HEENT: Techniques of Examination

Reference, unless noted: Bates' Guide to Physical Examination and History Taking, 12e, Ch. 7

The Head
Because abnormalities under the hair are easily missed, ask if the patient has noticed anything
wrong with the scalp or hair. Hairpieces and wigs should be removed.

Completion Technique Possible Findings Other info Notes

The Hair: note its quantity, See loose flakes of dandruff
distribution, texture, and any or lice nits
pattern of loss
Fine hair in hyperthyroidism
Seborrhea
Coarse hair in
hypothyroidism
Acromegaly

The Scalp: part the hair in several
places and look for scaliness,
lumps, nevi, or other lesions
Scaling and redness may
indicate seborrheic dermatitis
or psoriasis
Soft lumps: pilar cysts (wens)

Pigmented nevi: melanoma

Scalp melanoma Parkinson’s disease

The Skull: Observe general size Irregularities near the suture

and contour. Note deformities, lines between the parietal
depressions, lumps, or tenderness and occipital bones

Enlargement: hydrocephalus
or Paget’s disease
Nephrotic syndrome
Bony step offs: after head Closed depressed
trauma skull fracture

Myxedema

The face: Note the patient's facial Acne in adolescents

expression and contours. Observe
for asymmetry, involuntary Hirsutism: excessive facial
movements, edema, and masses hair (ex: in some women with
PCOS)
Observe the skin on the face and
head, notings it color,
pigmentation, texture, thickness,
hair distribution, and any lesions Parotid gland
Cushing's syndrome enlargement

The Eyes
Completion Technique
Visual Acuity:
To test the acuity of
central vision, use a
well-lit Snellen eye
chart. Position the
patient 20 feet from the
chart. Patients who wear
glasses other than for
reading should put them
on. Ask the patient to
cover one eye with a
card (to prevent looking
through the fingers) and
to read the smallest line
of print possible. Identify
the smallest line of print
where 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. Visual acuity
is expressed as two
numbers (e.g., 20/30):
the first indicates the
distance of the patient
from the chart, and the
second, the distance
at which a normal eye
can read the line of
letters.
Possible Findings Other Info Notes
Myopia
Presbyopia
Blindness or legally blind
If you have no charts,
screen visual acuity with
any available print. If
patients cannot read
even the largest letters,
test their ability to count
your upraised fingers and
distinguish light (such as
your flashlight) from dark.
In the US, a person is
considered legally blind
when vision in the better
eye, corrected by
glasses, is 20/200 or
less. Legal blindness
also results from a
constricted field of vision:
20 degrees or less in the
better eye
Visual Fields:
Confrontation testing of Visual field defects: A formalized automated
the visual fields is a perimetry test by an eye
valuable screening doctor is needed to make
technique for detection a definitive diagnosis of a
of lesions in the anterior visual field defect. Refer
and posterior visual pts with suspected visual
pathway. field defects for
● Static finger evaluation
wiggle test:
arms length
away from
patient; Close
one eye and
have the
patient cover
the opposite
eye while
staring at your
open eye. For
example, when Static finger wiggle test
the patient
covers the left
eye, to test the
visual field of
the patient's Anterior pathway defects: *Occasionally, in stroke
right eye you glaucoma, optic neuropathy, patients, for example,
should cover optic neuritis, glioma patients will complain of
your right eye partial loss of vision, and
to mimic the Posterior pathway defects: testing of both eyes
patent's field of stroke and chiasmal tumors reveals a visual field
view. Place defect, an abnormality in
your hands peripheral vision such as
about 2 feet homonymous
apart out of the hemianopsia. Testing
patient's view. only one eye would miss
Wiggle your this finding.
fingers and
slowly bring
your moving
fingers forward * Bates, Ch. 17, neuro
into the
patient's center
of view. Ask
the patient to
tell you as soon
as he or she
sees your
finger
movement.
Test each clock
hour, or at least
each quadrant.

An enlarged blind spot occurs

● Kinetic red
 target test: in conditions affecting the optic
Facing the nerve such as glaucoma, optic
patient, move a neuritis, papilledema
5-mm red-
topped pin
inward from
beyond the
boundary of
each quadrant
along a line
bisecting the
horizontal and
vertical
meridians. Ask
the patient
when the pin
first appears to
be red

Position of eyes: Esotropia: Inward deviation

Stand in front of the
patient and survey the Exotropia: Outward deviation
eyes for position and
alignment Abnormal protrusion: Grave’s
disease or ocular tumors

Eyebrows: Scaliness: seborrheic dermatitis

Inspect, noting fullness,
hair distribution, Lateral sparseness:
scaliness hypothyroidism

Eyelids:
Note position of lids
in relation to the
eyeballs

Ptosis
Entropion

Exophthalmos (Graves dz) Ectropion

Conjunctiva, and
Sclera:
Ask the pt to look up as
you depress both lower
lids with your thumbs,
exposing the sclera and
palpebral conjunctiva
and look down, ect..

Note vascular pattern

and color Pinguecula Episcleritis

Stye Chalazion

Blepharitis
Xanthelasma

Cornea, Lens and

Pupils:
With oblique lighting,
inspect the cornea of
each eye for opacities,
injuries Pupil sizes
Kayser-Fleischer Ring
Inspect the iris
See neuro exam
Inspect the pupils for
size, shape, and
symmetry *Anisocoria, or a
● The light difference of >0.4 mm in
reaction: ask Pterygium the diameter of one pupil
the pt to look compared to the other, is
into distance, seen in up to 38% of
and shine a healthy individuals.
bright light
obliquely into *Bates, ch. 17, neuro
each pupil.
Look for direct Cataracts
and
consensual Anisocoria: if equal in dim and
reaction bright light=benign, if brisk
pupillary constriction

Adie pupils *The near response,

● If the reaction tests pupillary
to light is Argyll Robertson pupils constriction (pupillary
impaired, test constrictor muscle) and
the near accommodation of the
reaction in both lens (ciliary muscle).
dim and normal
 light. Hold your
finger 10 cm *Bates, Ch. 17, Neuro
from pts eye.
Ask the pt to
look at it and
then directly
behind it.
● Inspect the
light reflection
of corneas.
They should be
visible slightly
nasal to the
center of the
pupils

Horner's syndrome

Oculomotor nerve paralysis

Extraocular There are a number of

movements: abnormal patterns of gaze See Neuro Exam
Assess the normal
Nystagmus: a fine rhythmic
conjugate movements of
oscillation of the eyes
the eyes in each
direction. Note any
Lid lag: as the eyes move from
deviation from normal
up to down: hyperthyroidism

Test the six EOM:

 Poor convergence in
hyperthyroidism

* Convergence test
(medial rectus muscles)

Test for convergence: *Bates, Ch. 17, Neuro

Ask the patient to follow
your finger as you move
it toward the bridge of
the nose. The
converging eyes
normally follow the
object w/in 5 to 8 cm of
the nose

Fundi (view with

opthalmoscope):
Examine your
patients eyes w/o
dilating their pupils
(obscures important
neuro findings)

Papilledema See next page on how

to use

Normal

Glaucomatous cupping
 Neovascularization

Steps for Using the Ophthalmoscope

● Darken the room. Switch on the ophthalmoscope light and turn the lens disc until you see the large round
beam of white light.* Shine the light on the back of your hand to check the type of light, its desired
brightness, and the electrical charge of the ophthalmoscope.
● Turn the lens disc to the 0 diopter. (A diopter is a unit that measures the power of a lens to converge or
diverge light.) At this diopter, the lens neither converges nor diverges light. Keep your finger on the edge of
the lens disc so that you can turn the disc to focus the lens when you examine the fundus.
● Hold the ophthalmoscope in your right hand and use your right eye to examine the patient's right
eye; hold it in your left hand and use your left eye to examine the patient's left eye. This keeps you
from bumping the patient's nose and gives you more mobility and closer range for visualizing the fundus.
With practice, you will become accustomed to using your nondominant eye.
● Hold the ophthalmoscope firmly braced against the medial aspect of your bony orbit, with the handle
tilted laterally at about 20° slant from the vertical. Check to make sure you can see clearly through
the aperture. Instruct the patient to look slightly up and over your shoulder at a point directly ahead
on the wall.
● Place yourself about 15 inches away from the patient and at an angle 15° lateral to the patient's line
of vision. Shine the light beam on the pupil and look for the orange glow in the pupil—the red reflex. Note
any opacities interrupting the red reflex.
● Examiner at 15-degree angle from patient's line of vision, eliciting red reflex.
● Now place the thumb of your other hand across the patient's eyebrow, which steadies your examining hand.
Keeping the light beam focused on the red reflex, move in with the ophthalmoscope on the 15° angle toward
the pupil until you are very close to it, almost touching the patient's eyelashes and the thumb of your other
hand.
● Absence of a red reflex suggests an opacity of the lens (cataract) or, possibly, the vitreous (or even an
artificial eye). Less commonly, a detached retina or, in children, a retinoblastoma may obscure this reflex.

○ Try to keep both eyes open and relaxed, as if gazing into the distance, to help minimize any
fluctuating blurriness as your eyes attempt to accommodate.
○ You may need to lower the brightness of the light beam to make the examination more comfortable
for the patient, avoid hippus (spasm of the pupil), and improve your observations.
 The Ear
The ear has 3 compartments: the external ear, the middle ear, and the inner ear

Completion Techniques Possible Findings Other info Notes

Inspection:
Look at auricle and
surrounding tissue for
deformities, lumps, and
skin lesions

If ear pain, discharge, or

inflammation: move the
auricle up and down, Benign necrotizing
press the tragus, and otitis externa
press firmly behind the
ear Positive “tug test” in Tenderness
acute otitis externa behind the ear in
acute otitis media
Otoscope eval of ear
canal and drum:

Acute otitis media

Straighten the ear canal
to insert otoscope

Hemotympanum

Brace against pts face:

Eardrum
perforation

Insert speculum at a
slight downward angle:

The whispered voice Interpretation:

Auditory Acuity:
The whispered voice test
To begin, ask the patient “Do
Detects >30 test is a reliable
○ Normal: Patient
decibels of hearing screening test for
loss hearing loss if the
you feel you have a hearing examiner uses a repeats initial
loss or difficulty hearing?” If the standard method of
patient reports hearing loss, testing and exhales sequence
proceed to the whispered voice before whispering. correctly.
test.
● Stand 2 feet behind A formal hearing test ○ Normal: Patient
is the gold standard
the seated patient so responds
that the patient cannot incorrectly, so test
read your lips. a second time with
● Occlude the non test
a different
ear with a finger and
number/letter
gently rub the tragus
combination;
in a circular motion to
prevent transfer of patient repeats at
sound to the non test least three out of
ear. the possible six
● Exhale a full breath numbers and
before whispering to letters correctly.
ensure a quiet voice. ○ Abnormal: Four of
● Whisper a
the six possible
combination of three
numbers and
numbers and letters,
letters are
such as 3-U-1. Use a
different number/letter incorrect. Conduct
combination for the further testing by
other ear. audiometry.

Testing Conductive vs
Neurosensory Hearing
Loss:
See neuro exam

The Nose and Paranasal Sinuses

Completion Techniques Possible Findings Other info Notes

Inspection: Tenderness at the tip

The anterior and or alae suggest local
inferior surfaces infection: (i.e furuncle)
of the nose

Gentle pressure Note any asymmetry

on the tip of the
nose usually
widens the
nostrils

Test for
obstruction (as
indicated): Press
on each ala nasi
in turn and ask
the patient to
breathe in

Inspect inside
nares with
otoscope:
Tilt the head
back a little,
avoid contact
with the Nasal polyps
sensitive nasal
septum. Look for Viral or allergic rhinitis
blood, edema,
ulcers, ect..

Palpate Local tenderness,

sinuses: together with
symptoms of facial
pain, pressure,
fullness, purulent nasal
discharge >
7days=acute bacterial
rhonosinusitis
Frontal sinus
Maxillary sinus

The Mouth and Pharynx

If the patient wears dentures, offer a paper towel and ask the patient to remove them so that
you can inspect the underlying mucosa. If you detect any suspicious ulcers or nodules, put on a
 glove and palpate any lesions, noting any thickening or infiltration of the tissues that might
suggest malignancy

Completion Techniques Possible Findings Other info Notes

Inspection: Denture stomatitis

The lips
Oral mucosa Central cyanosis

Observe color and Pallor from anemia

moisture. Note any
lumps, ulcers, cracking,
or scaliness

Look inside the mouth

with a good light and with
the help of a tongue
blade to look at buccal
mucosa and
under/around tongue Angioedema

Look at
gums/teeth/tongue which
are normally pink

HSV, I

Angular cheilitis

Gingivitis

Inspection:
Pharynx:

Ask the patient to say

“ah” or yawn

Alternatively, you can

use a tongue blade to
press the tongue down.
 Inspect the soft palate,
anterior/posterior pillars,
uvula, tonsils, and
pharynx

Also assess voice

Diphtheria

Hoarseness, choking
with speaking or
swallowing

The Neck

Completion Technique Possible Findings Other info Notes

Inspection:
Divide each side of the
neck into two triangles
and visualize the borders
of the neck

Note symmetry, masses, Scar from thyroid

scars over thyroid gland surgery
or deviation of trachea

Tip the pts head slightly

back and using tangential
lighting direct downward
from the tip of the pts
chin, ID the contours of
the gland
Deviated trachea

Ask the patient to sip Nodular goiter

some water and to
extend the neck again
and swallow. Watch for
upward movement of the
thyroid gland, noting its
contour and symmetry.

Palpation: A pulsating “tonsillar Occasionally, you

Palpate superficial and node” is the carotids. may mistake a band
deep lymph node chains A small hard tender of muscle or an
using index and middle tonsillar node high artery for a lymph
fingers. The pt should be and deep between node. Unlike a
relaxed with the neck the mandible and muscle or an artery,
flexed slightly forward. SCM is probably you should be able
styloid process to roll a node in two
Subclavicular nodes: directions. Neither a
For the submental node, esp left, suggest muscle or an artery
it is helpful to feel with possible mets from will pass this test.
one hand while bracing thoracic or abd
the top of the head malignancy

Palpate the trachea:

Note deviation

Palpate thyroid gland:
ROM
Auscultation:
Trachea: allows subtle
counting of respirations
and is a point of reference
when assessing upper
versus lower airway
causes of SOB
caused by masses,
atelectasis, or large
pneumothorax
Tenderness in
thyroiditis This may seem
difficult at first. Use
Retrosternal goiters the cues from visual
can cause inspection. Find
hoarseness, sob, your landmarks—
stridor, or dysphagia the notched thyroid
from tracheal cartilage and the
compression cricoid cartilage
below it Locate the
Restriction of ROM
thyroid isthmus,
Stridor: ominous,
usually overlying
high-pitched musical the second, third,
sound from severe and fourth tracheal
subglottic or tracheal rings.
obstruction=emergen
cy