History and Physical Exam:
HEENT
Wendy Langen and
William Demshok MS,PA-C
January 19, 2011
Physical Exam Technique
•
•
•
•
Inspection
Palpation
Percussion
Auscultation
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Body habitus (physique or body build)
• Grooming and hygiene
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Body habitus (physique or body build)
• Grooming and hygiene
Level of Consciousness
• Alert and oriented to person, place, and time
(alert and oriented x3)
• Confusion:
– Inappropriate response to a question
– Decreased attention span and memory
• Lethargy:
– Drowsy, falls asleep quickly, responds
appropriately once aroused
Levels of Consciousness
• Delirium:
– Confusion with disordered perceptions and
decreased attention span
– Marked anxiety with motor and sensory
excitement
• Stupor
– Arousable for short periods of time to visual,
verbal, or painful stimuli
– Simple motor or moaning responses to stimuli
– Slow responses
Levels of Consciousness
• Coma
– Neither awake nor aware
– Decerebrate posturing to painful stimuli
EYE OPENING RESPONSE
“Four Eyes”
• SPONTANEOUS-OPEN WITH BLINKING AT BASELINE:
4 POINTS
• TO VERBAL STIMULI, COMMAND, SPEECH: 3 POINTS
• TO PAIN ONLY (NOT APPLIED TO FACE): 2 POINTS
• NO RESPONSE:
1 POINT
VERBAL RESPONSE
“THE JACKSON 5”
• ORIENTED
5 POINTS
• CONFUSED CONVERSATION, BUT ABLE
TO ANSWER QUESTIONS
4 POINTS
• INAPPROPRIATE WORDS
3 POINTS
• INCOMPREHENSIBLE
SPEECH
2 POINTS
• NO RESPONSE
1 POINT
6 Motor
“6 cylinder motor”
• OBEYS COMMANDS FOR MOVEMENT
6 POINTS
• PURPOSEFUL MOVEMENT TO PAINFUL
STIMULUS
5 POINTS
• WITHDRAWS IN RESPONSE TO PAIN
4 POINTS
• FLEXION IN RESPONSE TO PAIN (DECORTICATE
POSTURING)
3 POINTS
• EXTENSION RESPONSE IN RESPONSE TO PAIN
(DECEREBRATE POSTURING)
2 POINTS
• NO RESPONSE
1 POINT
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Body habitus (physique or body build)
• Grooming and hygiene
Signs of Distress
•
•
•
•
•
•
•
Acute pain
Tachypneic
Cyanotic
Tripod posturing
Accessory muscle use
Agitated
Screaming/ crying
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Grooming and hygiene
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Grooming and hygiene
General Survey
•
•
•
•
Level of consciousness
Signs of distress
Height/ weight/ build
Appearance appropriate to age and body
habitus (physique or body build)
• Grooming and hygiene
Example of How the General
Survey is Written
• WD, WN Asian F (♀) in NAD, appears to
have pain with swallowing, A and O X3,
cooperative
• Vital Signs:
T= 100.8F
Pulse= 88 reg.
R= 16 reg,
BP =126/68 Rt. arm, sitting
1/14/2011
16
History of the Head
• Trauma/ concussion
• Abnormalities
• Hair loss
Summary Exam of the Head
•
•
•
•
•
Inspection of head and face
Palpation of skull, scalp and hair
Paplates facial bones
Palpates TM joint
Auscultates for temporal, orbital
artery bruits
1/14/2011
18
Summary Exam of the Head
• Inspection of head and face
• Palpation of skull, scalp and hair
• Auscultates for temporal, orbital
artery bruits
1/14/2011
19
Examination of the Temporal
Arteries
• Palpate noting the
following:
– Thickening
– Hardness
– Tenderness
• Auscultate the
temporal arteries for
bruits
20
1/14/2011
Eye History
• Vision and correction (with glasses/
contacts)
• “The better to see to you” (to sign the
consent for surgery)
– Hyperopia (farsighted)
– Myopia (nearsighted)
Eye History
•
•
•
•
•
•
Color changes
Pain
Pruritus (itching)
Diplopia (double vision)
Scotomata (blind spot in visual field)
Detached retina history, personal or family
Eye Anatomy
•
•
•
•
•
•
Pay attention to:
Conjunctiva
Cornea
Pupils
Iris
Extraocular Muscles
For pain remember :
OLD CARTS
•
•
•
•
•
•
•
•
O nset
L ocation
D uration
C haracter (sharp, dull, aching, throbbing)
A ggravating factors: What makes it worse?
R esolution: What makes it better?
T iming: When does it occur?
S everity:On a scale from 1-10, 10 is the
worst pain of your life
Pneumonic for pain
• P rovocative/ palliative- what makes it
worse or better
• Q uality
• R egion
• S everity (scale of 1-10)
• T iming- onset, when does it come on, go
away, relation to activities
Eye PMHx
•
•
•
•
•
Trauma
Surgery
Hypertension, Diabetes
Glaucoma
O2 use in Premature infants
Eye Family Hx
•
•
•
•
•
•
Retinoblastoma
Detached retina
Cancer of retina
Cataracts
Glaucoma
Diabetes
Eye Social History
• Employment exposure to chemicals,
foreign bodies, wind, environment
• Sports and eye protection used
• Allergies and pets
Eye Exam, Vision
• Far visual acuity with Snellen chart (20 ft),
and/or near visual acuity with Rosenbaum
chart (14 inches- use string attached to
chart)
• 20/20= twenty feet away/ a normal eye can
see this at 20 feet
20/40= a normal eye can see this at 40 feet
• Can also use pinhole
• Remember to cover one eye!
• Visual Fields by confrontation
EYE INSPECTION
•
•
•
•
Eye lids, brow, orbit
Notice exophthalmus (bulging)
Note discharge, lid ptosis (drooping)
Note lesions, skin abnormalities
Inspect Cornea/Pupils
•
•
•
•
•
•
•
•
•
•
Clear, cloudy, lesions
Pupil size and shape
Direct and Indirect light reflex
“PERRLAC”
P upils
E qual
R ound
R eact to light
A ccomodation
C onvergence/ consensual response
Testing Direct & Consensual
Pupillary Light Reflex
– Dim room lights as necessary
– Ask patient to look into distance
– Shine a bright light obliquely into each pupil in
turn
– Look for both direct (same eye) & consensual
(other eye) reactions
– Record pupil size in mm & any asymmetry or
irregularity
Testing Pupillary Reactions to
Accommodation
– Hold your finger 10 cm from patient's nose.
– Ask them to alternate looking into distance &
at your finger.
– Observe pupillary response in each eye.
– Pupils should constrict when the eyes focus
on near object.
Corneal Reflex
(Tests Cranial Nerves V and VII)
Bilateral Pupil Abnormalities
• Miosis (constriction)
– Pupillary constriction < 2 mm in diameter
– Contributing factors
• Miotic eye drops (pilocarpine for glaucoma)
• Drugs
Bilateral Pupil Abnormalities
• Mydriasis (“d” for dilitation)
– Pupillary dilatation > 6 mm
– Contributing factors
• Mydriatic or cycloplegic drops (atropine,
phenylephrine, tropicamide)
• Midbrain lesions or hypoxia
• Oculomotor (CN III) damage
Bilateral Pupil Abnormalities
• Failure to constrict with increased light
stimulus
– Contributing factors
•
•
•
•
•
Corneal or lens opacity
Retinal degeneration
CN II destruction
Syphilis (tabes dorsalis)
Optic neuritis
Unilateral Pupil Abnormalities
• Anisocoria
– Unequal size of pupils
– Cetral retinal artery or venous occlusion
(CRAO/ CRVO)
– Detached retina
– Contributing factors
• Congenital as 20% of healthy people have minor
or noticeable differences in pupil size, but reflexes
are normal
• Caused by local eye medications
Unilateral Pupil Abnormalities
• Iritis Constrictive Response
– Constriction of pupil accompanied by pain and
circumcorneal flush (redness)
– Secondary to acute uveitis which is frequently
unilateral
Unilateral Pupil Abnormalities
• Opthalmoplegia
– Associated headache, orbital cellulitis
– Usually a medical emergency if acute onset
• Oculomotor nerve (CN III) damage
– Pupil dilated and fixed; eye deviated laterally
and downward; ptosis
– Causes
•
•
•
•
•
MS
DM
Meningovascular syphilis
Cerebral aneurysms
Other intracerebral space occupying lesions
Testing Extraocular Movement
• Stand 3-6 ft. in front of patient
• Ask patient to follow your finger with their
eyes without moving their head
• Check gaze in six cardinal directions using
a cross or "H" pattern.
• Check convergence by moving your finger
toward the bridge of patient's nose.
• Look for nystagmus, lid lag
Pterygium
Periorbital edema
Ectropion
Conjunctivitis with Ectropion
Entropion
Xanthelasma
Arcus Senilis
Hordeolum
1/14/2011
49
Chalazion
Blepharitis
Subconjunctival Hemorrhage
Exophthalmos
MartyFeldman.jpg.url
MartyFeldman.jpg.url
Surgical Pupil
Anisocoria
Extraocular muscles
Ptosis and Palsy
Visual Fields by Confrontation
• Stand opposite the patient at eye level
• Ask patient to cover the right eye while you cover your
left eye (Open eyes are directly opposite each other)
• Extend your arm midway between patient & yourself &
then move it centrally with fingers moving
• Have the patient tell you when the moving fingers are
first seen
• Test nasal, temporal, superior/ inferior, nasal fields
• Compare patient’s response to time you first note fingers
• Patient’s fields are (grossly) full if they correspond with
yours
Visual Fields by Confrontation
(poor form)
Fundoscopic exam
• Learn proper form, and practice, practice
• Practice on fellow students, relatives,
significant others, pets, postal workers, etc
WHAT DO THE COLORS ON
THE OPHTHALMOSCOPE
MEAN?
• GREEN/ BLACK= positive DIOPTERS (CONVEX) for
far sighted
• RED= negative DIOPTERS )CONCAVE( for near
sighted
Fundoscopic Exam
• Darken room as much as possible.
• Adjust ophthalmoscope so light is no
brighter than necessary.
• Adjust aperture to a plain white circle.
• Set diopter dial to zero.
Fundoscopic Exam
• Use your L hand & L eye to examine
patient's L eye & R hand & R eye to
examine the patient's R eye.
• Place free hand on patient's forehead with
thumb near eyebrow for better control
• Ask patient to stare at a point on wall
• Look through the ophthalmoscope & shine
light into patient's eye from about a foot
away.
Fundoscopic Exam
• Should see the retina as a "red reflex."
• Follow the red color to move within a few
inches of the patient's eye.
• Adjust diopter dial to bring the retina into
focus (start at “0” or “+15” (green or black)
• Find a blood vessel and follow it to the
optic disk
• Inspect outward from optic disk in at least
4 quadrants & note any abnormalities
Fundoscopic Exam
• Macula site of central vision & located 2 disc
diameters temporal to optic disc
• To bring macula into field of vision, ask patient
to look directly at the light of the opthalmoscope
• Arteries (brighter red) emanate from central
optic disk
• Larger caliber & darker retinal veins extend back
to the optic disk
• Vessels evenly distributed
• Margins of the optic disk sharp and clear
• Cup disc ratio approximately 3:1
• (incorrectly labeled on Bate’s video)
LEFT EYE
Papilledema
• Margins of optic disk
are indistinct with
blurring, because of
swelling with
elevation of optic
nerve head
Cupping of optic disc
• Increased pressure
over time leads to
deepening of the optic
cup with excavation
• Vessels appear to
"fall into" deepened
optic cup
Hypertensive Retinopathy
1/14/2011
70
Retinal Hemorrhages
• Whenever seen in
infants, one must
suspect abuse &
investigate carefully
• Commonly present in
“shaken-baby
syndrome”
Diabetic Retinopathy
Lipemic Retinitis
Choroidal Nevus
Cytomegalovirus (CMV) Retinitis
•
•
•
•
Common cause of blindness in HIV
Hemorrhage
Exudates
Necrosis of Retina
Retinoblastoma
• Congenital malignant
tumor occurring in
first 2 years of life
• White “cat’s eye”
reflex
• Chalky-white areas of
calcification
History ears
• Vertigo “room spinning around”(?) with vomiting
• Tinnitus (high pitched like feedback) or abnormal
sounds
• Ear pain, discharge
• Hearing loss and hearing aides
• Surgery
• Use of ototoxic medications, ie tobramycin
Auricle (pinna) Anatomy
Ear exam
•
•
•
•
•
Whisper or watch test for hearing
Weber and Rinne tests
Inspection of auricle
Palpation of auricle
Palpation of pre and postauricular lymph
nodes (may be done as part of neck
exam)
• Otoscopic exam
Cauliflower Ear
• From abrasive forces
such as wrestling
Basal Cell Carcinoma
Postauricular Abscess
Mastoiditis
Weber Test
• Do you hear the tone better on one side or
is it equal?
Rinne (rin′nĕ) Test
• Put tuning (512HZ) fork on mastoid
process
• “Tell me when you stop hearing the sound”
and note time
• Put the tuning fork next to auricle
• “Tell me when you stop hearing the sound”
and note time
• Air conduction should be 2X bone
conduction
(please note wrong size tuning fork!)
Otoscopic Exam
• Keep hand steady against patient’s head
• Your hand should be between patient’s
head and instrument. Best to point handle
of instrument towards patient’s nose.
Inspection of External Auditory
Canal
– Note integrity. Is it clear?
– Any tenderness, discharge, odorous
– Is it patent? If occluded: cerumen, foreign
body? edematous, swollen?
Correct
otoscope
hand
position
Hold it like a pencil,
with hand between
otoscope and
patient head
Best to point
instrument towards
patient’s ear, with
your pinky on the
xygomatic process
Otitis Externa with Discharge
Cerumen Impaction
Inspection of Tympanic Membrane
(TM)
– Start with normal side
– Pull top of ear to straighten canal for easier
viewing
– Use largest speculum that canal will
accomodate
– Note color & translucency; intact TM shiny,
opaque, & translucent
– Note if perforated, bulging, red & inflamed,
retracted, dull or scarred
Normal Tympanic Membrane (left)
Ear Tubes
Cholesteatoma
Perforated Tympanic Membrane
Otits Media
Serrous Otitis Media
Nose History (Hx)
• Chronic nosebleeds (epistaxis)
• Obstruction
• Surgery
• Trauma
• Repeated sinusitis
• Allergies
• Chronic postnasal drip
Nose Exam
• Inspect for shape, flaring, trauma,
discharge
• Palpate bridge
• Check for nasal patentcy
• Nasal cavity exam with speculum: look at
mucosa, septum, polyps, turbinates
• Sense of smell is part of Neuro exam
Nasal Discharge
Septal Deviation
Nasal Polyp
Rhinophyma (associated with
rosacea)
Sinus exam
• Inspect frontal & maxillary areas for swelling
• Palpate frontal sinus by pressing upward under
both eyebrows with thumbs.
• Palpate maxillary sinus by using either thumbs
or index & middle fingers to press up under the
zygomatic processes
• Percuss sinuses by pressing/ tapping directly
over sinus areas with index finger
Mouth and Throat Hx
Use of any tobacco product
Dental care, surgeries, orthodontics
Use of dental appliances (dentures)
Tonsillectomy/Adenoidectomy
Frequent documented streptococcal
infections
Hoarseness
Dysphagia (pain with swallowing)
Mouth exam
• Inspect lips for symmetry, color, edema,
lesions, cheilitis
• Look at buccal mucosa for color, lesions,
teeth occlusion
• Remove dental appliances and inspect
gingiva
• Palpate gingiva for tenderness if gingivitis
• Percuss teeth for suspected abscess
Angular Cheilosis
Labial Edema
Herpes Simplex
Squamous Cell Carcinoma
Tongue exam
• Inspect for color, swelling, coating,
deviation from midline, tremors or
fasciculations (part of neuro exam)
• Inspect dorsal surface for frenulum,
varicosities
Geographic Tongue
Tongue Edema
Deviation
Varicosity
Hairy Tongue
Throat Exam
• Inspect palate and uvula “yawn” or “say
ah”
• Check hard palate for lesions or swelling
• Note if uvula is midline and check gag
reflex (neuro exam)
• Use tongue blade if needed
• Inspect oropharynx and tonsils
• Tonsil enlargement is rated 1-4+
• Optional: palpate floor of mouth (WITH
gloves)
Oral Candidiasis
Torus Palatine
Tonsillar Stones
Exudative Tonsils
Grade
1
3
2
4
Peritonsillar Abscess
Summary Exam of the Neck
• Palpates following lymph node groups
–
–
–
–
–
–
–
–
–
–
Anterior cervical
Posterior cervical
Occipital
Pre and post auricular
Tonsillar
Submandibular
Submental
Supraclavicular
Infraclavicular
Deep cervical
1/14/2011
134
Neck
• Inspect the neck for the following:
– Asymmetry
– Scars
– Fullness
– Alignment of trachea
– Masses, webbing, and skin folds
– Jugular venous distension
– Carotid artery pulsation and bruit (one at a
time)
1/14/2011
135
Neck
• Palpate for tenderness, deformity, or
masses. Note:
– Tracheal position
– Tracheal tug
– Movement of hyoid bone and cartilages with
swallowing
– Thyroid nodules
1/14/2011
136
References
• William Demshok, PA-c lecture content
• Mosby’s Guide to Physical Examination, p 83,
4th edition, Seidel, 1999
• http://www.entusa.com/eardrum_and_middle_ear.htm