Health Assessment

1. Health Assessment Head, Eyes, Ears, Nose, Mouth, & Neck

2. 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

3. 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.

4. 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.

5. 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. TMJ

6. Anatomy

8. 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

9. 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?

10. ROS: Eyes • Wear glasses or contacts? • When was last exam by ophthalmologist or optometrist? • <40 y/o every 3-5 years • >40 y/o every 2 years • >65 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

11. RN Chart Symptoms • Burning • Discharge • Discomfort • Dryness • Ecchymosis • Edema • Itching • Pressure • Redness • Sclera hemorrhage • Stye • Tearing • Visual field loss

12. 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

13. Confrontation tests/Peripheral Visual Fields • Gross measure of a patient’s 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. • Normal=when 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.

14. 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.

15. 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.

16. 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.

17. 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.

20. 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.

21. 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)

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

23. Ophthalmoscopic Exam • Getting Started • Start at the “0” diopters • Use large, round beam of light • Use your right hand and right eye for patient’s right eye, and your left eye for patient’s left eye • Get close • Darken room • Have patient gaze at a distant object

24. 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.

25. 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

26. 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.

27. 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

28. Ophthalmoscopic Exam • Vessels • Arterioles brighter than veins, 25% smaller • A:V ratio 2:3 • Arterioles and veins cross each other without changing in diameter Observed vessels were without nicking. AV ratio 2:3 • 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.

29. Ear Anatomy

30. Anatomy

31. 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

32. 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

33. 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.

34. 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

35. 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.

36. Examining the Ear Canal and Drum • Use an otoscope with the largest ear speculum that the canal will accommodate • Position the patient’s 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 patient’s face • Insert the speculum gently into the ear canal, directing it somewhat down and forward

37. 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.

38. 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.

39. Abnormal TM

40. 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.

41. 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

42. 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: AC>BC (2:1 ratio) • Conductive hearing loss- BC=AC or BC>AC • Sensorineural hearing loss- heard longer thru air, but less than 2:1 ratio

43. 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)?

44. Nose and Paranasal Sinuses • Allergic Rhinitis • Itching • Swelling • Rhinorrhea • Sneezing • Tearing eyes • Later- stuffy nose, coughing, decreased smell, sore throat, dark circles under eyes

45. 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.

46. 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.

47. 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

48. Mouth and Pharynx • ROS • Sore throat • Sore tongue • Bleeding from the gums • Tooth pain • Hoarseness

49. 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.

50. 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.