PHCL 326 Hadeel Alkofide April 2011 1

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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 3

Head & Neck 4

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

Head & Neck

Inspection

 Inspect the skull for size, shape & evidence of trauma

Palpation

 Palpate the skull for lumps, bumps & evidence of trauma 6

Head & Neck

Inspection

 Inspect for quantity& distribution

Palpation

 Palpate the hair for texture (fine, dry, oily) 7

Head & Neck

Scalp

 Inspect scalp for lesions & scales

Face

 Inspect the face for expression, symmetry, movement, lesions & edema 8

Head & Neck

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 9

Head & Neck 10

Head & Neck

Inspection

 Inspect external nose for symmetry, inflammation & lesions

Palpation

 Palpate the frontal, ethmoid & maxillary sinuses for tenderness 11

Head & Neck 12

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 13

Head & Neck

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 14

Head & Neck

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 15

Head & Neck

Weber Test

 Place the tip of a vibrating fork on the center of patient's forehead  Normally sound is heard equally in both ears 16

Head & Neck 17

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 18

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?) 19

Head & Neck 20

Head & Neck

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 21

Head & Neck

Inspection

 Test peripheral visual fields with the confrontation technique  Assess extraocular muscles movement 22

Head & Neck

Inspection

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

Head & Neck

Inspection

 Inspect the retinal blood vessels & optic disc, 24

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

 Stethoscope  Peak flow meter 28

 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

 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

 Percuss over intercostal spaces to assess lung density 31

 Percuss over intercostal spaces to assess lung density 32

Posterior Chest Anterior Chest

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Percussion Notes & Their Meaning

Flat or Dull Pleural Effusion or Pneumonia Normal Hyperresonant Healthy Lung or Bronchitis Emphysema or Pneumothorax 34

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

Breath Sounds: Normal Sounds

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

Breath Sounds: Abnormal Sounds

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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

Breath Sounds: Abnormal Sounds

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Stridor

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

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

Breath Sounds: Abnormal Sounds

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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

 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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Abbreviation

FVC

Name Description

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

Abbreviation

FEV 1 /FVC

Name

FEV1%

Description

• The ratio of FEV 1 to FVC •

Normal:

75–80% •

In obstructive diseases

value (<80%, often ~45%) (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 •

In restrictive diseases

(such as pulmonary fibrosis) the FEV 1 & FVC are both reduced proportionally & the value may be normal or even increased 44

Abbreviation Name Description

PEF FEF 25–75% or 25–50% Peak Expiratory Flow Forced Expiratory Flow 25– 75% or 25– 50% The maximal flow (or speed) achieved during the maximally forced expiration initiated at full inspiration, measured in liters/second • 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

expected value such as asthma this value will be reduced, perhaps <65% of • This may be the first sign of small airway disease detectable 45

Abbreviation Name Description

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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 Inspection  Palpation  Auscultation (Heart Sounds) 49

 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

JVP

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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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Physical Landmarks

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

 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

 See figure 4-12 for peripheral pulses 56

 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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 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

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

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

 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

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

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

S3…

   Due to volume overload Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky)

S4…

   Due to pressure overload Due to slow ventricular contraction: atrial gallop S4-S1 — S2 (Ten-nes—see) 66

S3…

    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

S4…

     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

 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

They are classified by

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

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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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