Head and Neck
“Hi, my name is . I am a nursing student at USA and I am going to conduct an assessment of your head and neck.”
“The head is normocephalic with no visible lumps or lesions. The facial features are symmetric and proportional. Expression is appropriate. The eyebrows, palpebral fissures, nasolabial folds and sides of the mouth are symmetric. No noted changes in skin color or pigmentation. No swelling or involuntary movements.”
“The hair is shiny and evenly distributed. No pest inhabitants. No lumps or lesions noted.”
“Open and close your mouth. Now, clench your jaw and try to keep it closed.”
Instruct patient on cotton ball test.
“Sensory and motor function of CN V (Trigeminal) are intact.”
“External nose is symmetric, midline and proportional. No deformities or lesions. Tilt your head back please. Muscosa are pink and moist. Septum is midline and intact. No bleeding or deviation noted. Middle and inferior turbinates are pink. No polyps present.”
“Occlude one nostril and sniff. And the other. Close your eyes and tell me what you smell.”
“CN I (Olfactory) is intact.”
“Now smile, frown. Close your eyes and resist my pressure to open them. Raise your eyebrows, show your teeth and puff out your cheeks.”
“Motor portion of CN VII (facial) is intact. To test sensory function, I would apply a sweet, salty, or sour solution to the tongue for identification.”
“Tell me if you feel any tenderness as I check your lymph nodes. Pre-auricular, Post-auricular, occipital, submental, submandibular, jugulodigastic (tonsillar), superficial cervical, deep cervical, posterior cervical, and supraclavicular. All lymph nodes are non-palpable. No tenderness or masses noted.”
“Now I will examine your thyroid. Trachea is midline. Thyroid is non-palpable with no masses or nodules.”
“Now I will assess CN XI (spinal accessory). Try to push against my hand. And shrug your shoulders. CN XI intact.”
“Now I will assess your eyes. Eyeballs are smooth and glossy, normally aligned in their sockets, no protrusion or sunken appearance. The palpebral conjunctiva are pink and moist. The bulbar conjunctiva are clear. The sclera is white. Cornea and lens are clear. No opacities noted. Iris is round and symmetrical. Pupils are equal in size. No aniscoria noted.”
“Close your eyes. Palpebral fissures are horizontal. No lid lag or drooping. Brow hair and lashes present and intact. Lacrimal gland and puncta are intact, no redness, swelling, or discharge noted.”
“I will use the 6 Cardinal Positions to test the extraocular muscles. Follow my finger with only your eyes. Keep your head still. Parallel tracking with both eyes. CN III(Oculomotor), CN IV(Trochlear), and CN VI(Abducens) are intact. No nystagmus present.”
“Now for the Corneal Light reflex test. Please stare straight ahead. Reflection is the same position in each eye, indicating symmetry.”
“And the Cover test… Please stare straight ahead, I will cover one of your eyes. And now the other. No eye muscle weakness noted. Stare was fixed and steady.”
“For the confrontation test, I need you to cover one eye and let me know when you see my finger. Assuming I have normal peripheral vision, the patient has a superior angle of 90 degrees, inferior 70 degrees, nasal 60 degrees, and temporal 90 degrees.”
“For the Snellen eye chart, the patient would stand 20 feet from the chart and read the smallest visible line while covering each eye. Normal vision is 20/20. If the patient saw 20/100, then they can see at 100 feet what one with normal sight can see at 20 feet.”
“Please hold the Rosenbaum card 14 inches from your eye. Cover one eye and read the smallest line you can see. Now do the other eye. Patient has 20/20 in both eyes.”
“Let’s take a look at your pupils. Left is 3 mm and right is 3mm. They are round, equal in size. Now look at the clock on the wall. Simultaneous pupil constriction noted. Still look at the clock on the wall, now look at my finger. Convergence and accommodation noted. Thus, pupils equal, round, reactive to light, there is accommodation and convergence.”
“Now I will look into your eye with the opthalmoscope. Remain focused on the clock. Red reflex noted on retina. Arterioles and venules present. Optic disc is round, creamy yellow with sharp margins. Macula is brownish, and even in color.”
“Now for the external ear. Helix and antihelix are firm. No nodules or tenderness noted. EAM has no swelling, redness or discharge. The tragus is firm and non-tender. Antitragus is intact. No swelling or tenderness noted in the lobule.”
“Now for the inside of the LEFT ear. Tympanic membrane is intact, it is flat, pearly gray and translucent. Cone of light present at 7 o’clock. The bony landmarks of the short process are present.”
“Now for the inside of the RIGHT ear. Tympanic membrane is intact, it is flat, pearly gray and translucent. Cone of light present at 5 o’clock. The bony landmarks of the short process are also present.”
“To test the hearing we will first start with the Whisper test to evaluate high tone hearing loss. Please cover your left ear. Tell me what I say… football. Now cover your right ear.”
“Now for the Rinne test. Tell me when you cannot hear the sound any longer. And again. Air conduction should be twice as long as bone conduction in a normal result. In this case it was.”
“The Weber test is for conductive or sensorineural hearing loss. Please tell me if you can hear the sound better in one ear than the other or if it is the same.”
“Finally we will look at your mouth. Lips are pink and moist with no lesions. Buccal mucosa is pink, smooth and moist. No lesions noted. Gums are pink with no swelling or bleeding noted. Thirty-two teeth present, bite down… no malocclusion. Jaws aligned. Please stick out your tongue. Touch the roof of your mouth. Tongue is pink and moist, no lesions on or under tongue. Tongue is midline, no deviation. CN XII (Hypoglossal) intact. Hard palate is white, soft palate is pink. No lesions present. Say ‘ah’… uvula is pink and rises with phonation. Stick out your tongue… Tonsils visible, 1+.”
