Health Assessment

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Health Assessment

• Head, Eyes, Ears, Nose, Mouth, Neck

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ROS Head

• Recent head trauma?
• Loss of consciousness?
• Headaches?
• Sinus, migraine, neurological
• Use of helmet when appropriate?
• Occupation, contact sports or cycling,
  rollerblading, and skateboarding

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Face Inspection

• Inspect the face for
• Facial expressions
• Symmetry
• Note symmetry of eyebrows, palpebral fissures,
  nasolabial folds, and sides of mouth.
• Facial expressions appropriate to situation. Face
  symmetrical without drooping or involuntary
  movements.

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Skull Inspection/Palpation

• Normocephalic-round, symmetric skull that is
  appropriately related to body size
• Cranial bones with normal protrusions forehead,
  lateral angle of parietal bone, occipital bones,
  mastoid process
• Palpate for masses or nodules
• Assess infant sutures for bulging or
  depressed/sunken appearance
• Normocephalic without masses, lesions, or
  tenderness.

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TMJ

• Palpate
• In groove in front of ears
• ROM
• Open and close
• Protrusion and retraction
• Lateral side-to-side motion
• Muscle Strength
• Bite down while palpating the masseter muscles
• Clench teeth while placing downward pressure on
  the chin
• TMJ with full ROM and 5/5 muscle strength. No
  popping, clicking, or tenderness noted.

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Anatomy
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Basics of Vision

• Light reflected from image
• Light passess through pupil and cornea bends
  incoming light rays so they will be focus on the
  inner retina
• Retina with sensory neurons
• Nerve impulses sent through optic disc

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ROS Eyes

• Any visual or eye complaints?
• Pain, photophobia, burning, itching, excess
  tearing or crusting, diplopia, blurred vision,
  curtain over eye, floaters, flashing lights, or
  halos
• Any personal or family history of eye disease?
• Glaucoma, retinopathy, cataracts, macular
  degeneration (Box 33-13)
• Closed angle (acute) is ocular emergency
• sudden ocular pain, halos, red eye, very high
  pressure in eye, n/v, decreased vision, fixed
  mid-dilated pupil
• Any history of eye trauma, diabetes,
  hypertension, or eye surgery?

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ROS Eyes

• Wear glasses or contacts?
• When was last exam by ophthalmologist or
  optometrist?
• lt40 y/o every 3-5 years
• gt40 y/o every 2 years
• gt65 y/o, presence of eye disorder, or at risk for
  eye disease annually or more often if indicated
• Use of eye protection when appropriate
• Use of chemicals, welding, sawing, fencing,
  motorcycling

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RN Chart Symptoms

• Burning
• Discharge
• Discomfort
• Dryness
• Ecchymosis
• Edema

• Itching
• Pressure
• Redness
• Sclera hemorrhage
• Stye
• Tearing
• Visual field loss

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Vision Exam CN II .

• Snellen Chart
• Normal 20/20
• Abnormal 20/30 or above
• Legally blind 20/200 with correction
• Abnormal vision
• Hyperopia farsighted
• Myopia nearsighted
• Presbiopia inability to accommodate due to weak
  ciliary muscles, and inability to bulge with near
  vision (leads to hyperopia)
• Diplopia double vision due to weakness of
  extraocular muscles
• Vision by Snellen chart O.D. 20/20, O.S. 20/30,
  O.U. 20/20

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Confrontation tests/Peripheral Visual Fields

• Gross measure of a patients peripheral vision
  compared to that of your own
• Have your patient look at you in the eyes 2 ft
  away
• Move your fingers into the vision field and have
  the patient state now when they can see your
  fingers.
• Normalwhen you can see your own fingers at the
  same time that the patient does
• If you find a defect, test each eye separate and
  establish the boundaries.
• Enlarged blind spots occur in glaucoma, optic
  neuritis and papilledema
• Peripheral visual fields intact by confrontation
  test.

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Extraocular Muscles

• Six muscles attaching eyeball to orbit
• Extraocular muscles are stimulated by three
  cranial nerves
• CN VI (abducens) innervates the lateral rectus
  muscle (abducts the eye)
• CN IV (trochlear) innervated the superior oblique
  muscles (moves eye down and in)
• CN III (oculomotor) innervates all the rest
  superior, inferior, medial rectus and the
  inferior oblique muscles.

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Extraocular Muscles

• Extraocular Muscle function test function of
  each muscle by asking the patient to move eyes
  (keep head still) through six cardinal positions
  of gaze.
• Normal Eyes parallel without nystagmus.
• EOMs intact without nystagmus or lid lag.

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Inspection

• Position and alignment of the eyes
• Abnormal protrusion in Graves disease,
• orbital tumors or inflammation
• Crossing of eyes (strabismus) with neuromuscular
  injury or inherited abnormalities
• Eyes without protrusion or sunken appearance.
• Eyebrows quantity and distribution and
  scaliness of underlying skin
• Sparseness noted in hypothyroidism or elderly
• Eyebrows present bilaterally and move
  symmetrically. No scaling or lesions.
• Eyelids Inspect
• Width of palpebral fissures, ptosis, edema of the
  lids, color of the lids, lesions, condition and
  direction of eyelashes, adequacy of eye closure
• Eyelids intact without redness, swelling, dc, or
  lesions.Eyelashes evenly distributed and curve
  outward.

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Inspection

• Lacrimal apparatus
• Inspect lacrimal gland and sac for redness
  swelling
• Assess for excessive tearing or dryness
• No swelling of lacrimal apparateus noted. Puncta
  patent, without erythema, or tenderness.
• Conjunctiva and sclera depress both lower lids
  with your thumbs, exposing the sclera and
  conjunctiva, ask the patient to look up/down and
  side/side to get a good view
• Assess color, vascular patterns, nodules or
  swelling.
• Conjunctiva clear, sclera white. No lesions or
  foreign bodies noted.

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Inspection

• Pupils
• Size, shape and symmetry
• If pupils are large, small or unequal, measure
  them
• Pupillary reaction to light
• In a darkened room, have a patient look into the
  distance
• Shine a bright light obliquely into each pupil
• Direct reaction pupillary constriction in the
  same eye
• Consensual reaction pupillary constriction of
  the opposite eye
• PERRLA (only if perform accommodation). Pupils R
  4/2 L 4/2.

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Pupils

• Accommodation convergence of eyes, constriction
  of pupil as patient shifts gaze from a distance
  to a near object
• Documentation PERRLA (Pupils Equal Round,
  Reactive to Light Accommodating)

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Inspection

• Cornea and lens
• Inspect for opacities (cataracts)
• with oblique lighting
• Smooth without opacities.

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Ophthalmoscopic Exam

• Getting Started
• Start at the 0 diopters
• Use large, round beam of light
• Use your right hand and right eye for patients
  right eye, and your left eye for patients left
  eye
• Get close
• Darken room
• Have patient gaze at a distant object

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Light Reflex

• Stand 15 inches away from the patient and off to
  the side of the patient, shine the light beam on
  the pupil and look for the orange glow in the
  pupil. Normally light reflex. Abnormal
  absent light reflex (may be due to opacity of the
  lens, i.e. cataract)
• Red reflex present bilaterally.

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Examining the Optic Disc and Retina

• First, locate the optic disc (you can follow a
  blood vessel centrally to find it)
• Focus by adjusting the lens of your
  ophthalmoscope
• If the patient is nearsighted (myopic), rotate
  the lens disc counterclockwise to the minus
  diopters
• If the patient is farsighted (hyperopic), move
  the disc clockwise to the plus diopters
• You can correct your own refractive error in the
  same way

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Ophthalmoscopic Exam

• Inspect for
• General background of fundus
• Color, lesions
• Fundus red without lesions
• Optic Disc
• Sharpness or clarity of the disc outline
• Color of the disc, normally yellowish orange to
  creamy pink
• Size of the central physiologic cup (if present),
  usually yellowish white. The horizontal diameter
  is usually less than half the horizontal diameter
  of the disc.
• Normal Optic disc findings
• 1.5mm in size, round
• Margins sharp
• Demarcated from retina
• Optic disc creamy yellow, round, with sharply
  demarcated margins.

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Abnormal Optic Disc

• Papilledema swelling of the optic disc and
  anterior bulging of the physiologic cup. Related
  from increased intracranial pressure
• May be related to meningitis, trauma, mass,
  lesions

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Ophthalmoscopic Exam

• Vessels
• Arterioles brighter than veins,
• 25 smaller
• AV ratio 23
• Arterioles and veins cross each other without
  changing in diameter
• Observed vessels were without nicking. AV ratio
  23
• Macula
• Located 2 DD temporal to disc
• Color even and darker than rest of fundus
• May see fovea light reflex
• Macular dark red, even, and homogenous.

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Ear Anatomy
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Anatomy
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Physiology

• Sound waves strike the tympanic membrane
• Vibrations transmit through the auditory ossicles
  (malleus, incus, stapes) to oval window
• Vibrations travel to cochlea and then to the
  round window
• CN VIII (acoustic)
• Nerve sends message to brain

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The Aging Adult

• Decreased hearing because
• Presbycusis
• Gradual sensorineural hearing loss caused by
  nerve degeneration in inner ear or auditory nerve
• Onset around 50 years old
• First notices a high-frequency tone loss
• Harder to hear consonants than vowels
• Words sound garbled
• Accentuated by background noise
• Music, dishes clattering, large party noise

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The Aging Adult

• Cilia lining the ear canal becomes coarse and
  stiff
• Decreased hearing as impedes sound waves
• Causes cerumen to accumulate and oxidize
• Cerumen drier due to atrophy of apocrine gland
• Auditory reaction time increases after age 70.
• Takes longer for the older adult to process
  sensory input and respond to it.

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ROS Ear

• How is your hearing?
• Use of hearing aid?
• Taking ototoxic drugs?
• Have you had any trouble with your ears or
  balance?
• Are you having any vertigo? (feeling as if the
  room is spinning, different from dizzy)
• Are you having any tinnitus? (musical ringing in
  the ear)
• Does anyone smoke in your household?
• Increased risk of otitis media in children

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Inspection and Palpation

• Outer Ear Auricles (pinna)
• Helix should be in a line extending from the eye
  the occipital area
• Symmetrical
• No masses, lesions, or tenderness
• Manipulate the pinna tragus to assess for
  external otitis
• Ears equal bilaterally. No
• Swelling or thickening of
• cartilage. Skin intact without
• massess or lesions.
• No tenderness noted.

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Examining the Ear Canal and Drum

• Use an otoscope with the largest ear speculum
  that the canal will accommodate
• Position the patients head so that you can see
  through the scope
• Straighten the ear canal be grasping the auricle
  firmly and pull it upward, backward and slightly
  away from the head
• Brace your hand against the patients face
• Insert the speculum gently into the ear canal,
  directing it somewhat down and forward

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Examining the Ear Canal and Drum

• Inspect the ear canal
• Discharge, foreign bodies, redness of the skin
  and swelling
• Cerumen (wax) can be yellow to brown, soft or
  hard, may obscure your view
• External canal without erythema, edema, foreign
  bodies, lesions, or dc.

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Inspect the Eardrum

• Identify the handle of the malleus
• Identify the short process of the malleus
• Inspect the pars flaccida and Pars tensa
• Normal
• Shiny, transparent, pearly gray, slight concave,
  non-bulging, no perforation
• TM gray and intact bilaterally
• without erythema, bulging,
• or retraction.

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Abnormal TM

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Auditory Acuity

• Estimating Hearing
• Occlude one ear of your patient
• Stand 1-2 feet behind patient
• Whisper a word (i.e. 88)
• Repeat with other ear
• Gross hearing intact by whisper test.

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Auditory Acuity

• Weber Test
• Tap against palm and place midline vertex of head
• Normal Hears equally in both ears
• Conductive hearing loss- best in impaired ear
• Sensorineural hearing loss- only in normal ear

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Auditory Acuity

• Rinne Test
• Tap against palm and place on mastoid process.
  When no longer hears place 1-2 cm from ear until
  no longer hears
• Normal ACgtBC (21 ratio)
• Conductive hearing loss- BCAC or BCgtAC
• Sensorineural hearing loss- heard longer thru
  air, but less than 21 ratio

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Nose and Paranasal Sinuses

• ROS
• Nasal congestion or runny nose (rhinorrhea)?
• Sneezing?
• Medications that may cause stuffiness?
• Pain, tenderness in the face over the sinuses?
• Is the pain limited to one side?
• Trauma or bleeding from the nose (epistaxis)?

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Nose and Paranasal Sinuses

• Allergic Rhinitis
• Itching
• Swelling
• Rhinorrhea
• Sneezing
• Tearing eyes
• Later- stuffy nose, coughing, decreased smell,
  sore throat, dark circles under eyes

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Nose and Sinuses

• Inspect the anterior and inferior surfaces of the
  nose
• Note any asymmetry or deformity
• Inspect for discharge
• Test patency
• Press on each nostril one at a time and have the
  patient breath in
• Palpate for any masses, lesions or tenderness
• Nose symmetrical midline. No deformities or skin
  lesions. Nares patent bilaterally.

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Nose and Sinuses

• Inspect the inside of the nose
• Inspect vestibule, septum and
  turbinates
• Color of nasal mucosa
• Foreign body
• Discharge (note color clear, yellow, green,
  bloody)
• Masses, lesions, polyps
• Septum deviation, perforation, bleeding
• Turbinates color, swelling, exudate, polyps
• Normally no swelling, mucoid drainage redder
  than oral mucosa
• Septum without deviation, perforation, or
  bleeding. Turbinates pink, without dc, edema,
  exudate, or polyp.

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Nose and Sinuses

• Palpate for sinus tenderness
• Press up on the frontal sinuses from under the
  bony brows (avoid pressure on the eyes)
• Press up on the maxillary sinuses
• Normal pt will feel pressure but no pain with
  palpation
• Frontal and maxillary
• sinuses nontender
• to palpation

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Mouth and Pharynx

• ROS
• Sore throat
• Sore tongue
• Bleeding from the gums
• Tooth pain
• Hoarseness

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Mouth and Pharynx

• Inspect lips
• Color
• Moisture
• Lumps
• Ulcers
• Cracking
• Symmetry
• Swelling (edema)
• Inspect oral mucosa (inside of mouth)
• With good light and a tongue blade, inspect for
  color, ulcers, white patches, and nodules.
• Lips pink and moist without cracking or lesions.
  Buccal mucosa pink without nodules or lesions.

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Mouth and Pharynx

• Teeth/Gums
• Inspect for missing teeth, caries, conditions,
  discoloration
• Note the color of the gums
• Normal
• Pink
• Margins without swelling
• No bleeding
• Teeth white, straight, evenly spaced, clean and
  free of decay. Gums pink without swelling or
  bleeding.

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Mouth and Pharynx

• Tongue
• Ask the patient to stick out his tongue
• Inspect for symmetry (CN XII)
• Note the color and texture of the dorsum of the
  tongue
• Deep fissures with dry mucosa could indicate
  dehydration
• Inspect the sides and undersurface of the tongue
• Inspect the floor of the mouth (these are the
  areas where cancer most often develops)
• Note any white or reddened areas, nodules, or
  ulcerations.
• Tongue pink, moist, without lesions.

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Mouth and Pharynx

• Pharynx
• With the patients mouth open, have the patient
  say ah
• As the patient says ah check the rise of the
  soft palate (CN X)
• Gag reflex (CN IX , X)
• If needed press a tongue blade firmly down upon
  the midpoint of the arched tongue
• Inspect the soft palate, anterior and posterior
  pillars, uvula, tonsils and pharynx
• Note color, swelling, ulceration
• Tonsillar enlargement
• Exudate
• Breath odor (halitosis)
• Soft palpate pink, rises midline. Tonsils pink
  without enlargement or exudate. Pharyngeal wall
  pink without exudate or lesions. No halitosis
  noted.

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Neck

• ROS
• Neck pain?
• Lumps or swelling?
• History of neck surgery?
• History of neck trauma?

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Neck Inspection Palpation

• Inspect for
• Head position
• Neck muscle symmetry
• Masses or scars
• Abnormal pulsations
• Neck supple symmetrical
• Without masses, scars, or abnormal pulsations

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Trachea

• Inspect
• Should be midline
• Palpate
• For tracheal shift
• Place finger in sternal notch and slip to each
  side.
• Trachea midline.

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Cervical Lymph Nodes

• Palpate the lymph nodes
• Use the pads of your index and middle fingers
  with a gentle rotary motion.
• Preauricular
• Posterior auricular
• Occipital
• Tonsilar
• Submandibular
• Submental
• Superficial cervical
• Posterior cervical
• Deep cervical chain
• supraclavicular

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Cervical Lymph Nodes

• Note location, size, shape, delimitation,
  mobility, consistency and tenderness.
• Lymph nodes normally nonpalpable in healthy
  adults
• Small, soft, mobile, discrete, non-tender nodes
  (shotty) may be found in normal persons.
• Enlarged (gt1cm) firm, tender, and freely moveable
  often indicates infection.
• Hard, non-tender, and fixed often indicates
  malignancy.
• Enlarged supraclavicular node, especially on
  left, suggests possible metastasis from thorax
  or abdomen
• No lymphadenopathy noted or lymph nodes
  nonpalpable.

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Thyroid Gland

• Inspect first then
• palpate
• Assess for
• Enlargement
• Goiter
• Consistency
• Symmetry
• Nodules
• Movement
• Thyroid nonpalpable