light are diminished or absent, check the
reaction to accommodation (near reaction):
a) Hold your finger about 10cm from the patient's nose.
b) Ask them to alternate looking into the distance and at your finger.
c) Observe the pupillary response in each eye.

D. Ophthalmoscopic Exam
1. Darken the room as much as possible.
2. Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture
to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for
your eyes.
3. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right
eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better
control.
4. Ask the patient to stare at a point on the wall or corner of the room.
5. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet
away. You should see the retina as a "red reflex." Follow the red color to move within a few
inches of the patient's eye.
6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the
optic disk. Use this as a point of reference.
7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities.
8. Move nasally from the disk to observe the macula.
9. Repeat for the other eye. 10. Normal color should be creamy yellow-orange to pink.

Notes
1. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the
patient is from the chart and the second number is the distance from which the "normal" eye can
read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a
"normal" person can read from twice that distance.
2. You may, instead of wiggling a finger, raise one or two fingers (unilaterally or bilaterally) and
have the patient state how many fingers (total, both sides) they see. To test for neglect, on some
trials wiggle your right and left fingers simultaneously. The patient should see movement in both
hands.
3. Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of
small lens of different strengths on a wheel (positive diopters are labeled in green, negative in
red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for
both the patient's and your own vision.

Analysis/ Application:
Return Demonstration
Assessment:
 long quiz
 discussion
periodical exam