Physical Assessment Head, Neck, and Skin

1. PHCL 313 Emtenan AlHarbi,MCs Physical Assessment Head, Neck, and Skin

2. 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

3. Structure of the Head Head & Neck

4. Examination of The Head Head & Neck • Skull • Hair • Scalp & Face • Neck • Nose • Ears • Mouth & Pharynx • Eyes

5. Skull Head & Neck Inspection • for size, contour, shape & evidence of trauma Palpation • for lumps, bumps & evidence of trauma

6. Hair & Scalp Head & Neck Inspection • for quantity, texture & distribution of the hair • Inspect scalp for lesions & scales Palpation • for texture (fine, dry, oily)

7. Face Head & Neck • Inspect the face for expression, symmetry, movement, lesions & edema

8. Neck Head & Neck Inspection • Inspect the neck for symmetry,  masses, and enlargement of gland and lymph node.

9. 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.

10. Neck • Palpate the thyroid gland for size, shape, symmetry, tenderness, and nodules.

11. Neck

12. Neck • Assess Jagular • Venus Pressure • (JVP)

13. Nose Head & Neck

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

15. Nose Sinuses inspection

16. Ears Head & Neck

17. Ears 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

18. Ears

19. Hearing 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

20. Hearing Head & Neck Other test: Rinne Test Weber Test

21. Mouth & Pharynx Head & Neck

22. Mouth & Pharynx

23. Mouth & Pharynx 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

24. Mouth & Pharynx 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?)

25. Mouth & Pharynx

26. Eyes Head & Neck

27. 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

28. Eyes Head & Neck Inspection • Test pupil reaction to light • Dark condition ->> dilate • Bright ->> constrict • Normal response recorded as PERRLA??

29. Eye .. External structure

30. Eyes.. visual acuity 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

31. Eye.. visual acuity

32. Eye.. Checking Visual Fields Head & Neck Inspection • Test peripheral visual fields with the confrontation technique

33. Eyes.. Assess extraocular muscles movement

34. Eyes.. Assess extraocular muscles movement

35. Eyes.. Internal structures Head & Neck Inspection • Inspect the retinal blood vessels & optic disc,

36. Skin

37. 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

38. 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

39. 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

40. 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

41. 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)

42. 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

43. 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

44. 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

45. 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

46. Skin Abnormalities • Petechia • A small (< 2mm) hemorrhage (pinpoint hemorrhage) • Ecchymosis • A large (> 1 cm) hemorrhage, commonly known as a bruise • Purpura • Widespread blotchy hemorrhage

47. Skin Abnormalities • Clubbing • Increased angle ( > 180 degrees) between the base of the nail and nail bed • May be associated with COPD, endocarditis

48. 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