Assessment Normal Findings Abnormal Findings
Mouth
1. Note odor No unusual or foul odor noted Fruity or acetone breath = DM
Ammonia odor = Kidney disease
Foul odor = tooth decay
Fecal breath= bowel obstruction
2. Inspect and palpate lips, buccal Lips smooth, moist, no Lips
mucosa, gums and tongue. lesions.
Pallor lips = anemia
Stensen and Wharton ducts Buccal mucosa tissue is
smooth and moist. Bluish lips = cyanosis hypoxia
Tongue is rough with no
lesions. Reddish lips = carbon monoxide
Gums are reddish with no poisoning or COPD
discoloration. Swelling lips = allergies
Stensen duct is visible with
flow of saliva. Buccal mucosa
Wharton’s duct no swelling
Leukoplakia (chalky white patches) =
and tenderness, frenulum is
smoking
midline.
Thrush = infection
Koplik spots = measles
Canker sores = irritation or trauma
Tongue
Black hairy tongue= antibiotic use
Red beefy tongue= VB12 deficiency
(pernicious anemia)
Gums
Dark discoloration of gums = Lead
poisoning
Stensen’s Duct
Reddened opening is seen with
mumps
Wharton’s Duct
Usually 1st sign of cancer
3. Inspect gums for hyperplasia No hyperplasia noted, unusual growth Gingivitis= red, swollen and easily
on the gums. bleed
Receding gums (periodontitis)
Kaposi sarcoma= cancer of HIV
(purplish and bluish discoloration)
4. Inspect teeth (number and shape) 32 pearly whitish teeth with smooth Yellowish teeth may be caused by
edges. excessive smoking or drinking tea or
coffee
5. Inspect and palpate tongue Tongue is rough, pink and moist. Vit B12 deficiency red beefy tongue
With no lesions present
Leukoplakia (ud and down) =smoking
Hairy leukoplakia (sides)
Thrush (easily scrape) = hygiene and
fungi
Throat
6. Inspect throat Throat is normally pink no lesions Bright red throat w/ yellowish
exudate indicates pharyngitis
Color, consistency, uvula (say ahh) Uvula is midline and singular
(inflammation of the pharynx)
Assymetric uvula may indicate CVA
or CN 10 paralysis
7. Inspect tonsils Tonsils are normally pink Grade +1, Enlarged tonsils indicate tonsillitis
no swelling, lesions or exudate
present
Nose
8. Inspect and palpate external nose Color is same as skin tone, smooth, Nasal tenderness may indicate
Color, shape, tenderness, and symmetric, and no tenderness. infection
patency
Able to sniff through nostril even if Difficulty on air flow may indicate
other is closed polyps, Obstruction, or rhinitis
9. Inspect internal nose Nasal mucosa is dark pink, moist. Swollen nasal mucosa may indicate
Color, swelling, exudate, bleeding, Septum is intact and no perforations. allergies.
ulcers, perforated septum or polyps No bleeding or lesions
Nose bleeding (epistaxis) may be due
to irritation or vessel rupture.
Perforated septum may be seen in
cocaine users, trauma, or chronic nose
picking.
Snuses
10. Palpate sinuses for tenderness Frontal and maxillary sinuses are Tender to touch may indicate allergies
-palpate using thumb nontender and no crepitus evident or rhinosinusitis.
11. Percuss and transluminate Sinuses are not tender and produces Tenderness may indicate allergies. If
sinuses red glow upon transillumination there is no red glow it may indicate
sinusitis.
