1. PHCL 326 Hadeel Alkofide April 2011 1

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3.  The HEENT, or Head, Eye, Ear, Nose & Throat Exam is usually the initial part of a general physical exam, after the vital signs  Like other parts of the physical exam, it begins with inspection, & then proceeds to palpation  It requires the use of several special instruments in order to inspect the eyes & ears, & special techniques to assess their special sensory function Head & Neck 3

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5.  Skull  Hair  Scalp & Face  Neck  Nose  Ears  Hearing  Mouth & Pharynx  Eyes Head & Neck 5

6. Inspection  Inspect the skull for size, shape & evidence of trauma Palpation  Palpate the skull for lumps, bumps & evidence of trauma Head & Neck 6

7. Inspection  Inspect for quantity& distribution Palpation  Palpate the hair for texture (fine, dry, oily) Head & Neck 7

8. Scalp  Inspect scalp for lesions & scales Face  Inspect the face for expression, symmetry, movement, lesions & edema Head & Neck 8

9. Inspection  Inspect the neck for symmetry, masses, goiter or scars Palpation  Palpate the trachea with the thumb on one side & the index & middle finger on other side of trachea  Trachea: should be midline  Deviation may be sign of a mass or a tension pneumothorax Head & Neck 9

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11. Inspection  Inspect external nose for symmetry, inflammation & lesions Palpation  Palpate the frontal, ethmoid & maxillary sinuses for tenderness Head & Neck 11

12. Head & Neck 12

13. Inspection  Inspect external ear for lesions, trauma, & size  Inspect ear canal & tympanic membrane with otoscope  Inspect the canal for foreign bodies, discharge, color & edema  Inspect the tympanic membrane for color & perforation Palpation  Palpate the external ear for nodules Head & Neck 13

14. Simple  Assess the ability of the patient to hear a sequence of equally accented words/numbers (3-5-2-4) whispered from a distance of a couple of feet Head & Neck 14

15. Rinne Test  Compares bone & air conduction  Place tip of vibrating tuning fork on the mastoid process behind the ear  Ask the patient to indicate when he no longer hears the vibrating turning fork  Hold the fork in front but not touching the ear canal to test air conduction  Normally patient can hear vibration better than feeling them Head & Neck 15

16. Weber Test  Place the tip of a vibrating fork on the center of patient's forehead  Normally sound is heard equally in both ears Head & Neck 16

17. Head & Neck 17

18. Inspection  Inspect the lips & mucosa for color, ulcerations, hydration & lesions  Inspect the teeth & gums for color, bleeding, inflammation, caries, missing teeth, ulcerations & lesions Head & Neck 18

19. Inspection  Inspect the tonsils for color, exudates, lesions & ulcerations  Inspect the sides of the tongue for color, symmetry, ulceration & lesions  Note the odor of breath (examples?) Head & Neck 19

20. Head & Neck 20

21. Inspection  Inspect the external & internal structures of the eyes & assess visual acuity  General acuity can be obtained by reading a general sentence from any printed material  The Snellen eye chart provides more accurate assessment Head & Neck 21

22. Inspection  Test peripheral visual fields with the confrontation technique  Assess extraocular muscles movement Head & Neck 22

23. Inspection  Inspect the pupil size, shape & equality  Assess iris for abnormal pigments or deposits  Test pupil reaction to light Head & Neck 23

24. Inspection  Inspect the retinal blood vessels & optic disc, Head & Neck 24

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27.  Equipment needed  Inspection  Palpation  Percussion  Auscultation  Pulmonary Function Test (Spirometry) 27

28.  Stethoscope  Peak flow meter 28

29.  Observe the rate, rhythm, depth, & effort of breathing. Note whether the expiratory phase is prolonged  Listen for obvious abnormal sounds with breathing such as wheezes  Observe for retractions & use of accessory muscles (abdominals)  Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter  Confirm that the trachea is near the midline 29

30.  Identify any areas of tenderness or deformity by palpating the ribs & sternum  Assess expansion & symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, & ask them to breath deeply 30

31.  Percuss over intercostal spaces to assess lung density 31

32.  Percuss over intercostal spaces to assess lung density 32

33. Posterior ChestAnterior Chest 33

34. Percussion Notes & Their Meaning Flat or Dull Pleural Effusion or Pneumonia NormalHealthy Lung or Bronchitis Hyperresonant Emphysema or Pneumothorax 34

35. Breath Sounds  Using a stethoscope  Instruct patient to breath deeply & slowly  Use a systematic approach, compare each side to the other, document when & where sounds are heard  Normal breath sounds: tracheal, bronchovesicular, bronchial, & vesicular 35

36. Breath Sounds: Normal Sounds  Trachea: tracheal  Large central bronchi: bronchovesicular  Small airways distal to central bronchi: bronchial  Small lateral airways: vesicular 36

37. Breath Sounds: Abnormal Sounds  Wheeze - may be heard with or without stethoscope high-pitched squeaky musical sound; usually not changed by coughing; Document if heard on inspiration, expiration, or both  Noise is caused by air moving through narrowed or partially obstructed airway  Heard in asthma 37

38. Breath Sounds: Abnormal Sounds  Stridor - may be heard without stethoscope, shrill harsh sound on inspiration ; is an inspiratory wheeze associated with upper airway obstruction (croup)  Laryngeal obstruction 38

39. Breath Sounds: Abnormal Sounds  Crackles - heard only with stethoscope (rales):  These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers  May clear with cough  Most commonly heard in bases; easier to hear on inspiration (but occurs in both inspiration & expiration) 39

40. Breath Sounds: Abnormal Sounds  Gurgles - heard only with stethoscope (rhonchi):  Low pitched, coarse wheezy or whistling sound  Usually more pronounced during expiration when air moves through thick secretions or narrowed airways  Sounds like a moan or snore; best heard on expiration (but occur both in & out)  Any extra sound that is not a crackle or a wheeze is probably a rhonchi 40

41.  Most common of the Pulmonary Function Tests (PFTs)  Measures lung function, specifically the of the amount (volume) &/or speed (flow) of air that can be inhaled & exhaled  Spirometry is an important tool which can helpful in assessing conditions such as asthma, pulmonary fibrosis, cystic fibrosis, & COPD  It can be used as a baseline or a post bronchodilator test (Post BD), & is an important part in diagnosing asthma versus COPD 41

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43. AbbreviationNameDescription FVC Forced Vital Capacity The volume of air that can forcibly be blown out after full inspiration, measured in liters FEV 1 Forced Expiratory Volume in 1 Second The maximum volume of air that can forcibly blow out in the first second during the FVC, measured in liters. Along with FVC it is considered one of the primary indicators of lung function 43

44. AbbreviationNameDescription FEV 1 /FVCFEV1% The ratio of FEV 1 to FVC Normal: 75–80% In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV 1 is diminished because of increased airway resistance to expiratory flow and the FVC may be increased this generates a reduced value (<80%, often ~45%) In restrictive diseases (such as pulmonary fibrosis) the FEV 1 & FVC are both reduced proportionally & the value may be normal or even increased 44

45. AbbreviationNameDescription PEF Peak Expiratory Flow The maximal flow (or speed) achieved during the maximally forced expiration initiated at full inspiration, measured in liters/second FEF 25–75% or 25–50% Forced Expiratory Flow 25– 75% or 25– 50% The average flow (or speed) of air coming out of the lung during the middle portion of the expiration (also sometimes referred to as the MMEF, for maximal mid-expiratory flow) In small airway diseases such as asthma this value will be reduced, perhaps <65% of expected value This may be the first sign of small airway disease detectable 45

46. AbbreviationNameDescription FIF 25–75% or 25–50% Forced Inspiratory Flow 25– 75% or 25– 50% This is similar to FEF 25–75% or 25–50% except the measurement is taken during inspiration FET Forced Expiratory Time This measures the length of the expiration in seconds 46

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49.  Inspection  Palpation  Auscultation (Heart Sounds) 49

50.  Chest for visible cardiac motion  Estimate Jugular Venous Pressure (JVP)  Patient supine & head elevated to 15-30 degrees  JVP is the distance b/w highest point at which pulsation can be seen & the sternal angle 50

51. JVP 51

52. JVP  An indirect measure of right atrial pressure  Measured in centimeters from the sternal angle & is best visualized with the patient's head rotated to the left  Described for its quality & character, effects of respiration, & patient position-induced changes 52

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54. Physical Landmarks  Suprasternal notch  Sternum  Manubriosternal angle – Angle of Louis  Intercostals Spaces 54

55.  Palpate for (Point of Maximal Impulses) PMI; easiest if patient sits up & leans forward  Has a diameter of ≈ 2cm & located with 10 cm of the midsternal line  Palpate for general cardiac motion with fingertips and patient in supine position  Palpate for radial, carotid, brachial, femoral & other peripheral pulses 55

56.  See figure 4-12 for peripheral pulses 56

57.  With a stethoscope  Use diaphragm to assess higher pitched sounds  Needs a lot of practice & experience  Listen in a quiet area or to close eyes to reduce conflicting stimuli  See also figure 4-10 for auscultatory Sites 57

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60.  The auscultatory Sites are close to but not the same as the anatomic locations of the valves  Aortic area  2 nd ICS at the right sternal border  Pulmonic  2 nd ICS at the left sternal border  Tricuspid  lt lower sternal border  Mitral  cardiac apex 60

61.  Heart sounds are characterized by location, pitch, intensity, duration, & timing within the cardiac cycle 61

62.  High-pitched sounds such as S 1 & S 2, murmurs of aortic & mitral regurgitation, & pericardial friction rubs are best heard with the diaphragm  The bell is preferred for low-pitched sounds such as S 3 & S 4 62

63.  S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1)  Correlates with the carotid pulse  Loudest at the cardiac apex  Can be split but not often 63

64.  S2: Closure of Semilunar valves (aortic & pulmonic)  Loudest at the base of the heart  May have a split sound (A2 before P2) 64

65.  S 1 & S 2 assessed in all four sites in upright and supine position  S 1 precedes and the S 2 follows the carotid pulse 65

66. S3…S4…  Due to volume overload  Due to Rapid ventricular filling: ventricular gallop  S1 -- S2-S3 (Ken--tuc-ky)  Due to pressure overload  Due to slow ventricular contraction: atrial gallop  S4-S1 — S2 (Ten-nes—see) 66

67. S3…S4…  Low-pitched sound  Heard at apex of the heart  Caused by rapid filling & stretching of the left ventricle  Characteristic of volume overloading, such as in CHF (especially left-sided heart failure), tricuspid or mitral valve insufficiency  A dull, low-pitched postsystolic atrial gallop  Caused by reduced ventricular compliance  Best heard at the apex in the left lateral position  Present in conditions such as aortic stenosis, hypertension, cardiomyopathies, & coronary artery disease  Less specific for CHF than S3 67

68.  Turbulent blood flow across a valve or a disease such as anemia or hyperthyroidism  Listen for murmurs in the same auscultatory sites APETM  Systolic b/w S1 & S2  Diastolic b/w S2 & S1 68

69. They are classified by  Timing & duration within the cardiac cycle (systolic, diastolic, & continuous)  Location  Intensity  Shape (configuration or pattern)  Pitch (frequency)  Quality, & radiation 69

70.  Grade I: barely audible  Gr II: audible but quiet and soft  Gr III: moderated loud, without thrust or thrill  Gr IV: loud, with thrill  Gr V: louder with thrill, steth on chest wall  Gr VI: loud enough to be heard before steth on chest 70

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