Narrator: : Next assess the head, eyes, ears, nose, and throat. Palpate the scalp, looking for any depressions of the skull, which might indicate head trauma or previous surgery. Inspect the hair and its texture, looking for nevi, lesions, or parasites. Inspect the face, noting whether the facial expressions and eyebrows are symmetric. Palpate for sinus tenderness by pressing up on the frontal sinuses from under the bony brows, then press up on the maxillary sinuses.
Lynn Bickley: Okay. Now I’m going to check your sclera and conjunctiva. Look up.
Narrator: Inspect each cornea, iris, and lens.
Lynn Bickley: And look down.
Narrator: Check the color of the conjunctiva and sclera. Compare the pupils and test their reactions to light and accommodation.
Lynn Bickley:Good. All right, now I’m going to look inside your eyes. Okay, what I want you to do is look straight ahead at that dot. Okay, and just bring your head down a little bit. That’s it.
Narrator: With an ophthalmoscope, inspect the ocular fundi.
Next, you may wish to perform a brief assessment of the cranial nerves. Cranial nerve I, the olfactory nerve, is typically not tested unless a neurological problem is suspected. In the head to toe assessment, cranial nerve II, the optic nerve, can be assessed with a test for visual acuity.
Mr. Barry:: F-D-P-L-T-F-E-Z-C-L-O-F-T-B.
Lynn Bickley: Good.
Narrator: Cranial nerves III, IV, and VI control extraocular movement. Look for abnormal movements or nystagmus of the eyes in each of the six cardinal directions of gaze. Ask the patient to follow your finger or a pencil as you make a wide “H” in the air. Then test for convergence.
Next, test for several components of cranial nerve V, beginning with motor response. Check masseter and pterygoid function by asking the patient to clench his teeth. Check the nerve’s sensory response by using a sharp object to stimulate the patient’s forehead and cheeks at the points indicated.
Mr. Barry: Sharp.
Narrator: Test for light touch using a cotton swab.
Lynn Bickley: Shut your eyes. Keep them shut. Okay, relax. Puff your cheeks. Okay. Smile. Good. And show your teeth. Good. Okay.
Narrator: Next, assess cranial nerve VIII, which is responsible for hearing.
Lynn Bickley: Hear anything there? Narrator: Test one ear at a time.
Mr. Barry: Yes. Lynn Bickley: Very good. Tell me what I’m saying to you. (Whispers: 13.)
Mr. Barry: Thirteen.
Lynn Bickley: (Whispers: 21.)
Mr. Barry: Twenty-one.
Lynn Bickley: Assess cranial nerves IX and X by listening to the patient’s voice. Is it hoarse or does it have a nasal quality?
Mr. Barry: 2120 Mission Road, San Diego, California.
Narrator: Is there a gag reflex? After warning the patient, test the gag reflex by stimulating the back of the throat lightly on each side in turn.
Lynn Bickley: Very good.
Narrator: Ask the patient to say, “Ah,” or to yawn as you watch for elevation of the uvula and soft palate.
Lynn Bickley: And say, “Ah.”
Mr. Barry: Ahhh.
Narrator: Inspect the uvula, the soft palate, the interior and posterior pillars, and pharynx.
Assess cranial nerve XI from behind the patient. Look for atrophy or fasciculations in the trapezius muscles. From the front, ask the patient to shrug both shoulders upward against your hands. Note the strength of the trapezius. As the patient turns his head to each side against your hand, observe the contraction and force of the opposite sternomastoid and note the force of the movement against your hand.
Lynn Bickley: Okay. Narrator: Assess the 12th cranial nerve by inspecting the patient’s tongue for atrophy or fasciculations. Then, with the patient’s tongue protruded, look for asymmetry and deviation from the midline.
Lynn Bickley: Okay. Very good.
Narrator: This completes the assessment of the twelve cranial nerves. Next, inspect the anterior and inferior surfaces of the nose. Note any asymmetry or deformity.
Lynn Bickley: Okay, this will be a little bit uncomfortable. Tip your head back.
Narrator: Then inspect the inside of the nasal passages with an otoscope.
Lynn Bickley: Okay. Excellent.
Narrator: And using your largest ear speculum, examine the ear canal and drum. Inspect the mouth, observing the symmetry, color, and moisture of the lips and note any masses, ulcers, cracking, or scaliness.
Lynn Bickley: Check the teeth.
Narrator: Inspect the oral mucosa and note the color of the gums, normally pink. Inspect the gum margins and the interdental papillae for swelling or ulceration. Inspect the patient’s teeth and look for abnormalities. Inspect the hard and soft palates, the uvula, tongue, and other structures of the mouth. Pay particular attention to the floor of the mouth and the sides and undersurface of the tongue, for here is where cancer may develop.
Lynn Bickley: Excellent. Very good.
Narrator: Begin your inspection of the neck, including the sternomastoid muscles, by noting any swellings or abnormal posture. Look for enlargement of the parotid and submandibular glands and note any visible lymph nodes. With the patient relaxed, palpate the lymph nodes in the anterior cervical chain and above the clavicle. You can usually examine both sides at once.
Flex the patient’s neck slightly forward toward the side being examined then palpate the posterior cervical chain. For each node, note its size, mobility, and any tenderness. Next, palpate in the sternal notch to check the position of the trachea. It should be midline. Inspect for the thyroid gland by first tipping the patient’s head back a bit. Inspect and palpate the region below the cricoid cartilage for the thyroid isthmus and for any glandular enlargement. Ask the patient to swallow a sip of water. As he swallows, inspect for upward movement of the thyroid gland.
Lynn Bickley: Tip your head back. Now swallow.
Narrator: Next, palpate the thyroid gland. Note the size, shape, and consistency of the gland and identify any nodules or tenderness. The posterior approach is demonstrated. You may prefer the anterior approach.