Exam Summary

1. Introduction

  • Introduce yourself and the exam
  • Position the patient so that you will be looking at them at eye level
  • Hand hygiene

2. Ear

a. Pinna

The pinna is the visible, external part of the ear

i. Inspection

  • Size
  • Shape
  • Swelling
  • Scars
  • Obvious Discharge (Otitis externa)
  • Gouty tophi

ii. Palpate

Palpate for:
  • Swelling
  • Nodules

b. Otoscopy

  • Ask patient to tilt their head slightly to the side
  • Pull the pinna up, out and back
  • Stretch out the fingers on the hand with the otoscope to touch the patient's cheek, to stabilise the otoscope and prevent the otoscope from advancing too far.

i. External canal

Look for:
  • Inflammation
  • Discharge
  • Blood or Cerebrospinal fluid (skull fracture)
  • Vesicles (Shingles)

ii. Tympanic Membrane

Look for:
  • Light reflex (anteriorly and inferiorly) - absence may be abnormal
  • Shape
  • Transparency
  • Dilated blood vessels - a sign of otitis media

c. Hearing

  • Test each ear individually
  • Rub fingers in front of the ear not being tested
  • Whisper words or numbers about sixty centimetres from the patient. Make sure to do this behind the patient so that they cannot lipread

d. Tunning Fork

i. Rinnè's Test

  • Place a vibrating tuning fork on the mastoid process (bone conductance)
  • When the patient can no longer hear it, move the tuning fork close to the ear opening (air conductance)
  • The patient should be able to hear the tuning fork again.

ii. Weber's Test

  • Place a vibrating tuning fork in the centre of the patient's forehead
    • It will normally be heard equally in both ears
    • Nerve deafness will cause the vibration to be heard better in the normal ear
    • Conduction deafness will cause the vibration to be heard better in the abnormal ear

3. Nose

a. General Inspection

  • Inspect skin - an enlarged nose may be due to a skin condition called rhinophyma
  • Look for deviation of the nose by standing behind the patient and looking down
  • Look for periorbital swelling (from sinusitis)
  • Inspect the nares by tilting the nose upwards with your thumb.

b. Palpation

  • Nasal bones
  • Facial swelling

c. Sinuses

Illuminate the sinuses with a torch in a dark room in one of two ways:
  • Place the torch in the patient's mouth and watch the sinuses.
  • Place the torch on the patient's sinuses and look into the mouth

4. Throat

a. Lips and Mucosa

Look for:
  • Herpetic Ulcers
  • Cyanosis
  • Signs of Dehydration
  • Angular Stomatitis
  • Masses
  • Inflammation (mucosa)
  • Parotid duct inflammation
  • Leukoplakia (painless white plaque) - premalignant condition
  • Erythroplakia (red papules that bleed easily) - premalignant condition

b. Gums and Teeth

Look for
  • Gum hypertrophy - may be due to phenytoin (drug), leukaemia or pregnancy
  • Dental Health/ Missing teeth

c. Tongue

  • Ask patient to poke out tongue straight, then side to side
  • Look for:
    • Geographical Tongue - common and benign
    • Elongation
    • Pigmentation - food or tobacco
    • Candida

d. Floor of Mouth

  • Ask patient to lift tongue up also
  • Look for a ranula which is mucous retention cyst in the salivary glands, it may cause dysphagia.

e. Palpation

  • Using a gloved hand feel the anterior two-thirds of the tongue for hardening or masses.
  • Feel the floor of the mouth. Push the patient's cheeks in between their teeth so you don't get bitten.
  • Feel the submandibular salivary glands.

f. Pharynx

  • Ask the patient to say "Ah!" and use a tongue depressor
  • Look for uvula deviation - due to vagus nerve problem
  • Assess the pharynx for
    • Redness
    • Ulceration

g. Tonsils

Look for:

5. Lymph nodes

Examine the cervical lymph nodes from behind the patient.

6. Conclude

Thank the patient and offer assistance.


Talley and O'Connor Clinial Examination - 7th edition pp516-526