Head, Neck and Oral Examination of a 34-Year-Old Woman: Three Normal Variants and One Finding That Needed Referral
Student Name
American College of Education
NUR4033: Health Assessment
Module 3 Assignment
Instructor Name
March 16, 2026
Client, Reason for Examination and Technique
The client is a 34-year-old woman who works as a bookkeeper and came to a primary care clinic for a routine physical examination before starting a new job. She reported no current symptoms of the head, eyes, ears, nose, mouth or throat. Relevant history includes smoking about ten cigarettes a day for sixteen years, drinking two or three glasses of wine on weekends and wearing contact lenses. She has had no dental visit in about four years. The client and clinic are composites written for this assignment.
The examination was performed in a well-lit room with the client seated, using an otoscope, a penlight, tongue blades, gauze and gloves. Inspection preceded palpation in every region, and the oral examination included the lateral borders and underside of the tongue, which requires holding the tongue with gauze and moving it to each side. Bickley (2021) notes that the lateral and ventral surfaces of the tongue and the floor of the mouth are the sites where oral cancers most often arise and are also the areas most often skipped in a quick examination. An oral examination that stops at say ah has not examined the parts of the mouth that matter most.
Findings by Region
Head and face. The skull is normocephalic with no tenderness, masses or lesions on palpation. Hair is evenly distributed. The face is symmetric at rest and with expression. Temporomandibular joints move smoothly without clicking or tenderness. The frontal and maxillary sinuses are nontender to palpation.
Eyes. Visual acuity by Snellen chart with contact lenses in place is 20/20 in each eye. Conjunctivae are pink without discharge; sclerae are white. A small, yellowish, slightly raised area is present on the nasal side of the bulbar conjunctiva in the left eye, not extending onto the cornea. Both pupils measure 3 mm, constrict briskly to 2 mm with direct and consensual light, and narrow on near focus. Extraocular movements are intact without nystagmus. Red reflex is present bilaterally.
Ears and nose. External ears are without lesions. Ear canals contain a small amount of soft brown cerumen; both eardrums are translucent gray, with the malleus and a bright triangular light reflex seen on each side. The whispered voice test is passed on both sides. Nasal mucosa is pink and moist with the septum midline and no polyps.
Mouth and throat. Lips are pink and moist, with several pinpoint pale yellow spots along the vermilion border of the upper lip. Teeth show two visible caries on the lower molars and mild yellow staining. Gums are pink without bleeding. A smooth, hard, midline bony ridge about 2 cm long runs along the hard palate. The dorsal tongue shows several smooth red patches with slightly raised whitish borders, giving it a map-like appearance. On the left lateral border of the tongue, opposite the second molar, is a flat white patch about 1.2 by 0.8 cm that does not wipe off with gauze, is not tender and has no ulceration. The uvula rises midline, tonsils are grade 1 and the posterior pharynx is pink without exudate.
Neck. The trachea is midline. The thyroid is not enlarged and moves with swallowing, with no nodules felt. No cervical, submandibular, submental or supraclavicular lymph nodes are palpable.
Three Normal Variants
Torus palatinus. The hard midline ridge on the palate is a torus palatinus, a benign bony outgrowth that is common in adults and usually painless. Tori are developmental bony prominences whose cause is thought to involve both genetic and functional factors, and most need no treatment unless they interfere with a denture or are repeatedly injured (García-García et al., 2010). Its features here, midline location, bone-hard consistency, smooth covering mucosa and no symptoms, are the features that identify it. It is recorded so that a future examiner does not mistake a long-standing variant for a new mass.
Geographic tongue. The smooth red patches with whitish borders on the dorsal tongue represent benign migratory glossitis, commonly called geographic tongue. Assimakopoulos et al. (2002) describe it as a common, benign inflammatory condition in which areas of the tongue lose their filiform papillae and then regrow, so the pattern changes location over days or weeks. The client confirmed that her tongue has looked like a map on and off for years and occasionally stings with spicy food. Because the pattern migrates, asking whether it changes is a useful part of the history.
Fordyce spots and the conjunctival finding. The pinpoint yellow spots along the upper lip are Fordyce spots, visible sebaceous glands that are a normal finding in many adults (Bickley, 2021). The raised yellowish area on the nasal bulbar conjunctiva is consistent with a pinguecula, a benign change common in adults with sun exposure and contact lens wear; it was noted because it is harmless unless it becomes inflamed or grows toward the cornea. Naming each variant precisely is not a formality; it is how the examiner earns the right to call the next finding abnormal.
The Finding That Needed Referral
The white patch on the left lateral border of the tongue is different in kind from the variants above. It does not wipe off, which rules out the most common benign cause of a white coating, candidiasis, and it has no obvious cause such as a sharp tooth or denture edge rubbing at that spot. A white patch that cannot be wiped off and cannot be attributed to another cause meets the working definition of leukoplakia, which an international consensus report classifies among the oral potentially malignant disorders (Warnakulasuriya et al., 2021). Its location matters as much as its appearance: the lateral and ventral tongue is a higher-risk site than the dorsum.
The history adds to the concern. Tobacco use is the most important risk factor for leukoplakia and for its progression, and alcohol use adds risk, particularly in combination with smoking (Warnakulasuriya et al., 2021). This client has sixteen years of smoking and regular alcohol use. The absence of ulceration, induration, pain and enlarged lymph nodes is reassuring but does not exclude dysplasia, which can be present in a lesion that looks and feels unremarkable. Only a biopsy can determine that, and it is not a decision for the examining nurse to make alone.
The finding was reported to the nurse practitioner during the visit, with the size, location, color, texture, the negative wipe test and the negative lymph node examination described exactly as documented above. The nurse practitioner confirmed the finding and placed a referral to an oral and maxillofacial surgery clinic for evaluation and likely biopsy. The client was told in plain language that the patch was not an emergency and was often benign but needed to be checked by a specialist, and that stopping smoking was the single most helpful thing she could do for her mouth. She accepted a referral to the state quitline. The whole value of the examination lay in that one patch, and it would have been missed if the tongue had not been lifted and turned.
Conclusion
This examination produced a normal head, eye, ear, nose and neck examination, three benign variants and one finding that required referral. The variants were worth documenting because a future examiner will see them again, and knowing they were present and unchanged prevents unnecessary worry. The white patch was worth finding because it sits in a higher-risk site in a client with the main risk factors for progression. Both outcomes depended on a systematic technique that examined every surface and on knowing the range of normal well enough to recognize something outside it.
References
Assimakopoulos, D., Patrikakos, G., Fotika, C., & Elisaf, M. (2002). Benign migratory glossitis or geographic tongue: An enigmatic oral lesion. The American Journal of Medicine, 113(9), 751-755. https://doi.org/10.1016/S0002-9343(02)01379-7
Bickley, L. S. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
García-García, A., Martínez-González, J., Gómez-Font, R., Soto-Rivadeneira, A., & Oviedo-Roldán, L. (2010). Current status of the torus palatinus and torus mandibularis. Medicina Oral, Patologia Oral y Cirugia Bucal, 15(2), e353-e360. https://doi.org/10.4317/medoral.15.e353
Warnakulasuriya, S., Kujan, O., Aguirre-Urizar, J. M., Bagan, J. V., González-Moles, M. Á., Kerr, A. R., Lodi, G., Mello, F. W., Monteiro, L., Ogden, G. R., Sloan, P., & Johnson, N. W. (2021). Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer. Oral Diseases, 27(8), 1862-1880. https://doi.org/10.1111/odi.13704
How this NUR 4033 Module 3 example is structured
NUR 4033 Module 3 commonly begins the system examinations, and many sections expect normal variants to be named before any abnormal finding; your classroom decides which systems and what format. This example opens with the reason for the examination and the technique, reports findings region by region in the order they were examined, and gives the normal variants their own section so each can be defined and distinguished from a look-alike. The abnormal finding comes last, with the features that set it apart, the risk factors from the history and the referral made. That order mirrors the reasoning the module is teaching: know the range of normal before calling anything abnormal.
NUR4033 Module 3 questions, answered
What is usually covered in NUR4033 Module 3?
NUR4033 Module 3 commonly begins the system-by-system examinations, often starting with the head, neck, eyes, ears, nose, mouth and skin. Many sections expect students to document findings objectively and to recognize normal variants before labeling anything abnormal. Your classroom's instructions decide which systems are included and whether the deliverable is a write-up, a recorded examination or both.
Why do normal variants matter in a health assessment paper?
Normal variants such as torus palatinus, geographic tongue and Fordyce spots are common and harmless, but they can look alarming to an examiner who does not know them. Naming each one correctly shows that you know the range of normal, which gives credibility to any finding you then call abnormal. Graders often look for at least one variant identified and explained.
How much detail should I give for an abnormal finding?
Describe it well enough that another clinician could picture it without seeing it: size in centimeters, exact location, color, texture, tenderness and the result of any simple test such as wiping. Then explain what makes it abnormal, which risk factors from the history apply, whom you notified and what happened next. Leave the diagnosis to the appropriate provider.
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