Page 432 - 2021 IDMT Digital

26. Palpate auricles and tragus “nontender bilaterally”
27. Inspect external auditory canals “no swelling, redness, or obstruction”
28. Inspect general appearance of “TMs are pearly gray and translucent;
TMs light reflex is ant-inf. quadrant; pars
tensa, pars flaccida, umbo, handle of
malleus visualized and undistorted”
29. Inspect for fluid in middle ear “no fluid behind TM”
30. Inspect mobility of TMs “TM’s mobile”
31. Otoscope exam technique
32. Whisper test “CN VIII intact”
33. Perform Weber test “Weber is equal bilaterally’
34. Perform Rinné test “Rinné is AC > BC bilaterally”
Nose and Sinuses
35. Inspect/palpate nose “nose is midline and without lesions or
tenderness”
36. Check patency of nares “nasal passageways are patent”
37. Discrimination of odors “CN I intact”
38. Inspect septum, turbinates, and “mucosa is pink and moist without
floor of nasal cavity lesions; septum is without perforations;
unable to visualize superior turbinate,
middle and inferior turbinates are
without polyps, edema, exudates or
discharge”
39. Technique of nasal speculum
40. Palpate and percuss paranasal “no maxillary or frontal tenderness”
sinuses
Mouth and Throat
41. Inspect lips, oropharyngeal “lips are pink, mucosa moist without
mucosa, gingiva lesions, swelling or discoloration”
42. Inspect tonsils and uvula “Tonsils are [grade size] and equal with
midline uvula; no exudates or lesions”
43. Inspect tongue surface “no discoloration or lesions”
44. Inspect Stensen’s and Wharton’s “no stones or obstructions”
ducts
45. Perform bimanual exam “no edema, masses or lesion”
(Palpate lips, tongue, gingival and buccal
mucosa)
46. CN XII “Tongue is midline, CN XII intact”
47. Inspect and percuss teeth “teeth are in good repair and
nontender”
48. CN IX/X “Uvula rises with phonation and gag
reflex is present”
Neck
49. Inspect skin of neck “no lesions, swelling, discoloration and
musculature is symmetrical”
50. Inspect for trachea position “trachea is midline”
51. Palpate trachea for mobility “trachea is mobile”
52. Palpate lymph nodes of neck and “no lymphadenopathy”
head
(occipital, pre and postauricular,
submental, submandibular, tonsillar,
superficial cervical, deep cervical,
posterior cervical, supra and
infraclavicular )
53. Inspect and palpate thyroid gland “thyroid is normal size, shape, and
consistency without nodules or
tenderness”
54. Test active ROM of neck “full active ROM without pain”
(flexion, extension, lateral bending,
rotation)
55. Strength testing “CN XI intact”

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