Third Return Demonstration

Head to Neck (Script)

Nurse – Bianca Sandoval
Patient – Gloria Navalta

Preparation
Nurse: Good afternoon po, this is Bianca Sandoval po, I will be
your student nurse for today. What may I call you po Ma’am?

Patient: Good afternoon! You may call me Ma’am Glo.

Nurse: Alright Ma’am Glo. So, for today I am here to inform you
po what we will be doing, it focuses on head to neck assessment.
Basically, it is for holistic approach and proper diagnosis po.

Patient: Oh great, is that all?

Nurse: Hm, for an instance Ma’am, I will be asking you po to do

some things like look at your left, look at your right, some things
like that po. And I will touch and hold your face po. So, I am
hoping for your deepest cooperation po Ma’am.

Patient: Alright, it’s fine. I will cooperate.

Nurse: Thank you so much po, Ma’am. By the way, I already

performed my hand hygiene po so we could be able to continue
afterwards. And for a while po, I will just be assembling the
equipment that we will be using.

Patient: Sure, go on.

Nurse: Oh, and ma’am I will just ensure your privacy by closing
the curtain and the door.
Head and Face

Nurse: I will begin po first by inspecting your head. (inspect the

head)

Nurse: The size of your head is just the same size as how it should
be for your age po. There is no seen abnormal or twitching of the
face po and you have a normal face symmetry po Ma’am.

In addition to that po, your eyes and ears have the same level. And
now, I will be palpating your head po and kindly please let me
know if there are tenderness. Is that fine po Ma’am?

Patient: Yes, you may.

Nurse: Let me just put on my gloves for a second. (Lagay gloves,

tapos palpate the head)

Alright, thank you po Ma’am. I will now palpate your temporal

artery to feel for any unequal and abnormally strong or weak
pulsations. (perform and palpate)

Okay po Ma’am, thank you. Now po, I will be palpating your

temporomandibular joint. I will be asking you po to open and close
your mouth and again please let me know if there is tenderness
while I am palpating. Is that fine po Ma’am?

Patient: Yes, it’s fine, go ahead.

Nurse: Alright po. (Begin palpating, ask to open and close the
mouth) Hmm, I feel none for any grading or clicking sensations po
Ma’am. Thank you for letting me po.
Neck

Nurse: I will begin po by inspecting your neck. Can you please

extend your neck po up a little bit? (Gagawin ni lola) Alright,
thank you po. Your trachea is in midline po, and by looking po I
don’t see any lesions or lumps. Thank you po. Now, I will be
inspecting the movement po of your neck structures. I will ask you
po to move your head alright, is it fine with you po, Ma’am?

Patient: Yes, it’s alright.

Nurse: Can you please move your head po from side to side? Up
and down? (gagawin ni Lola)

Okay po, thank you. Next one po, can you please move your head
po to the left side (gagawin ni lola) Now to the right side po.
(gagawin ni lola) Alright po Ma’am thank you so much, can you
please do side bending po, you were just like reaching your
shoulders po. (gagawin ni lola) Then, can you bring your chin into
your neck and stretch a little bit. (gagawin ni lola) Lastly, please
bring your chin again into your neck and this time stretch more and
look up.

Thank you so much for your cooperation Ma’am, are you feeling
any discomfort po?

Patient: None, I’m good.

Nurse: Okay po Ma’am, your cervical spine is within normal

curvature anteriorly and posteriorly.

Let’s proceed to the next one po Ma’am, I will be palpating your

trachea. (execute) Do you feel any tenderness po Ma’am?
Patient: No, I don’t feel any.

Nurse: Alright. By palpating it, I don’t feel any lumps po. Next
one, I will be palpating your thyroid gland and please let me know
if there is tenderness. (palpate it) Can I ask you to swallow
Ma’am? Thank you po. It is soft, smooth, symmetrical, and non-
tender po Ma’am and it slides upward slightly when swallowing.

Moving on, I will be palpating your lymph nodes po. As I do it po,

tell me if you feel any tenderness po, okay?

Patient: I will, thank you.

Nurse: Alright po, I will begin. (Palpate)

Alright Ma’am, there is no swelling or enlargement and no

tenderness po.

EYES

Nurse: I will begin po by testing distant visual acuity po. Kindly

take a look at the Snellen chart po, do you wear glasses po Ma’am?

Patient: No, I don’t.

Nurse: Alright. Now, look at the chart po Ma’am, try to read the
lowest line that you can read po. What line can you read po
Ma’am?

Patient: Line 5.

Nurse: Okay po, read it for me Ma’am.

Patient: P E C F D
Nurse: Okay, good po. Now, let us proceed by testing near visual
acuity. First, you will cover your right eye po, then your left eye,
and then we’ll do both eyes. Okay Ma’am, please cover your right
eye. (gagawin ni lola) Tell me po what line can you read.

Patient: Still the same line. P E C F D.

Nurse: Okay Ma’am, please cover your left eye. What line can you
read po?

Patient: Line 5. P E C F D.

Nurse: Alright, now po read po with your both eyes. And again,
what line po Ma’am?

Patient. Line 5 still. P E C F D.

Nurse: Please read the next line still with the left eye covered.
(instruct the patient to read each line, stop only if she can no longer
read it; record the visual acuity. Then move on by covering the
other eye with the same instruction) Thank you so much Ma’am.
Now, look straight into my eyes and I will move this pen upward
and downward then tell me if you can see the pen I am holding.
(execute) Next po, cover your right eye, and I will be closing my
left eye. And do the same, tell me again po if you can see the pen
that I am holding. (execute) Okay po Ma’am, you have a normal
visual field that measures about 90 degrees temporally, 50 degrees
superiorly, 60 degrees nasally, and 70 degrees inferiorly. Next up, I
will perform a corneal light reflex Ma’am, is that fine with you po?

Patient: Yes, carry on dear.

Nurse: I will hold a penlight 12 inches away from you and shine
the light towards the bridge of your nose while you stare straight
ahead, understood po Ma’am?

Patient: Yes.

Nurse: Alright po. (execute) You don’t have an uneven gaze

Ma’am; my penlight is showing up very clearly in both pupils in
relatively the same spot on the medial upper aspect of the pupil.
This means po that the test is negative for any sort of disk
asymmetry between in the gaze or between the two pupils.] On to
the next one Ma’am, we will be performing a cover test. Kindly
stare straight ahead po and focus on a distant object. Cover one of
your eyes po. (gagawin ni lola, then observe ako sa any movement
nung covered eye) Alright Ma’am, cover the other eye and do the
same thing. (gagawin ni lola, then observe) Okay Ma’am, thank
you so much po. Noted that there is no any ocular deviation po, no
strabismus or misalignment that is present po.

Patient: That is very nice to know.

Nurse: Alright, I will be inspecting your eyelids and eyelashes. For

your eyelids po, there is no scales or lumps. No noted redness,
swelling, discharge or lesions. Your eyes are set in the eye socket
equal po. Also, it is fitted smoothly against the eyeball. May I pull
down your lower lid po and kindly please look up? (execute) Okay
Ma’am, thank you po. The palpebral conjunctiva is pink and has
no discharge noted. The eyelids and eyelashes are pointing
outwards away from the eyeballs. Then, the bulbar conjunctiva and
sclera is white and no noted icterisia. Alright next one po, I will
evert the upper eyelid Ma’am. Kindly look down po Ma’am.
(execute) Thank you po Ma’am, there is no noted foreign body.
Now, I will inspect and palpate the lacrimal apparatus. As I
palpate, tell me if you feel any tenderness. (execute) It is
symmetrical. No noted tenderness during palpation. I will now
inspect the cornea and lens. I will shine my light through the
midline of your eyes. Cornea is translucent, smooth, and avascular.
And lens is transparent and uniform in density. Now, I will inspect
the iris and pupils.

You have a normal pupil, equal in size, and round. I will now
perform Pupillary Light Reflex Ma’am, I will shine the penlight on
the side of your eyes, and I will observe the sizes of your pupils.
Also, I will assess your consensual response, it’s when I shine light
into the side of the eye, I will or will not see that the other pupil
constricts simultaneously with the eye. (Execute) They constrict po
to direct illumination and to illumination of the opposite eye which
is the consensual response po. And upon inspection po, your pupils
are reactive to both direct and consensual light reflex with 2-3 mm
in size which means that it is normal po.

Now, I will test the accommodation of your pupils. Kindly fixate

your eyes po on this penlight in front of you, and I will slowly
move it towards your face po, then I will be observing your pupils
and see how well they are fixating on the object, whether they are
doing it together, and are those pupils are constricting as the object
moves closer. (Execute) Okay Ma’am thank you po, those pupils
accommodate appropriately. Pupils are equal, round, reactive to
light and has accommodation.
EARS

Nurse: I will begin po first by inspecting your auricle, tragus, and

lobule. There are no noted lesions on the auricle, tragus, and
lobules. Next one, upon inspecting the external auditory canal, it is
not hyperemic, no lesions noted, no ear discharge po and no
apparent obstruction. Now, I will be palpating po your auricle and
mastoid process. Please tell me if you feel any tenderness Ma’am,
okay?

Patient: Okay, I will.

Nurse: There is no noted tenderness po Ma’am upon palpation of

auricle and mastoid process. Next po, I will be performing for a
whisper test and let me know if you were able to hear on each ear.
(execute)

Patient: Yes dear, I am able to hear.

Nurse: Alright Ma’am, you were able to hear the whispered sound.
Then, I will now perform Weber’s Test. I will tap the tuning fork
strongly on my palm po and then press the butt of the tuning fork
on the top of your forehead in the midline and tell me po where do
you hear the sound.

Patient: Alright. (execute) I can hear on both ears.

Nurse: Okay po Ma’am, the sound is heard equally in both sides it

means that there is no bone conduction problem.

Now, let’s do the Rinne’s test.

I'll place a tuning fork on your mastoid area; please let me know
when you stop hearing it; after which, I'll place it near your ear so
you can hear it once again. The abnormal finding is when you
don’t hear it when I placed it near your ear so kindly please tell
me. Ma’am. May I po?

Patient: Yes, you may.

Nurse: (execute)

Patient: I don’t hear it anymore.

Nurse (placing the tuning fork on the side of the ear) Do you hear
it now?

Patient: Oh, yes!

Nurse: Good, it means that the air conduction is greater than the
bone conduction po. Next one, I will be performing a Romberg’s
Test. I will be asking you po to stand up, stretch your arms
sidewards and close your eyes for 5 seconds. I will just be here
behind you po just in case, to prevent you po from falling. You
may begin po.

Patient: (execute)

Nurse: Alright po Ma’am, thank you. We may now go back to our

seats; you are able to stay on upright position po without difficulty
even when the eyes are closed.

Patient: That’s good to hear.

NOSE

Nurse: I will begin by inspecting and palpating your external nose.

(palpate) Okay Ma’am, there is no noted lesions upon inspection
and no noted tenderness upon palpation of the nose. Now, I will
check patency of airflow through your nostrils po. I will place this
piece of paper in front of your right nostril while covering your left
nostril po then exhale. Then we will repeat in on the opposite side.
May we begin po?

Patient: Yes, you may.

Nurse: (execute) Okay po Ma’am, thank you. Upon checking, both

nostrils are patent, air flows with ease po. Next one, I will be
inspecting the nasal cavity and nasal septum. Please raise your
head a bit po Ma’am. (inspect) Alright Ma’am, there is no noted
lesions, and the nasal septum is not deviated upon inspection.

SINUSES

Nurse: I will begin po by palpating your sinuses and to be followed

by percussing your sinuses. Just tell me po if you feel any
tenderness when I palpate.

Patient: Alright.

Nurse: (execute) There is no noted tenderness po upon palpation of

the maxillary and frontal sinuses and both frontal and maxillary
sinuses are tympanitic upon percussion po.
MOUTH AND THROAT

Nurse: I will begin po by inspecting your lips, to be followed by

inspecting your teeth and gums. I will ask you to open your mouth,
like that. Is it fine po Ma’am?

Patient: Yes, it is fine.

Nurse: Alright po Ma’am. (inspect) Your lips are moist with no

lesions noted po. Can you please open your mouth po? (inspect)
And you are wearing dentures with no noted swelling po and
inflammation on the gums. Now, I will inspect your buccal
mucosa. Please open your mouth again po. (inspect) There is no
lesion noted on the buccal mucosa po. Let’s proceed po by
inspecting and palpating the tongue. Just let me know if you feel
any tenderness po. Let me just wear my gloves Ma’am. (wear and
execute) For a while Ma’am, I will just discard these gloves po.
(discard) Alright Ma’am, there are no noted lesions on the tongue
and no tenderness noted po upon palpation. Next up, I will be
assessing po the ventral and lateral surface of your tongue and
wharton’s duct. Kindly open your mouth po and lift your tongue.
(gagawin ni Lola) Okay Ma’am thank you po, there are no noted
lesions on the ventral surface of your tongue po, the wharton’s duct
are patent po with no visible obstructions and inflammation noted
upon inspection, also there is no whitish or reddish discoloration
on the lateral area of your tongue. Are you feeling any discomfort
Ma’am, are you still good po?

Patient: Nothing. I am fine, thank you for asking.

Nurse: Next up, I will now check the strength of your tongue.
Kindly move your tongue po from side to side. (gagawin ni Lola)
Okay, thank you po Ma’am. The tongue has an equal strength po
upon movement on both sides. Then, I will now be inspecting the
hard (anterior) and soft (posterior) palates and uvula. Together
with that, I will inspect your tonsils and posterior pharyngeal wall.
For an instance, I will be asking you po to open your mouth and
say ahh, things like that. Do you get that Ma’am?

Patient: Yes, carry on.

Nurse: Okay Ma’am, kindly open your mouth po and raise your
head a bit. (inspect) Thank you Ma’am, the uvula is in the midline
po. There is no lesion noted on both soft and hard palate po. In
addition, there is no noted untoward odor while the mouth po is
wide open. And again, uvula po is in the midline. Next up, I will
now inspect your tonsils. Can you please open your mouth again?
(inspect with tongue depressor and penlight) Say Ahhh po while I
push down your tongue using this tongue depressor. (use
equipment) There, thank you Ma’am, there is no noted hyperemia,
discharge, and hypertrophy upon inspection po of the tonsils, there
is also no noted hyperemia and discharge po upon inspection of the
posterior pharyngeal wall.