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Study Sheet: Head, Neck, Eye, Ear, Nose, Mouth
Assessment
1. Eye Assessment
1.1 External Anatomy & Inspection
Eyelids & lashes: symmetry, ptosis (drooping), incomplete closure, entropion, ectropion, hordeolum, blepharitis
Ptosis causes: aging, trauma, congenital, myasthenia gravis Incomplete closure: risk of exposure keratitis Conjunctiva & sclera
Bulbar conjunctiva: overlays eyeball—normal pink over lower lids, white over sclera; abnormal: redness, pallor, cyanosis Limbal conjunctiva merges with cornea at limbus Sclera: tough, protective, continuous with cornea Lacrimal apparatus
Anatomy: lacrimal gland (upper outer corner), puncta at inner canthus → canaliculi → sac → nasolacrimal duct → inferior meatus Palpation technique: patient looks down; lift outer upper lid; press puncta—normal no response; abnormal: redness, swelling, pain, regurgitation indicates obstruction/infection
1.2 Cornea & Lens Inspection
Technique: shine light across surface—should be smooth, transparent Abnormal: cloudiness, irregular ridges (abrasion)
1.3 Extraocular Muscles & Gaze
Six muscles: four recti (straight), two obliques (rotary) Innervation:
CN III (oculomotor): superior, inferior, medial rectus; inferior oblique CN IV (trochlear): superior oblique CN VI (abducens): lateral rectus Cardinal fields of gaze: assess alignment, muscle function, convergence
Normal: smooth tracking, convergence at ~5 inches Abnormal: EOM weakness, CN dysfunction, strabismus
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1.4 Corneal Light Reflex & Cover Tests
Corneal light reflex (Hirschberg): assess parallel alignment of visual axes Cover-uncover: detect phoria (latent deviation) or tropia (manifest deviation)
1.5 Pupil & Iris
PERRLA: pupils equal, round, reactive to light and accommodation Anisocoria: physiologic ±20%; pharmacologic dilation; Horner’s syndrome; CN III palsy
1.6 Visual Acuity & Fields
Distance: Snellen chart (20 ft) or pocket Snellen/Rosenbaum (14 in) Near: Rosenbaum card with pupil gauge Confrontation: gross peripheral fields; abnormal suggests peripheral vision loss Screening guidelines for glaucoma (AAO):
40–54 yr: every 1–3 yr; 55–64 yr: 1–2 yr; ≥65 yr: every 6–12 mo
1.7 Ophthalmoscopic Exam
Fundus: red reflex; optic disc (flat, sharp margins); vessels (no crossing defects); retina (no hemorrhages/exudates); macula even coloration Inner layer: retina, optic disc, vessels, macula
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Abnormal:
Acute otitis media: red, bulging TM, diminished landmarks, air-fluid level Serous otitis media: yellow-amber TM Chronic OM: thickened TM, perforations Fungal: black/white dots Foreign bodies: ticks, beans
2.3 Hearing Assessment
Voice (whisper) test: one ear at a time, 1–2 ft behind, whisper a 2-syllable word Tuning-fork tests:
Weber: midline—lateralizes to poor ear (conductive), good ear (sensorineural) Rinne: AC vs BC—AC > BC normal; BC > AC conductive loss
2.4 Equilibrium
Labyrinth (inner ear): semicircular canals, vestibule inform brain of head position Inflammation → vertigo, staggering gait
2.5 Middle Ear Function
Conducts vibrations, protects via acoustic reflex, equalizes pressure via Eustachian tube
2.6 Anatomy
Outer ear → TM → ossicles (malleus, incus, stapes) → cochlea & vestibular apparatus (bony labyrinth) → CN VIII
3. Nose Assessment
3.1 External Nose
Inspect symmetry, midline, proportionality, lesions, skin changes Palpate for pain, deformities; test patency both nostrils Anatomy: dorsum, sidewalls, tip, columella (divides nares), vestibule (nares widening)
3.2 Internal Nose
Septum: Kiesselbach’s plexus common epistaxis site Turbinates: superior, middle, inferior—increase surface area Paranasal sinuses: frontal (age 6–7), maxillary (by 4), ethmoid, sphenoid (by 6) Transillumination in children: poor sensitivity/specificity for sinusitis
3.3 Sinus Palpation & Percussion
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3.4 Health History Cues
Discharge, frequent colds, sinus pain, trauma, epistaxis, allergies, smell changes
4. Mouth & Throat Assessment
4.1 Lips
Inspect color, moisture, cracking, lesions
Pallor: anemia/shock; cyanosis: hypoxemia; cherry-red: CO/aspirin poisoning; cheilitis, angular cheilitis (Crohn’s, SCC risk)
4.2 Teeth & Gums
Inspect missing/cracked/decayed teeth, alignment, color, swelling, sponginess Consider gingivitis, periodontal disease, scurvy, meds (Dilantin, cyclosporin)
4.3 Tongue & Oral Mucosa
Tongue: color, surface, moisture, movement, ventral veins; abnormal: tremor, fasciculations, cracks, dryness, Candida under dentures, Staph/nutritional deficiency on natural teeth, herpes simplex, angioedema Nasopharynx: adenoids, Eustachian tube openings
4.4 Throat & Pediatrics
Dentition eruption schedules (child acuity ~20/50 by 12 mo, 20/40 <4 yr, 20/30 ≥4 yr)
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Vascular anatomy: carotid arteries, external & internal jugular veins, temporal artery (palpate/auscultate for bruit, tenderness)
5.4 Thyroid Examination
Anatomy: two lobes + isthmus straddling trachea above cricoid, highly vascular, secretes T3/T Inspect with neck hyperextended—nodules, symmetry, enlargement; palpate posterior approach— normally not palpable; abnormal: enlarged, tender, nodular
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5.5 Thyroid Dysfunction
Hypothyroidism: dry hair, puffy face, bradycardia, weight gain, constipation, brittle nails, cold intolerance, depression, fatigue, memory loss, heavy menses, muscle aches, hair loss Hyperthyroidism: weight loss, heat intolerance, sweating, tachycardia, exophthalmos, irritability, insomnia, scant menses
6. Key Clinical Tips
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