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Physical Assessment Head, Neck, and Skin

PHCL 313Emtenan AlHarbi,MCs

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Introduction

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

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Structure of the HeadHead & Neck

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Examination of The Head

Skull Hair Scalp & Face Neck Nose Ears Mouth & Pharynx Eyes

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Skull

Inspection for size, contour,

shape & evidence of trauma

Palpation for lumps, bumps &

evidence of trauma

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Hair & Scalp

Inspection for quantity, texture &

distribution of the hair Inspect scalp for lesions &

scales

Palpation for texture (fine, dry, oily)

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Face

Inspect the face for expression, symmetry, movement, lesions & edema

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Neck

Inspection Inspect the neck

for symmetry,  masses, and enlargement of gland and lymph node.

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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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NoseHead & Neck

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Nose

Inspection Inspect external nose for symmetry,

inflammation & lesionsPalpation Palpate the frontal, ethmoid &

maxillary sinuses for tenderness

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Nose

Sinuses inspection

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EarsHead & Neck

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Ears

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 & perforationPalpation Palpate the external ear for nodules

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Ears

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Hearing

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

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Hearing

Other test:Rinne Test

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Weber Test

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Mouth & PharynxHead & Neck

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Mouth & Pharynx

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Mouth & Pharynx

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 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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EyesHead & 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

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 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

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

Inspection Inspect the retinal blood vessels &

optic disc,

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Skin

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

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

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

Objective InformationInspection 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

Objective InformationPalpation 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)

Objective InformationPalpation 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

Skin AbnormalitiesPoor 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

Skin Abnormalities Pruritus

Itching of the skin

Contact Dermatitis 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

Skin AbnormalitiesEczema (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

Skin Abnormalities Petechia

A small (< 2mm) hemorrhage (pinpoint hemorrhage)

Ecchymosis A large (> 1 cm) hemorrhage, commonly known as a bruise

Purpura Widespread blotchy hemorrhage

Skin AbnormalitiesClubbing

Increased angle ( > 180 degrees) between the base of the nail and nail bed

May be associated with COPD, endocarditis

Skin Abnormalities Onycholysis

Separation of the nail from the nail bed Associated with trauma,

malnutrition, & thyroid disease

Koilonychias Spooning of the nails Associated with iron deficiency anemia