Physical Assessment Part III Head & Neck Pulmonary & Cardiac (Lectures 2 & 3)

1. Physical Assessment Part IIIHead & NeckPulmonary & Cardiac(Lectures 2 & 3) PHCL 326 Hadeel Alkofide April 2011

2. Head & Neck

3. Head & Neck 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

4. Head & Neck Structure of the Head

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

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

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

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

9. Head & Neck 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

10. Head & Neck Nose

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

12. Head & Neck Ears

13. Head & Neck 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 & perforation Palpation • Palpate the external ear for nodules

14. Head & Neck 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

15. Head & Neck Hearing 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

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

17. Head & Neck Mouth & Pharynx

18. Head & Neck 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

19. Head & Neck 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?)

20. Head & Neck Eyes

21. Head & Neck Eyes 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

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

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

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

25. Chest & Pulmonary

26. Pulmonary

27. Chest & Pulmonary • Equipment needed • Inspection • Palpation • Percussion • Auscultation • Pulmonary Function Test (Spirometry)

28. Equipment Needed • Stethoscope • Peak flow meter

29. Inspection • 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

30. Palpation • 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

31. Percussion • Percuss over intercostal spaces to assess lung density

32. Percussion • Percuss over intercostal spaces to assess lung density

33. Percussion Posterior Chest Anterior Chest

34. Percussion

35. Auscultation 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

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

37. Auscultation 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

38. Auscultation 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

39. Auscultation 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)

40. Auscultation 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

41. Spirometry • 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

42. Spirometry

43. Spirometry

44. Spirometry

45. Spirometry

46. Spirometry

47. Cardiovascular System

48. It was once said:“The only things of interest are those linked to the heart”

49. Cardiovascular System • Inspection • Palpation • Auscultation (Heart Sounds)

50. Inspection • 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