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Physical Assessment Head, Neck, and Skin
PHCL 313 Emtenan AlHarbi,MCs
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Introduction Head & Neck 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
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Structure of the Head Head & Neck
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Examination of The Head
Head & Neck Skull Hair Scalp & Face Neck Nose Ears Mouth & Pharynx Eyes
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Skull Inspection Palpation
Head & Neck Inspection for size, contour, shape & evidence of trauma Palpation for lumps, bumps & evidence of trauma
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Hair & Scalp Inspection Palpation
Head & Neck Inspection for quantity, texture & distribution of the hair Inspect scalp for lesions & scales Palpation for texture (fine, dry, oily)
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Face Head & Neck Inspect the face for expression, symmetry, movement, lesions & edema
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Neck Head & Neck Inspection Inspect the neck for symmetry, masses, and enlargement of gland and lymph node.
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Neck Head & Neck Palpation Palpate the trachea with the thumb on one side & the index & middle finger on other side of trachea, it should be midline Palpate the lymph nodes for size, shape, mobility, and tenderness.
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Neck Palpate the thyroid gland for size, shape, symmetry, tenderness, and nodules.
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Neck
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Neck Assess Jagular Venus Pressure (JVP)
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Nose Head & Neck
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Nose Head & Neck Inspection Inspect external nose for symmetry, inflammation & lesions Palpation Palpate the frontal, ethmoid & maxillary sinuses for tenderness
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Nose Sinuses inspection
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Ears Head & Neck
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Ears Inspection Inspect external ear for lesions, trauma, & size
Head & Neck 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
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Ears
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Hearing Head & Neck Simple Assess the ability of the patient to hear a sequence of equally accented words/numbers ( ) whispered from a distance of a couple of feet
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Hearing Other test: Rinne Test Weber Test Head & Neck
Auditory Acuity: If the patient does not complain of hearing loss, this part of the exam is omitted. A crude assessment can be performed by asking the patient to close their eyes while you place your fingers a few centimeters from either ear. Rub the finger tips of first one hand and then the other. Make note of any obvious differences in hearing. Alternatively, you can stand behind the patient and whisper a few words in first one ear and then the other. Are they able to repeat the phrases back correctly? Does this seem to be equal on either side? These tests obviously are not very objective. Precise quantification requires sensitive equipment and is usually done by a trained audiologist. Detecting Conductive v. Sensorineural Deficits: As with acuity, these tests would only be performed if the patient complained of hearing loss. Transmission of sound can be broken into two components: Conduction: The passage of sound from outside to the level of the 8th cranial nerve. This includes transmission of sound through the external canal and middle ears. Sensorineural: The transmission of sound through the 8th nerve to the brain. Hearing loss can occur at either level. To determine which is affected, the following tests are performed: Weber: Grasp the 512 Hz tuning fork by its stem and get it to vibrate by either striking the tines against your hand or by "snapping" the ends between your thumb and middle finger. Then place the stem towards the back of the patient's head, on an imaginary line equidistant from either ear. The bones of the skull will transmit this sound to the 8th nerve, which should then be appreciated in both ears equally. Remind the patient that they are trying to detect sound, not the buzzing vibratory sensation from the fork. If there is a conductive deficit (e.g. wax in the external canal), the sound will be heard better in that ear. This is because impaired conduction has prevented any competing sounds from entering the ear via the normal route. You can create a transient conductive hearing loss by putting a finger in one ear. Sound transmitted from the tuning fork will then be heard louder on that side. In the setting of a sensorineural abnormality (e.g. an acoustic neuroma, a tumor arising from the 8th CN), the sound will be best heard in the normal ear. If sound is heard better in one ear it is described as lateralizing to that side. Otherwise, the Weber test is said to be mid-line. Weber Test Rinne: Strike the same tuning fork and place the stem on the mastoid bone, a bony prominence located just behind and below the ear. Bone conduction will allow the sound to be transmitted and appreciated. Instruct the patient to let you know as soon as they can no longer hear the sound. Then place the tines of the still vibrating fork right next to, but not touching, the external canal. They should again be able to hear the sound. This is because, when everything is functioning normally, transmission of sound through air is always better then through bone. This will not be the case if there is a conductive hearing loss (e.g. fluid associated with an infection in the middle ear), which causes bone conduction to be greater then or equal to air. If there is a sensorineural abnormality (e.g. medication induced toxicity to the 8th CN), air conduction should still be better then bone as they will both be equally affected by the deficit. Rinne Test
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Mouth & Pharynx Head & Neck
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Mouth & Pharynx
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Mouth & Pharynx Inspection
Head & Neck Inspection Inspect the lips & mucosa for color, ulcerations, hydration & lesions Inspect the teeth & gums for color, bleeding, inflammation, caries, missing teeth, ulcerations & lesions
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Mouth & Pharynx Inspection
Head & Neck 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?)
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Mouth & Pharynx
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Eyes Head & Neck
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Eye.. External structure
Inspection Inspect the external & internal structures of the eyes Inspect the pupil size, shape & symmetric Assess iris for abnormal pigments or deposits Sclera should be white Conjunctiva clear
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Eyes Inspection Test pupil reaction to light
Head & Neck Inspection Test pupil reaction to light Dark condition ->> dilate Bright ->> constrict Normal response recorded as PERRLA??
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Eye .. External structure
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Eyes.. visual acuity Inspection
Head & Neck Inspection General acuity can be obtained by reading a general sentence from any printed material The Snellen eye chart provides more accurate assessment
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Eye.. visual acuity
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Eye.. Checking Visual Fields
Head & Neck Inspection Test peripheral visual fields with the confrontation technique
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Eyes.. Assess extraocular muscles movement
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Eyes.. Assess extraocular muscles movement
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Eyes.. Internal structures
Head & Neck Inspection Inspect the retinal blood vessels & optic disc,
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Skin
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Skin Assessment Skin is evaluated using inspection & palpation
Accurate assessment of a dermatologic presentation requires a complete patient history including : Past & current medical history Past & current medications Family history Occupation & hobbies
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Skin Assessment For assessment of suspected drug related dermatologic reactions , it is important to know: When the medication was started Distribution of skin lesions Any systemic symptoms (fever, malaise) Time course of progression of the skin lesions
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Subjective Information
Tell me more about your skin problem? When did the condition start? Where on the body did the problem first appear? How did it spread? How have the lesions, rash, or skin color changed? Is there anything that appeared to trigger the reaction? What treatments have you tried? Does it itch? If yes, where does it itch? When did the itching start? Is it continuous or intermittent? Do you feel tenderness or pain? When did it start? Describe the pain. Are you experiencing nausea, dizziness, headache, or fatigue
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Objective Information Inspection
Note the color of the skin and its uniformity. If a lesion is found, note the characteristics of the lesion (location, type, color, shape, size, grouping, pattern) Note whether the lesions localized or generalized e.g. limited to sun-exposed skin or are more widespread Inspect nails and nail beds for clubbing, cyanosis or trauma
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Objective Information Palpation
Palpate the area to see if it is movable, tender, nodular, moist Note temperature (warm, cool), texture (rough, smooth), thickness (thick, thin), mobility (immobile, mobile, hypermobile), presence of edema Assess skin turgor by pulling up & quickly releasing a fold of skin In a well hydrated patient, skin quickly returns to normal If patient is dehydrated, it takes longer for the skin to return to normal or ‘’tents’’ & stands by itself when released (Poor Turgor)
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Objective Information Palpation
Assess edema by pressing tips of one or two fingers into the skin & noting how long the indentation remains after fingers are removed A plus scale (1+, 2+, 3+, 4+) is used to quantify the edema with 4+ denoting the most long-lasting indentations
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Skin Abnormalities Poor Skin Turgor
It takes longer for pinched skin to return to normal or ‘’tents’’ & stands by itself when released Present with dehydration or extreme weight loss
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Skin Abnormalities Pruritus Contact Dermatitis Itching of the skin
Refers to any rash that develops as a result of a substance coming into contact with the skin. Divided into two types: Irritant (nonallergic), caused by soap, detergent, cosmetics Allergic associated with metals (nickel & cobalt found in jewlery, latex, cigarette smoke, poison ivy) Charecterized by erythema, pruritus, vesicles, scaling
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Skin Abnormalities Eczema (Atopic Dermatitis)
Chronic inflammatory disorder of the dermis & epidermis Often appears during infancy or early childhood Patients often have risk factors e.g. personal or family history of allergic rhinitis, asthma, hay fever Signs and symptoms include pruritus, erythema
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Skin Abnormalities Petechia Ecchymosis Purpura
A small (< 2mm) hemorrhage (pinpoint hemorrhage) Ecchymosis A large (> 1 cm) hemorrhage, commonly known as a bruise Purpura Widespread blotchy hemorrhage
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Skin Abnormalities Clubbing
Increased angle ( > 180 degrees) between the base of the nail and nail bed May be associated with COPD, endocarditis
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Skin Abnormalities Onycholysis Koilonychias
Separation of the nail from the nail bed Associated with trauma, malnutrition, & thyroid disease Koilonychias Spooning of the nails Associated with iron deficiency anemia
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