IPD B: FINALS – HEENT TECHNIQUES OF EXAMINATION FOR HEAD (FROM BATES’)

(HEAD, EYES, EARS, NOSE & PARANASAL SINUSES, MOUTH & PHARYNX)
Ask if the patient has noticed anything wrong with the scalp or
hair. If you detect a hairpiece or wig, ask the patient to remove
it.
Objectives:
EXAMINE:
1. To describe the gross structure and assess the
Hair: Note its quantity, distribution, texture, and any pattern of
function of the head and face, including the eyes,
loss. You may see loose flakes of dandruff.
ears, nose, paranasal sinuses, mouth and pharynx.
2. To record the findings using a standard format.
Scalp: Part the hair in several places and look for scaliness,
lumps, nevi, or other lesions.

Skull: Observe the general size and contour of the skull. Not
EXAMINATION OF THE HEAD any deformities, depressions, lumps, or tenderness. Learn to
recognize the irregularities in a normal skull, such as those
1. Stand beside or behind the seated patient. near the suture lines between the parietal and occipital bones.
2. Inspect and palpate the hair taking note of:
a. Color – black, brown, gray (natural or dyed) Face: Note the patient’s facial expression and contours.
b. Quantity – thin, thick or fairly abundant Observe for asymmetry, involuntary movements, edema, and
c. Distribution – evenly distributed, pattern of masses.
hair loss if any, receding hairline
d. Texture – fine or coarse Skin: Observe the skin, noting its color, pigmentation, texture,
e. Moisture – dry or oily thickness, hair distribution, and any lesions.
3. Part the hair in several places and examine the scalp
for skin lesions (scars, scales, masses, etc.) and
lice.
4. Inspect and palpate the cranium and describe the: EXTRA NOTES FROM BATES’
a. Size/shape – normocephalic, microcephalic,
macrocephalic • Fine hair is seen in hyperthyroidism; coarse hair in
b. Symmetry – symmetric, asymmetric (usually hypothyroidism. Tiny white ovoid granules that
due to bony deformities) adhere to hairs may be nits (lice eggs).
c. Scalp – lesions (Describe) and tenderness
d. Temporal Arteries
i. Inspect the temporal fossae, if
visible, describe if tortuous or not
ii. Place your index and middle finger
pads over the temporal fossae
• Look for redness and scaling that may indicate
iii. Describe the amplitude and equality
seborrheic dermatitis or psoriasis; soft lumps that may
of pulsations, consistency of walls
be pilar cysts (wens); pigmented nevi.
(soft or hard)

FROM BATES’:
The superficial temporal artery
passes upward just in front of the
ear, where is is readily palpable.
• An enlarged skull may signify hydrocephalus or
In many normal people, Paget’s disease of bone. Palpable tenderness or
especially thin and elderly ones, step-offs may be present after head trauma.
the tortuous coarse of one of its
branches can be traced across
the forehead.

FINDINGS
Thick, black hair, evenly distributed, coarse and dry; clean • Acne is found in may adolescents. Hirsutism
scalp; normocephalic, no mass or tenderness (excessive facial hair) occurs in some women with
polycystic ovary syndrome.
Temporal arteries are not visible but palpable with strong,
equal pulsations, walls not thickened.
EXAMINATION OF THE FACE 2. Eyelids: swelling, edema, erythematous rim, ptosis,
sty
1. Stand or sit in front of the patient at eye level
2. Inspect the FACE to assess: BATES’: Note the position fo the lids in relation to the eyeballs.
a. Skin Inspect for the following: Width of the palpebral fissures,
i. Color (fair, brown, black) edema of the lids, color of the lids, lesions, condition
ii. Lesions – describe type (macule, and direction of the eyelashes, adequacy of eyelid
papule, patch, wheals, etc.) color closure.
changes (erythematous,
hyperpigmented, *Failure of eyelids to close exposes the corneas to
hypopigmented, depigmented, serious damage.
etc.) and distribution.
b. Shape – oval, triangular, round, square
c. Symmetry – symmetric or asymmetric,
describe (shallow right nasolabial fold,
ABNORMALITIES OF EYELIDS (BATES’)
drooping right angle of the mouth Ptosis
d. Facial expression (facie) and involuntary
facial movements. Drooping of the upper lid, causes
include myasthenia gravis,
damage to CN 3, and damage to
FACIES FROM BATES’ sympathetic nerve supply.
Entropion
More common in the elderly. An
inward turning of the lid margin.

Ectropion
Margin of the lower lid is turned
outward, exposing the palpebral
conjunctiva.
Lid Retraction and
Exophthalmos
A wide-eyed stare suggests
retracted eyelids. Exopphthalmos
describes protrusion of the
eyeball.
Sty
A painful, tender, red infection in a
gland at the margin of othe eyelid

Chalazion
FINDINGS A subacute nontender, usually
Oval, symmetrical, fair-skinned with several painless nodule involving a
hyperpigmented papules scattered over the face, no blocked Meibomian gland. Usually
masses, normal facie, no involuntary movements. points inside the lid rather than on
the lid margin.
Xanthelasma
EXAMINATION OF THE EYES Slightly raised, yellowish, well-
circumscribed plaques that appear
along the nasal portions of one or
both eyelids.
Inflammation of Lacrimal Sac
(Dacryocystitis)
A swelling between the lower
eyelid and the nose.

3. Palpebral Fissures: assess the palpebral fissure with

the patient looking straight ahead. Describe if normal,
widened or narrowed.
4. Eyeballs: Observe the position of the eyeball (globe)
1. Eyebrows: amount, distribution, lesion with the bony orbit (socket).

BATES’: Inspect the eyebrows, noting their quantity and

distribution and any scaliness of the underlying skin.
Lid Lag Test • Observe the pupils for size
With your finger or holding (measure the diameter of each
a penlight as a target in the pupil in mm).
midline above the eye level, • Observe for any irregularities or
about 20 inches (50 cm) asymmetry.
away, move the target
rapidly in the midline,
watching for the BATES’: If the pupils are large (>5 mm), small (<3 mm), or
appearance of white sclera unequal, measure them. Use a card with black circles of
between the iris and the varying sizes to measure pupillary size.
upper lid margin.

5. Eyelashes: Describe a) Direction of growth; b)

Matting of eyelashes (if there’s infected eyelids)
6. Conjunctivae and Sclerae:
a. Ask the patient to look up as you depress
both lower lids with your thumbs.
BATES’: Simple anisocoria, or a difference in pupillary size
b. Ask the patient to look down as you pull the of 0.04 mm or greater, is visible in approximately 35% of
upper lids upwards (these exposes the healthy people. If pupillary reactions are normal, anisocoria
sclerae and conjunctivae). Look for any is considered benign.
growth or edema.
c. Describe the color of sclerae (white or *Miosis refers to CONSTRICTION; Mydriasis to DILATION
icteric) and describe the palpebral
conjunctivae for color (pinkish, congested,
injected, pale). • Pupillary Light Reflex: Light entering the eye travels
along the optic nerve to the pretectal region of the
midbrain to cause pupillary constriction through the
BATES’: If you need a fuller view of the eye, rest your thumb visceral motor and short ciliary nerve components of
and finger on the bones of the cheek and brow, respectively, the oculomotor nerve.
and spread the lids.
1. Dim the lights, ask the patient to look into the
Ask the patient to look to each side and down. This distance, shine a bright light obliquely
technique gives you a good view of the sclera and bulbar (approaching laterally) into the pupil. Observe for
conjunctiva, but not of the palpebral conjunctiva of the upper the direct response (same eye) and
lid. For this, you need to evert the lid. indirect/consensual response (oopposite eye).

*A yellow sclera indicates jaundice. BATES’: Look for:

a)
direct reaction (pupillary constriction in the
same eye)
7. Cornea: With oblique lighting from a penlight, inspect b) consensual reaction (pupillary constriction in
for transparency or clarity, scars, abrasions and ulcers the opposite eye)
of the cornea. Always darken the room and use a bright light before
8. Iris, Pupils and Lens: With the light shining directly deciding that a light reaction is absent.
from temporal side, note for the:
a. Iris: assess color If the reaction to light is impaired or questionable, test the
near reaction in normal room light. Testing one eye at a
time makes it easier to concentrate on pupillary responses,
BATES’: Markings should be clearly defined. With your light without the distraction of extraocular movement. Hold your
shining directly from the temporal side, look for a finger or pencil about 10 cm from the patient’s eye. Ask the
crescentic shadow on the medial side of the iris. patient to look alternately at it and into the distance directly
Because of the iris is normally fairly flat and forms a behind it. Watch for pupillary constriction with near effort.
relatively open angle with the cornea, this lighting casts no
shadow.

b. Pupils: Assess size, shape, symmetry and

reaction to light.
 • Assess for an afferent pupillary defect: the swining OPTHALMIC EXAMINATION
flashlight test, by moving the light from one pupil to the
other back and forth. It is best done in a semi-darkened or a completely darkened
room.
• To assess the Accommodation Reflex: ask the
patient to look in the distance and then at the tip of their
nose. If the patient finds this maneuver difficult, have
them follow their extended thumb as it is brought in
towards the tip of their nose.

BATES’: Accommodation – an increased convexity of the

lenses caused by contraction of the ciliary muscles. This
change in shape of the lenses brings near objects into focus
but it is not visible to the examiner.

For this, ask the patient to follow your finger or pencil as you
move it in toward the bridge of the nose. The converging
eyes normally follow the object to within 5 cm to 8 cm of the
1. Sit or stand at the patient’s right side for examination
nose.
of the right eye.
2. Place the “O” in the illuminated dial.
3. Take the ophthalmoscope in the right hand and hold it
9. Extraocular Movements: examine both eyes vertically in front of your own eye with the light
simultaneously: beam directed toward the patient and place your
a. The examiner places himself approximately 1 right index finger on the edge of the lens dial in
meter in front of the patient order to change lenses easily if necessary.
b. Ask the patient to look to each side, up and 4. Instruct the patient to look straight ahead, preferably at
down following an “H” pattern some distant object at eye level.
c. Pursuit: ask the patient to follow a target such 5. Move to a position about 6 inches (15 cm) in front,
as your finger or a pen with their eyes without and 25 degrees to the right side of the patient and
moving their head direct the light beam into the pupil. A red “reflex”
d. Pause at the ends of each direction of gaze to should appear as you look through the aperture.
observe for nystagmus 6. While the patient continues to look straight ahead,
keep the “reflex” in view and slowly move toward
the patient. The optic disc should come into view
BATES’: From about 2 feet directly in front of the patient, shine when you are about 1 ½ to 2 inches (3-5 cm) from
a light onto the patient’s eyes and ask the patient to look at the patient. If it is not focused clearly, rotate lenses
it. Inspect the reflections in the corneas. They should be into the aperture with your index finger until the optic
visible slightly nasal to the center of the pupils. disc is as clearly visible as possible.
7. Now examine the disc for clarity of outline, color,
Assess the extraocular movements, looking for: elevation and condition of the vessels. Follow each
vessel as far to the periphery as you can. To locate
• The normal conjugate movements of the eyes in the macula, focus on the disc, then move the light
each direction or any deviation from normal temporally about 2 discs diameter. Examine for
• Nystagmus, a fine rhythmic oscillation of the eyes. abnormalities in the macula area.
If you see this, bring your finger in to within the field 8. To examine the extreme periphery, instruct the patient
of binocular vision and look again. to:
• Lid lag as the eyes move from up to down. a. Look up for examination of the superior retina
b. Look down for examination of inferior retina
To test for the 6 Extraocular Movements, ask the patient to c. Look temporally for examination of temporal
follow your finger/pencil as you sweep through the 6 cardinal retina
directions of gaze: d. Look nasally for examination of nasal retina
1. To the patient’s extreme right 9. Examination of the left eye is done in the same manner
2. To the right and upward except the ophthalmoscope is held in the left hand
3. Down on the right before the left eye and the examiner is at the patient’s
4. Without pausing in the middle to the extreme left side.
left
5. To the left and upward NOTE FOR THE FOLLOWING:
6. Down on the left 1. The clarity of the disc outline. The nasal outline may be
normally somewhat blurred.
*Because middle-aged or older people may have difficulty 2. The color of the disc, normally yellowish orange to
focusing on near objects, make this distance greater for creamy pink.
them than for young people. If necessary, hold the head in 3. The possible presence of normal white or pigmented
the proper midline position. If you suspect lid rings or crescents around the disc
lag/hyperthyroidism, ask the patient to follow your finger 4. The size of the central physiologic cup, if present. This
again as you move it slowly from up to down in the midline. cup is normally yellowish white. Its horizontal dimeter
The lid should overlap the iris slightly throughout this is usually less than half of the horizonal diameter of the
movement. disc.
 5. The symmetry of the eyes in terms of these
observations.

ARTERIOLES VEINS
COLOR Light red Dark red
SIZE Smaller (2/3 to ¾ Larger
the diameter of
veins)
LIGHT REFLEX Bright Inconspicuous or
absent

1. Follow the vessels peripherally in each of four direction

noting their relative size and the character of the
arterio-venous crossings.
2. Identify any lesions of the surrounding retina and note
their size, shape, color and distribution. As you search
for the retina, move your head and instrument as a unit,
using the patient’s pupil as an imaginary fulcrum.
3. Finally, by directing your light beam laterally or by
asking the patient to look directly into the light, inspect
the macula.

The macula is an avascular area somewhat larger than

the disc, with no distinct margins.

Except in older people, the tiny bright reflection at its

center—the fovea—helps to identify it. Shimmering light
reflection in the macular area are common in young people.

On ophthalmoscopic examination, the normal retina is

magnified about 15 times, the normal iris about 4 times.

The optic disc usually measures about 1.5 mm. At the

retina, 3 diopters of elevation = 1 mm.

NORMAL FUNDUS

• (+) ROR
• 2:3 A:V RATIO
• (-) Hemorrhages
• (-) Papilledema

FROM BATES’:
 BATES’: Use a well-lit Snellen eye chart. Position the patient
20 feet from the chart. Patients who use glasses other than
for reading should wear them.

Ask the patient to cover on eye with a card and to read the
smallest line of print possible.

A patient who cannot read the largest letter should be

positioned closer to the chart; note the intervening distance.

Determine the smallest line of print from which the patient

can identify more than half the letters.

Record the visual acuity designated at the side of this line,

along with the use of glasses, if any.

BATES’: Visual acuity is expressed as two numbers (20/30):

• 20 - indicates the distance of the patient from the
chart
• 30 - is the distance at which a normal eye can read
the line of letters.

TESTING FOR VISUAL ACUITY

BATES’: Vision of 20/200 means that at 20 feet the patient
1. Each test is tested separately can read print that a person with normal vision could read at
2. Test best corrected vision using eyeglasses 200 feet. The larger the second the number, the worse
3. Any patient with uncorrected visual acuity of less than the vision.
20/20 should be examined with a pinhole. Improvement
of vision through a pinhole indicate the error is “20/40 corrected” means the patient could reat the 40 line
refractive with glasses (a correction).
4. Test distant vision using a Snellen chart at 10 or 20
feet. Myopia is impaired far vision.
5. Test near vision using a near vision card at 14 inches
6. The patient is instructed to read progressively smaller Presbyopia is impaired near vision, found in middle-aged
lines of letters until they can go no further. and older people. A presbyopic person often sees better
when the card is farther away.

NORMAL RESPONSE
Vision of 20/20
Record for each eye separately. Right eye: OD; Left eye; OS

ABNORMAL RESPONSE
• 20/30-1 → The patient missed to letter of the 20/30 line
• 20/200 → legally blind. At 20 ft., the patients reads a
line that a normal eye could see at 200 ft.
• CF (Counting Fingers) → if a patient is unable to read
DISTANT VISION NEAR VISION the top line, have him count fingers at maximal distance.
Snellen’s Chart – 10 or 20 Near vision card – 14 inches • HM (Hand Motion) → if a patient cannot cound fingers,
feet ask them to determine direction of hand motion
• LP (Light Perception) → if a patient cannot perceive
hand motion, see if they can perceive a light
• NLP → No Light Perception

TESTING FOR VISUAL FIELDS

A. Peripheral Visual Field
a. Wiggling Fingers
b. Counting Fingers
c. White Pin
 B. Central Visual Field For further testing
a. Red Pin 5. If you find a defect, try to establish its boundaries. Test
one eye at time.
Visual fields are assessed by confrontation. The examiner 6. If you suspect a temporal defect in the LEFT visual field,
compares the patient’s visual field to their own and assumes that ask the patient to cover the right eye and with the left
theirs is normal. one to look into your eye directly opposite
7. Then slowly move your wiggling fingers from the
• Peripheral Visual Field defective area toward the better vision, noting where
1. First test each eye separately. the patient first responds. Repeat this at several levels
2. Examiner places himself approximately 1 meter away to define the border.
from the patient and advises the patient to look directly 8. A temporal defect in the visual field of one eye suggests
the examiner’s eye for monocular testing or nose for a nasal defect in the other eye.
binocular testing.
3. The test object (wiggling finger, one or two fingers or a
white pin head) is presented equidistant from the
patient’s and examiner’s eye
4. The patient is asked either to state the number of
fingers or say “yes” when they see first see a moving
target.

• Central Visual Field

1. The 20 degrees on either side of the vertical meridian,
the red pin is used.
2. The patient is instructed to state when they see the pin
as red.

Red pin is also used to map the blind spot.

Vision in the center of the visual field is more detailed than

in the peripheral areas. This is because of both the structure
of the retina and the connections of its neurons.

Light rays from the center of the visual field are focused on
BATES’: Kinetic Red Target Test
the macula in the center of the retina. In the macula, the
proportion of cones to rods is high. Cones are important for 1. Facing the patient, move a 5 mm red-topped pin inward
color vision. from beyond the boundary of each quadrant along a line
bisecting the horizonal and vertical meridians.
2. Ask the patient when the pin first appears to be red.

NORMAL RESPONSE
EXAMINATION OF THE EARS
The normal peripheral monocular visual field extends
approximately 90 degrees temporally, 60 degrees nasally,
60 degrees superiorly and 75 degrees inferiorly.

It is divided into nasal and temporal halves and superior and

inferior altitudinal halves. The normal central visual field
extends approximately 30 degrees on all sides of central
fixation.

The blind spot is located 15 degrees temporal to fixation just

below the horizontal meridian. It corresponds to the optic
disc.

TEST FOR AURICLE

BATES’: Static Finger Wiggle Test
1. Inspect each auricle and surrounding tissues for size,
1. Ak the patient to look with both eyes into your eyes. deformities, lumps, or skin lesions.
2. As you return the patient’s gaze, place your hands 2. If with ear ache, discharge or inflammation are
about 2 feet apart, lateral to the patient’s ears. present, move the auricle up and down, press the
3. Wiggle both your fingers simultaneously, and bring tragus and press firmly behind the ear. Note for
them slowly forward, curving inward along the tenderness.
imaginary surface of the bowl toward the central vision
line.
4. At each position, ask the patient to tell you as soon as
he or she sees the finger movement.
 Movement of auricle and tragus is BATES’:
painful in acute otitis externa 1. Insert the speculum gently into the ear canal,
(inflammation of ear canal) but not in directing it somewhat down and forward and
otitis media (inflammation of middle through the hairs, if any.
ear). 2. Inspect the ear canal, noting any discharge,
foreign bodies, redness of the skin, or swelling.
Tenderness behind ear may be Cerumen which varies in color and consistency
present in otitis media. from yellow and flaky to brown and sticky or even
to dark and hard, may wholly or partly obscure your
view.
OTOSCOPIC EXAMINATION/TEST FOR EAR CANAL AND DRUM 3. Inspect the eardrum, noting its color and contour.
The cone of light—usually easy to see—helps to
1. Tilt the patient’s head to the opposite side orient you.
2. Grasp the auricle firmly but gently, while pulling it 4. Identify the handle of the malleus, noting its
upward, backward and slightly outward position, and inspect the short process of the
3. Insert into the canal, slightly down and forward, the malleus.
largest ear speculum that the canal will accommodate 5. Gently move the speculum so that you can see as
4. Brace your hand against the patient’s head so that it much of the drum as possible, including the pars
can follow unexpected movements of the patient’s flaccida superiorly and the margins of the pars
head and thus avoiding injury to the ear canal. tensa. Look for any perforations. The anterior and
inferior margins of the drum may be obscured by
the curving wall of the ear canal.
BATES’:
1. Use an otoscope with the largest ear speculum that the Mobility of the eardrum can be evaluated with a pneumatic
canal will accommodate. otoscope.
2. Position the patient’s head so that you can see
comfortably through the instrument.
3. To straighten the ear canal, grasp the auricle firmly but
gently and pull it upward, backward, and slightly away
from the head.
4. Holding the otoscope handle between your thumb and
fingers, brace your hand against the patient’s face.
5. Your hand and instrument can then follow unexpected
movements by the patient.

Nontender nodular swellings

covered by normal skin deep in the
ear canals suggest exostoses.
These are nonmalignant
overgrowths which may obscure the
drum.
OBSERVE FOR THE FOLLOWING: In acute otitis externa, the canal is
often swollen, narrowed, moist,
1. Patency of ear canal pale, and tender. It may be
2. Identify any discharge reddened.
3. Describe the walls of the ear canal. Note any
redness or swelling
4. Inspect the tympanic membrane and note for the In chronic otitis externa, the skin of the canal is often
following: thickened, red, and itchy.
a. Color (pearly white or pinkish grey; An unusually prominent short process and a prominent
hyperemic in myringitis) handle that looks more horizontal suggest a retracted drum.
b. Intact or Perforated
c. Contour (bulging: fluid in the middle ear; EXAMINATION OF NOSE AND PARANASAL SINUSES
flat: normal; retracted: pulled upward
due to a block in the Eustachian tube).
d. Cone of light: A change in the normal EXAMINATION OF THE NOSE
contour suggests middle ear disease.
e. Identify the malleus (visible or not). 1. Position: Sit in front of your seated
2. Inspect the nose for symmetry and deformity
3. Palpable for tenderness
a. Gently press the tip of the nose upward using
your thumb
b. If tender, be gentle and manipulate the nose
as little as possible during the rest of the
examination
 3. Gently press your thumbs
o A normal nose will not be tender, tenderness upward to elicit tenderness
is usually associated with trauma or ii. Maxillary Sinuses
infection 1. Place the palmar aspect of
the thumbs slightly below
4. Test for patency of the nasal cavities and lateral to the ala nasi.
a. Ask the patient to press one ala nasi at a time 2. Anchor the rest of the
and breathe in and listen fingers on the patient’s
o If the opposite nasal cavity is patent (open), temples
the inspiration is quiet, or the sound will be 3. Gently press your thumbs
soft and smooth inward and upward
o If not patent (obstructed) the sound will be
rough or high-pitched
NORMAL RESPONSE
5. Assess the internal structures of the nose using a There should be no tenderness.
penlight or otoscope without a speculum
b. Transillumination using a penlight
A. Technique using a penlight
i. Frontal Sinuses
1. With your middle finger resting on the patient’s
1. With the light directed
mid-forehead, slightly tilt the patient’s head
upwards, position the
backward
penlight under the medial
2. Using the thumb of the same hand, push the tip of
side of the roof of the orbit.
the nose upward
2. Place the ulnar aspect of
3. To visualize the septum, hold the penlight on the
the hand on the eyebrow.
opposite hand and direct the light towards the
3. Turn on your light and
medial side of the nasal cavity and observe the
observe a normal sinus
nasal septum.
above illuminates.
a. Normal septum has pink mucosa, is
ii. Maxillary sinuses
straight at the midline and intact (not
1. Tilt the patient’s head
perforated).
slightly backward
b. A deviated septum is usually due to
2. Position your penlight
direct trauma
slightly lateral to the ala
c. A perforated septum is usually due to
nasi
the associated with aggressive nose
3. Turn on the light
picking of dry exudates from frequent
4. Ask the patient to open his
and prolonged rhinitis
mouth and observe if the
4. To visualize the turbinate’s, direct the light towards
hard palate (floor of the
the lateral (walls) side of the nasal cavity and
sinus) underneath
observe the middle and inferior turbinates
illuminates.
a. If the turbinates are normal, they will be
flat and dry with the same pink color as
the surrounding mucosa. BATES’:
1. Inspect the anterior and inferior surfaces of the
B. Technique using an otoscope without a nasal nose. Gentle pressure on the tip of the nose with
speculum your thumb usually widens the nostrils and, with
a. Tilt the patient’s head slightly backward the aid of a penlight or otoscope light, you can get
b. With the other hand, insert the otoscope a partial view of each nasal vestibule. If the tip is
gently into one nostril avoiding contact tender, be particularly gentle and manipulate the
with the nasal septum nose as little as possible.
c. Hold the otoscope handle to one side to 2. Note any asymmetry or deformity of the nose.
avoid the patient’s chin and improve your 3. Test for nasal obstruction, if indicated, by
mobility pressing on each ala nasi in turn and asking the
d. To visualize the septum, direct the patient to breathe in.
light medially 4. Inspect the inside of the nose with an otoscope
e. To visualize the turbinates, direct the and the largest ear speculum available. Tilt the
light laterally patient’s head back a bit and insert the speculum
gently into the vestibule of each nostril, avoiding
6. Assessment of the Frontal and Maxillary Sinuses contact with the sensitive nasal septum. Hold the
otoscope handle to one side to avoid the patient’s
a. Palpate for tenderness chin and improve your mobility. By directing the
i. Frontal Sinuses speculum posteriorly, then upward in small steps,
1. Place the palmar aspect of try to see the inferior and middle turbinates, the
the thumbs under the nasal septum, and the narrow nasal passage
medial sides of the roofs of between them. Some asymmetry of the two sides
the orbits (floor of the is normal.
frontal sinuses
2. Anchor the rest of the
fingers on top of the
patient’s head
 NOTE: The ideal penlight to use will be one whose barrel is f. Recession of the gingival margins
opaque and whose bulb does not protrude beyond the g. Pus in the margins
rim of the penlight barrel. The color of the light must be
yellow-orange, not white nor bluish tinge. BATES’: Note the color of the gums, normally pink. Brown
patches may be present, especially but not exclusively in
black people.
EXAMINATION OF MOUTH AND PHARYNX
Inspect the gum margins and the interdental papillae for
1. Face the patient with both of you seated at the same swelling or ulceration.
level
2. If the patient wears dentures, ask the patient to
remove them so that you can see the mucosa NORMAL RESPONSE
underneath Pink, smooth, no lesions.
3. Hold the tongue blade in the left hand and a penlight
in the right
4. Throughout the examination of the oral cavity, a good 4. Teeth – note absence of one or more teeth, presence
light source is needed of caries, discoloration, fillings, bridges and braces.

BATES’: If you detect any suspicious ulcers or nodules, put BATES’: Inspect the teeth. Are any of them missing,
on a glove and palpate any lesions, noting any thickening or discolored, misshapen, or abnormally positioned? Check for
infiltration of the tissues that might suggest malignancy. looseness with your gloved thumb and index finger.

EXAMINATION OF ORAL CAVITY NORMAL RESPONSE

Complete set (32 adult teeth), no dental caries, good oral
1. Lips – inspect the inner surface of the lips by retracting hygiene.
them with a tongue blade while the teeth are
approximated.
Inspect for: 5. Roof (palate) and floor of the mouth – observe for:
a. Color a. Color
b. Moisture b. Deformities
c. Lesions (fissures, ulcers) c. Any lesions and masses
d. Symmetry d. Odor
e. Deformities

NORMAL RESPONSE
NORMAL RESPONSE Pinkish, no lesions
Pinkish, moist, symmetrical, no lesions.

6. Tongue
BATES’: Observe their color and moisture, and note any • Ask the patient to open his mouth. Observe for
lumps, ulcers, cracking, or scaliness. abnormal movements (fasciculations, tremors).
• Ask the patient to protrude the tongue and observe for
the following:
2. Oral Mucosa – look into the patient’s open mouth and o Size
using a tongue blade, inspect the buccal mucosa for o Color
color, pigmentation, ulcers, patches, and nodules. o Surface
o Moisture
o Symmetry
BATES’: o Lesions
The wavy white line on the adjacent
buccal mucosa developed where the BATES’: Ask the patient to put out his or her tongue. Inspect
upper and lower teeth meet, related to it for symmetry—a test of the hypoglossal nerve (CN12).
irritation from sucking or chewing.
Note the color and texture of the dorsum of the tongue.

Inspect the sides and undersurface of the tongue and the

NORMAL RESPONSE floor of the mouth, areas where cancer often develops. Note
Pink, smooth, no lesions. any white or reddened areas, nodules, or ulcerations.

Palpate any lesions. Explain what you plan to do and put on

3. Gums – Observe for:
the gloves. Ask the patient to protrude the tongue. With your
a. Color
right hand, grasp the tip of the tongue with a square of gauze
b. Swelling
and gently pull it to the patient’s left. Inspect the side of the
c. Bleeding
tongue, and then palpate it with your gloved left hand, feeling
d. Retraction
for any induration. Reverse the procedure for the other side.
e. Discoloration
 7. Inspect the soft palate, uvula, tonsillar pillars, tonsils, c. Ask the patient to turn his chin towards his
and posterior pharyngeal wall right and left shoulders to assess lateral
o With the patient’s mouth open but the tongue rotation
not protruded, ask the patient to say “ah” d. Ask the patient bend his neck laterally
o This action may be enough to let you see the towards his right and left shoulders (ear to
pharyngeal wall. If not, press a tongue blade shoulder) to assess lateral
firmly down upon the midpoint of the arched flexion/bending.
tongue—far enough to get good visualization
of the pharynx but not so far that you cause PALPATION OF THE NECK
gagging.
o Ask patient to say “ah”. Note the rise of the 1. Palpation is performed with the examiner in front of and
soft palate—a test for the 10th cranial behind the patient.
nerve. 2. In front, palpate the posterior cervical spine,
o Inspect for the soft palate, uvula, anterior and mastoid process, trapezius and
posterior pillars, tonsils, and posterior sternocleidomastoid.
pharyngeal wall. Note the color and symmetry 3. From behind, palpate the thyroid gland and lymph
and any evidence of exudates, swelling, nodes.
ulcerations or tonsillar enlargement. If 4. If a mass is palpable, describe its location, consistency,
possible, palpate any suspicious area for size, and mobility.
induration or tenderness.
TRACHEA
BATES’: Tonsils have crypts, or deep infoldings of squamous
epithelium. Whitish spots of normal exfoliating epithelium 1. Palpate the trachea for any deviation from its usual
may sometimes be seen in these crypts. midline position by placing your finger (index finger or
thumb) along one side of the trachea and note the
space between it and the sternocleidomastoid.
2. Compare it with the other side. The spaces should be
symmetrical. If asymmetrical, there is deviation on the
narrower side.

NORMAL RESPONSE
Uvula in midline
Tonsils not enlarged
Pharynx is pink, no lesions, no exudates

EXAMINATION OF THE NECK

Objectives:
1. To describe the gross structure and assess the
function of the neck LYMPH NODES
2. To record the findings using a standard format
1. With the
examiner
INSPECTION AND RANGE OF MOTION standing behind
the seated
1. Stand or sit in front of the patient and examine the neck patient, palpate
anteriorly, laterally and posteriorly. the lymph
2. Inspect the neck for nodes.
a. Symmetry 2. Using the 2nd
b. Size (if unusually long or short) and 3rd finger
c. Deformity, mass and swelling pads of both
3. Observe how the patient carries his head (position – index and
tilted, rotated) and note the tone of the neck muscles. middle fingers,
4. Check the range of motion of the neck move the skin
a. Ask the patient to bend neck forward (chin over the
to chest) to assess flexion. underlying tissues in each area (rather than moving your
b. Ask the patient to tilt his head backwards to fingers over the skin) in a rotatory fashion. You can examine
assess extension both sides simultaneously.
3. For the submental nodes, feel the nodes with one finger
while bracing the top of the head with your other hand.
4. Feel in sequence for the following nodes:
a. Preauricular – in front of ear
b. Posterior auricular – superficial to the mastoid
process
c. Occipital – at the base of the skull posteriorly
d. Tonsillar – at the angle of the mandible
e. Submandibular – midway between the angle and
the tip of the mandible. These nodes are usually
smaller and smoother than the lobulated
submandibular gland against which they lie.
f. Submental – in the midline a few centimeters
behind the tip of the mandible 3. Enlarged or tender nodes, if unexplained, call for
g. Superficial cervical – superficial to the (1) re-examination of the regions they drain and
sternomastoid (2) careful assessment of lymph nodes elsewhere
h. Posterior cervical – along the anterior edge of the so that you can distinguish between regional and
trapezius generalized lymphadenopathy.
i. Deep cervical chain – deep to the sternomastoid
and often inaccessible to examination. Hook your
thumb and fingers around either side of the
sternomastoid muscle to find them THE THYROID GLAND
j. Supraclavicular – deep in the angle formed by
the clavicle and the sternomastoid INSPECTION
5. Palpable lymph nodes can be described as to: 1. With the patient seated, inspect the anterior lower half
a. Size of the neck.
b. Shape 2. Have him swallow to note any ascending mass in the
c. Surface/texture (smooth or irregular) midline or behind the sternocleidomastoid. The thyroid
d. Delimitation (discrete or matted) gland, the thyroid cartilage, and the cricoid cartilage all
e. Mobility (fixed or movable) normally rises as the person swallows.
f. Consistency (soft, firm or hard) 3. If the patient is obese, or has a short neck, tilt the
g. Tenderness patient’s neck backward, and ask him to place his
clasped hands on the occiput for support; instruct him
Note their size, shape, delimitation (discrete or matted to swallow while in this position.
together), mobility, consistency, and any tenderness. Small,
mobile, discrete, nontender nodes, sometimes termed PALPATION
“shotty,” are frequently found in normal people.
Best done behind the patient.

BATES’: 1. Place the fingers of both hands on the patient’s neck

1. Using the pads of the 2nd and 3rd fingers, palpate so that the index fingers are just below the cricoid
the preauricular nodes with a gentle rotary motion. cartilage—the basic landmark for examination.
Then examine the posterior auricular and occipital 2. Extend the patient’s neck but not far enough to tighten
lymph nodes. the muscles. Adjust the degree of extension as you find
necessary.
3. Feel the thyroid isthmus rise under your fingers as the
patient swallows
4. Rotate your finger slightly downward and laterally. Feel
as much of the lateral lobes as possible, including their
lower borders
5. During both maneuvers, the patient should sip water as
necessary to swallow as you repeat your palpation.

AUSCULTATION
Should be done if the thyroid gland is palpably enlarged. With
the bell of the stethoscope, listen for bruits while the patient
holds his breath.
2. Palpate the anterior superficial and deep cervical
The thyroid gland should be described as to:
chains, located anterior and superficial to the
1. Size
sternomastoid. Then palpate the posterior cervical 2. Shape
chain along the trapezius (anterior edge) and along 3. Symmetry
the sternomastoid (posterior edge). Flex the 4. Consistency
patient’s neck slightly forward toward the side 5. Presence of nodule
being examined. Examine the supraclavicular 6. Tenderness
nodes in the angle between the clavicle and the 7. Bruit
sternomastoid.
Two Physical Signs of Retrosternal Goiter: Sources/References:
1. Tracheal displacement • IPD B Manual
2. Venous engorgement in the neck • Bates’ Guide to Physical Examination and History
Taking (11th ed.)

NORMAL RESPONSE
The neck is normal in size, symmetrical, no visible mass,
normal muscle tone, no tenderness, full range of motion;
trachea in the midline, no palpable lymph nodes, the thyroid
Poks,
gland is not visible or palpable.

BATES’:
1. Inspect the trachea for any deviation from its
usual midline position. Then feel for any
deviation. Place your finger along one side of the
trachea and note the space between it and the
sternomastoid. Compare it with the other side. The
spaces should be symmetric.

2. Inspect the neck for the thyroid gland. Tip the

patient’s head back a bit. Using tangential lighting
directed downward from the tip of the patient’s
chin, inspect the region below the cricoid cartilage
for the gland. The lower shadowed border of the
thyroid glands shown here is outlined by arrows.

3. Observe the patient swallowing. Ask the patient

to sip some water and to extend the neck again and
swallow. Watch for upward movement of the
thyroid gland, noting its contour and symmetry. The
thyroid cartilage, the cricoid cartilage, and the
thyroid gland all rise with swallowing and then fall
to their resting positions.