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

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 Inspection Palpation
Head & Neck
Inspection
for size, contour, shape & evidence of trauma
Palpation
for lumps, bumps & evidence of trauma

6. 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)

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 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

18. Ears

19. 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

20. 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

21. Mouth & Pharynx
Head & Neck

22. Mouth & Pharynx

23. 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

24. 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?)

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 Inspection Test pupil reaction to light
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 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

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 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

41. 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)

42. 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

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 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

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 Ecchymosis Purpura
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 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