Topic: Head, Eyes, Ears, Nose & Throat SOAP NOTE

Physical Examination Checklist

Video #2 Focused Head and Neck Exam—patient sitting upright

Head (2 points)

__/1 point: Inspect general size and contour of the skull noting deformities, depressions, lumps, or tenderness

__/1 point: Inspect the face noting expression, contour, symmetry, involuntary movements, edema, and masses

Eyes (16 points)

__/1 point: Inspect eyelids, eyelashes, palpebral fissures, and alignment of eyebrows

__/1 point: Inspect lacrimal apparatus, conjunctiva, and sclera noting color, swelling, discharge, vascularity, or nodules

__/1 point: Inspect cornea, lens, and pupils noting opacities, size, shape, and symmetry

__/2 points: Assess visual acuity (CN II) (Use Snellen/Rosenbaum chart at 1 point:4”-ask the patient to cover one eye and read smallest print line possible)

__/2 points: Assess pupillary response to light (direct and consensual)

__/1 point: Assess pupillary response to accommodation

__/2 points: Assess visual fields by confrontation (CN II)

__/2 points: Assess extraocular movements (CN III, IV, VI) including convergence, noting nystagmus and lid lag

__/4 Perform ophthalmoscopic exam adjusting light, positioning the patient, and holding the ophthalmoscope correctly to identify red reflex, and optic disc, retina, fovea, and macula

Ears (8 points)

__/2 points: Inspect the auricles and surrounding tissue for symmetry, deformities, lumps, or lesions

__/2 points: Inspect the ear canal noting discharge, foreign bodies, redness, swelling, and cerumen

__/4 Perform otoscopic exam correctly positioning patient, auricle, and scope

__/1 point: Test auditory acuity using whisper test (CN VIII) (stand 1 point: to 2 points:’ behind patient, ask them to occlude one ear and whisper a two-syllable word)

Special Techniques (2 points)

__/1 point: Test for lateralization of sound—Weber Test

__/1 point: Compare air conduction and bone conduction of sound—Rinne Test

Nose (6 points)

__/1 point: Inspect for asymmetry, lesions, and deformity

__/1 point: Palpate nares to asses for nasal obstruction

__/1 point: Inspect the nares with the otoscope noting color, swelling, bleeding, exudate, ulcers, or polyps of nasal mucosa and deviation, Inflammation, or perforation of the septum

__/2 points: Palpate frontal and maxillary sinuses for tenderness

__/1 point: Test for olfactory function (CN I)

Mouth (3 points)

__/0.5 points: Inspect the lips noting color, moisture, lumps, ulcers, cracking, or scaliness

__/0.5 points: Inspect the oral mucosa noting color, areas of pigmentation, ulcers, white patches, and nodules

__/0.5 points: Inspect the gums and teeth noting color, swelling, ulceration, bleeding, retraction, abnormal position, or looseness

__/0.5 points: Inspect the tongue and floor of the mouth noting color and texture

__/1 point: Inspect the posterior pharynx, soft palate, anterior and posterior pillars, uvula, and tonsils noting rise and fall of the soft palate (CN X),

color, symmetry, swelling, ulceration, or exudate

Neck (13 points)

__/1 point: Inspect the neck noting symmetry, masses, scars, enlargement of glands, or visible lymph nodes

__/10 points: Palpate lymph nodes noting size, shape, mobility, consistency, and any tenderness—pre-auricular (front of ear); posterior auricular (superficial to the mastoid process); occipital (posterior base of skull); tonsillar (angle of the mandible); submandibular (midway between angle and tip of the mandible); submental (midline behind the tip of the mandible); superficial cervical (superficial to the sternocleidomastoid); posterior cervical (along anterior edge of the trapezius); deep cervical chain (deep to the sternocleidomastoid); and supraclavicular (deep in the angle formed by the clavicle and sternocleidomastoid)

__/1 point: Inspect and palpate trachea for deviation

__/1 point: Inspect and palpate the thyroid gland at rest and with swallowing noting size,symmetry, consistency, tenderness, and nodularity

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