Exam Three health assessment

Vision complaints direct a more focused assessment on what

eyes

Hearing complaints need these test

Weber, whisper, Rinne

Swallowing problems may indicate

neck, throat, or airway issues

The head includes the

cranium and face

The cranium protects the

brain

The face contains structures important for

sensation, expression, and communication

The mandible is considered the

only movable facial bone

how many cranial bones

8 bones

How many face bones

14 bones

Cranial structures

coronal, sagittal, squamosal, lambdoid

Fontanelles

anterior and posterior

Anterior fontanelle (diamond shaped)

front

13-24 months to close

Posterior fontanelle (triangular)

in the back of head

6-8 weeks

Sunken fontanelle may suggest

dehydration

Bulging fontanelle may suggest

increase intracranial pressure

expected findings of the head

• round skull

• midline

• appropriate size for body structure

• symmetrical facial features

• smooth skin with relatively uniform color

• no masses or lesions

expected variations for head

• mild asymmetry

• dry, brittle, or thinning hair

Unexpected findings

• significant asymmetry

• lumps or depressions

• ecchymosis

• lesions

• edema

• redness

• hair loss

• facial tension

• infestations

Microcephaly

small head for body

Normocephalic

normal head size for body

Acromegaly

big head for body

Clinical significance (Abnormal facial symmetry may suggest)

• stroke

• cranial nerve dysfunction

• Trauma

• infection

• endocrine disorder

Faces and TMJ - inspection

• facial symmetry

• movement

• expression

Faces and TMJ - palpate

• temporal artery

• temporomandibular (TMJ)

Face and TMJ - expected findings

• symmetric facial movement

• no abnormal involuntary movement

• temporal artery elastic and nontender

• TMJ without swelling, tenderness, or crepitus

• jaw opens and closes fully

Face and TMJ - unexpected

• facial droop

• limited jaw motion

• pain with chewing

• TMJ clicking or crepitation

Neck contains

• muscles

• lymph nodes

• thyroid and parathyroid glands

• major vessels

• trachea

Important muscles and landmarks in neck

• sternocleidomastoid

• trapezius

• neck divided into anterior and posterior triangles

sternocleidomastoid

rotates and flexes the head

Trapezius

extends the head and moves the shoulders

neck expected findings

• Centered and symmetric

• Normal color

• Smooth muscles

• No stiffness

• Smooth, controlled ROM

• Painless swallowing

• Trachea midline

• Thyroid cartilage rises symmetrically with swallowing

• C7 vertebra prominens visible/palpable

flexion normal range of motion

45 degrees

extension normal range of motion

55 degrees

lateral abduction range of motion

40 degrees

rotation normal range of motion

70 degrees

Neck unexpected findings

• pain or limited movement

• tracheal shifting

• swelling

• visible lymph nodes

• difficulty swallowing

• lump of anterior neck

• - stridor

• respiratory distress

neck clinical manifestations (abnormalities)

• infection

• thyroid disorder

• lymphatic problem

• mass

• airway compromise

Neck red flags : a lump on the anterior neck with

• stridor

• difficulty swallowing

• voice change

• respiratory distress

• requires prompt follow up

Eyes contain

• eyebrows

• eyelids

• eyelashes

• lacrimal apparatus

• conjunctiva (palpebral bulbar)

• sclera

• cornea

• irirs

• pupil

• lens

• extra ocular muscles (superior rectus, lateral rectus, inferior rectus)

• inferior oblique

• medical rectus

• superior oblique

expected findings on eyes

• Eyes parallel and aligned

• No protrusion or sinking

• Symmetrical eyebrows

• Even eyelash distribution

• Smooth eyelids

• No redness or edema

• Clear, glossy sclera

• Pink conjunctiva

• Pupils black, round, equal, about 3–5 mm

• Pupils constrict bilaterally to light

Visual tests

• visual acuity

• peripheral vision

• Accommodation

• pupillary reaction

• extrascular motor function

Visual acuity expected

• distant vision (20/20) snallen chart

• near vision (14/14) read passage 12-14 inches

peripheral vision expected

twinkle fingers until patient sees and when you see your finders so should the patient

Accommodation

move object closer to nose than farther away

pupillary response

• shine penlight into each eye one at a time looking for constriction and dilation

• consensual response

• direct response

Extrascular muscle function

• six cardinal fields of gaze

• eye movement should be smooth and symmetric

PERRLA

• P = pupil

• E = equal

• R = round

• R = reactive

• L = light

• A= accommodation

Esotropia

goes inward

Exotropia

goes outward

Hypotropia

goes downward

Hypertropia

unward turning

Ptosis

drooping eyelids

Strabismus

eye misalignment

Exophthalmos

bulging eye

Anisocoria

unequal pupils

Mydriasis

dilated pupil

Miosis

constricted pupil

Nystagmus

involuntary eye movement

Eye unexpected finding

• Exophthalmos

• Strabismus

• Eyelid redness

• Eyelid drooping

• Eyelid edema

• Discolored sclera

• Subconjunctival hemorrhage

• Conjunctivitis

• Unequal pupil size

• Altered pupillary reaction

Eye problems may mean (clinical significance of eye abnormalities)

• thyroid disease

• infection

• neurological injury

• trauma

• vision threatening disorder

• cranial nerve dysfunction

Note on nystagmus

slight nystagmus at extreme lateral gaze may be normal

More pronounced nystagmus may indicate

• inner ear disorder

• multiple sclerosis

• brain lesion

• narcotic use

Vision abnormalities

• cataracts

• Glaucoma

• Mascular degeneration

• Diabetic retinopathy

Cataracts

cloudy or dirty vision

Glaucoma

peripheral vision loss

Macular degeneration

central vision loss

Diabetic retinopathy

Patchy or sporadic vision loss

Eye reports

• sudden vision change

• painful red eye

• abnormal pupil findings

• unilateral sudden vision loss

Ears components

• external ear channels sound inward

• cerumen protects the canal

• tympanic membrane separates external and middle ear

• middle ear (malleus, incus, stapes)

• Eustachian tube equalizes pressure

• inner ear is responsible for (hearing, balance)

Inner ear structures

• vestibule

• semicircular canals

• Cochlea

Ear expected findings

• Auricles symmetric

  • Auricles aligned with outer corner of the eye

  • Normal skin color

  • No lumps, edema, or lesions

  • Canal walls pink and smooth

  • Cerumen may be yellow, orange, red, brown, gray, or black

  • Auricle, tragus, and lobule smooth and flexible

  • No tenderness

Ear unexpected findings

• Redness

• Drainage

• Blood

• Hearing deficit

• Tenderness

• Mastoid pain

• External deformity

Ear Clinical significance

• infection

• trauma

• conductive or sensorineural hearing loss

• skull fracture in trauma cases

Ear important red flags

Clear watery or blood-tinged drainage after trauma may indicate skull fracture

Hearing and Equilibrium Tests

• whisper

• weber

• rinne

• Romberg

whisper test

Correct repetition of whispered letters, numbers, or two-syllable words

Weber test

• Tuning fork placed at midline of skull

• Normal: sound heard equally in both ears

Weber interpretation

• Conductive hearing loss: sound lateralizes to affected ear

• Sensorineural hearing loss: sound lateralizes to good ear

Rinne test

• Compare air conduction and bone conduction

• Normal: AC > BC

Rinne interpretation

• Conductive loss: BC ≥ AC

• Sensorineural loss: AC > BC

Romberg test expected

Client stands for 20 seconds with minimal sway

Romberg test abnormal

Swaying or movement of feet may indicate vestibular disorder

Conductive hearing loss

Problem with sound transmission through:

• External ear

• Middle ear

Sensorineural hearing loss

• Inner ear

• Auditory nerve pathway

Bone conduction sound moves through

• Air

• Bone

• Fluid

Key distinction of conductive and Sensorineural

• Conductive = blockage or mechanical problem

• Sensorineural = nerve or inner ear problem

The nose job

• Warms air

• Moistens air

• Filters air

• Supports smell

The sinuses job

• Lighten skull weight

• Create voice resonance

• Drain mucus

nose and sinus expected

• External nose symmetric and midline

• Color consistent with face

• Nares patent

• Nasal mucosa dark pink and moist

• Septum midline

• No swelling

• No bleeding

• No discharge

• No obstruction

• Frontal and maxillary sinuses nontender

• No crepitus

nose and sinus Unexpected findings

• Pale mucosa

• Boggy mucosa

• Red swollen mucosa

• Bleeding

• Discharge

• Tenderness

• Obstruction

• Foul-smelling unilateral drainage

nose and sinus Clinical patterns

• Pale, boggy mucosa: allergies

• Red, swollen mucosa: URI/cold

• Yellow-green drainage: infection

• Foul unilateral drainage: foreign body or chronic infection

Sinus palpation

Frontal sinuses: under eyebrows

• Maxillary sinuses: below cheekbones

• Do not press on eyes

Mouth and Throat structures

• Lips

• Teeth

• Gums

• Buccal mucosa

• Tongue

• Hard palate

• Soft palate

• Uvula

• Tonsils

• Pharynx

Mouth and Throat Expected findings

• Lips smooth and moist

• Teeth pearly white

• No obvious decay

• 28–32 teeth

• Jaws aligned

• Gums smooth and tight around teeth

• Buccal mucosa pink and moist

• Tongue pink and moist with moderate papillae

• Hard palate intact and pale pink/white

• Soft palate intact, movable, pink, smooth

• Uvula pink, midline, movable

• Tonsils pink, symmetrical, no exudate

Mouth and SinuUnexpected findings

• Smooth dark red swollen tongue

• Swollen gums

• Yellow palate

• Petechiae

• Mouth or throat soreness

• Ulcerations

• White plaques

• Exudate

• Uvular deviation

Mouth and Throat Clinical significance

• Smooth dark red tongue: possible vitamin B12 deficiency

• Swollen/bleeding gums: gingivitis

• White plaques: possible thrush

• Exudate: possible infection

• Uvular deviation: abnormal neurologic or structural issue

Tonsil Grading

Tonsils should be described using a grading scale rather than vague terms

Also assess in tonsils

• Color

• Symmetry

• Swelling

• Exudate

Tension headache

Dull

• Tight

• Diffuse

• Often stress-related

Migraine

• Severe

• Throbbing

• Often unilateral

• May include nausea, photophobia, aura