H&P Exam I
Spring 2014 OMS I – Exam 1
Dermatology
 Primary lesions are the first to appear and are due to the disease or
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abnormal state.
Flat lesions: <1cm (5mm) macule ; >1cm (5mm) patch
Superficial raised (epidermal and/or superficial dermal location): <1cm
(5mm) papule ; >1cm (5mm) plaque
Deep raised (deep dermal and/or subcutaneous location): <1cm (5mm)
nodule ; >1cm (5mm) tumor
Serum filled: <1cm vesicle ; >1cm bulla
Hemorrhagic: <3mm petechi ;>3mm purpura/ecchymosis
Vascular: Telangiectasia
Transient well defined erythema and edema: wheal/urticaria/hive
Cyst – fluid or semisolid filled sac
Comedone: plug of sebaceous & keratinous material in the opening of the
hair follicle [open – black head, closed – white head]
Dermatology
 Secondary lesions develop as a result of manipulation of the primary
lesions, or they develop as part of the natural progression of primary
lesions
 Epidermal accumulations:
 Discrete keratinocyte accumulation – scale
 Same as scale with RBCs,WBCs, serum – crust
 Epidermal thickening with accentuated skin lines- lichenification
 Shedding of sheets of keratinocytes - desquamation
 Skin Thickness changes:
 Decreased epidermal, dermal and/or subcutaneous thickness- atrophy
 Abnormally thick scar that stays within the boundary of the lesion –
hypertrophic scar
 Abnormally thick scar that extends beyond the boundary of the lesion –
keloid
 Linear atrophy with fragmented collagen/elastin fibers – stria
Dermatology
 Break in Skin Surface:
 Linear break in skin – fissure
 Wider defect with partial epidermal loss – erosion
 Trauma induced by scratching or picking, either linear or papular -
excoriation
 Wider defect with full thickness epidermal loss – ulcer
 Pus accumulations: Superficial – pustule ; deep – abscess
 Shape & Distribution
 Annular (ring) , nummular (circular or oval)
 Polycyclic or arcuate (curved like a bow)
 Linear or reticular
 Serpiginous (creeping) , targetoid (bulls-eye like)
 Grouped or scattered
Dermatology
Dematology Exam
 Be sure to offer full skin exam, need proper lighting, can
incorporate into other parts of PE
 Hair inspection: quality, distribution palpation of hair & scalp
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Hair Pull Test: <10% telogen phase [not growing]
Trichotilomania – pulling out hair
Alopecia totalis – loss of nearly all hair
Alopecia areata – localized nonscarring hair loss
Hiruitism – excessive growth
Loss of leg hair – peripheral vascular disease
 Skin inspection: head to toe, front to back; view sunexposed &
hidden areas, exam under skin folds, color variation,
texture/thickness, moisure/dryness, tempature, turgor
 Lesion decription: Asymmetry, Border, Color, Diameter, Location
 Nails inspection: color, texture (grooves, pitting), capillary
refill [turn to pink in <3sec]
Ophthalmology
 Start:
 1. Check VISION : eye chart, finger counting, hand motion,
light perception, no light perception
 2. Shine light on PUPILS: red reflex (retinoblastoma),
reactivity, size & shape
 Accomadation: CN III, Afferent defect: CN II
 Anisocoria = unequal pupils
 3. Check ocular MOTILITY
 CN III: superior, inferior & medial rectus mm., inferior oblique m. pupils
 CN IV: superior oblique m.
 CN VI: lateral rectus m.
 Strabismus – improper alignment ; Hirschberg Test – corneal light reflex
to check for alignment (if hits in the same location on both eyes, eyes are
aligned)
Ophthalmology
 Visual Fields:
 Extends further temporally 100-110 degrees, nasally and upward 60 degrees &
downward 70 degrees
 Blind spot = optic nerve
 Unilateral visual loss = in front of chiasm, Bilateral visual loss = behind chiasm [strokes –
typically behind]
 Optic Nerve: should see margins & vessels coming from center
 Optic cup: disc ratio usually 1:3
 Ocular pressure: <21mmHg
 Fundus: posterior eye structures – retina, optic n, macula (yellow
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area, highest visual acuity) & fovea
Myopia: nearsightedness (minus lens), longer eye
Hyperopia: farsightedness (plus lens), shorter eye
Presbiopia: loss of lens flexibility (need bifocals)
Dilating eyes: (hx of glaucoma)
 Avoid neosynephrine if: pregnant, recent heart attack or stroke, shortness of breath
 Pilocarpine 1% if needed for reversing dilation
Ophthalmology
 Diseases:
 Proptosis (forward projection of eye) – commonly w. Graves’ diseas, usually medial or
lateral rectus muscle thickinging and usually bilateral
 Blepharitis (swelling/inflammation of eyelids) – can be bacterial, can lead to meibomian
gland dysfunction (mucin deficient tears, corneal scarring, ocular surface irritation)
 Rx: steroids, antibiotics, baby shampoo
 Sty (inflammation around hair follicle) Chalazion (inflamed, clogged meibomian gland)
 Conjunctivitis (almost always go away alone) – allergic, bacterial [has mucous-type
drainage & more red], viral [most common]
 Birth: given erythromyocin to prevent conjunctivitis & scarring from it, 6/1000 Ophthalmia neonatorum
(Chlamydia)
 Episcleritis/Scleritis (CT inflammation between conjunctiva & sclera) 30% assoc. w. RA,
Lupus, Sjogren, sarcoidosis, IBS, Wegners, TB
 Rx: steroid drops, wean off slowly
 Vitreous: “floaters” = liquefaction of vitreous
 Can be blood (diabetic), piece of retina (flashes of light)
 Cherry red spot – the macula, no arteries, sign of central artery occlusion (rest of retina
appears white)
 Vein occlusion – back up of blood flow
 Hyperlipidemia – fatty deposits, arcus senilus (white ring around cornea)
 Papilledema – optic nerve edema seen as disc blurring
Ophthalmology
 Unilateral PAINLESS Vision Loss:
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Artery or vein occlusion
Retinal detachment
Glaucoma (open angle)
Cerebrovascular disease (occipital lobe)
Macular degeneration (wet)
Cataract
Hollenhorst plaque (plaque from carotid artery lodged in optic artery)
 Unilateral PAINFUL Vision Loss:
 Angle closure glaucoma
 Optic neuritis (inflammed optic n., 50% develop MS [1st symptom], typically ♀ under 45y/o)
 Temporal Arteritis (Giant Cell - >50y/o, +/- Transient Ischemic Attacks or high Westergren Sed
Rate, weight loss, jaw claudication, untreated  total blindness, managed by rheumatologist
w. steroids)
 Trauma
 Bilateral PAINLESS Vision Loss:
 Diabetic Retinopathy
 Macular Degeneration
 Genetic retinal diseases
 Cataract
 Occipital lobe stroke
 Brain mass (Papilledema)
 Drug toxicity (ethambutol)
 Uveitis (inflammation)
Ophthalmology
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Normal Fundus
 Disc: clear outline, central cup is pale
 Retina: red/orange color, macula is dark, avascular area temportally
 Vessels: arterial 2: venous 3 ratio; arteries bright red, veins slight purplish
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HTN Retinopathy
 Disc: clear outline  elevated, edematous w. blurred margins
 Retina: exudates (fluid collectins in retina from damaged vessels) & flame hemorrhages 
prominent flame hemorrhages surrounding vessels near disc
 Vessels: attenuated arterial reflex  attenuated retinal arterioles
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Diabetic Retinopathy
 Disc: normal  new vessels on disc surface  partially obscured by fibrovascular proliferation
 Retina: numerous scattered exudates & hemorrhages   obscured by proliferating tissue
 Vessels: mild dilation of retinal veins  dilated veins  abnormal new vessels in fibrous tissues (in
vitreous)
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Papilledema
 Disc: elevated, edematous w. blurred margins & engorged vessels
 Retina: flame retinal hemorrhage close to disc
 Vessel: engorged tortuous veins
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Optic Atrophy
 Disc: marigins sharp & clear, pale white color
 Retina: normal
 Vessel: arteries attenuated, veins normal
Ophthalmology Exam
 Be at same level as patient!
 1. Vision [eye chart] – with glasses
 2. Pupils – equal, round reactive
 Marcus Gun Pupil – flashing light back & forth, 1 constricts &
other dilates upon light being shone into it
 3. Motility – full, limited  have them follow your finger
 4. Visual fields – hands should be equidistant, cover same
eye reflectively as patient [their L, your R]
 Have them stare at your eye
 move fingers in (both sides) & then up
Ophthalmology Exam
 Ophthalmoscope
 Turn down the lights!
 Same eye level as your patient
 Your right eye, to THEIR right eye
 Get CLOSE
 To decrease corneal reflection: use smaller aperture reduces area of retina
illuminated, direct light toward pupil’s edge instead of center or used a
crossed linear polarizing filter
 Focus your instrument:
 Correct for you & your patient
 near-sighted correction=RED (object will get smaller, or moves with glasses
movement)
 far-sighted correction=GREEN (object will get larger, or moves against glasses
movement)
 Hold scope with pointer on side dial, middle finger under & rests on
patient’s cheek
 Patient looks straight ahead, you angle in from the side ~15º & start
focusing
 See vessel, follow vessel as it enlarges (heading toward nerve)
Neck & Lymph
 Anatomy Review:
 Anterior Triangle: SCM laterally, Mandible superiorly, Neck midline medially
 Posterior Triangle: Trapezius laterally, Clavicle inferiorly, SCM medially
 Neck Inspection
 Proper exposure, symmetry, muscle mass, chin alignment, skin lesions,
masses, trachea position, lymphadenopathy, thyromegaly
 Tracheal deviation – urgent if also in respiratory distress
 SAME side deviation – pneumothorax, OPPOSITE side deviation – tension
pneumothorax
 ROM – flexion, extension, side bending, rotation
 Auscultation
 ALWAYS listen before feeling carotid a.
 Use BELL to detect low-pitched systolic bruits (don’t want to apply pressure
if one is present, could dislodge thrombus or cut off flow)
 Carotid a. is beneath the SCM
 Have patient take breath in, let it out & hold it, then listen [don’t listen for
too long – 5-6 heart beats - & let them breathe in between sides]
 Thyroid : increased blood flow causes bruit, sign of hyperthyroid ; follow
same procedure as listening to carotid arteries
Neck & Lymph
 Palpation [always use PADS of fingers]
 FRONT of patient : palpate posterior neck anatomy (cervical
vertebrae, paraspinal m., occiput & posterio cervical chain
lymph nodes) , tracheal deviation
 Lymph nodes: preauricular, postauricular, occipital, tonsilar,
submandibular, submental, superficial cervical, deep cervical,
posterior cervical, supraclavicular, infraclavicular
 BEHIND patient: **explain to patient what you’re doing, to
feel structure – not strangling**
 Thyroid: Starting at chin moving down soft tissue  thyroid cartilage 
cricothyroid membrane  cricoid  thyroid rings  isthmus located
over rings 2-4, move lateral from there for lateral lobes (can translate
trachea to feel lateral lobes better)
 Can have patient swallow to feel smaller nodules [offer glass of water]
 Carotid A.: use pointer and middle finger, gentle traction on SCM, slowly
depress carotid artery [not for expanded time & NEVER both at once]
**absent bruit ≠ absent stenosis
Neck & Lymph
 Lymphatics
 Major: cervical, axillary, epitrochlear (if arm dysfunction), inguinal
 Inspect then palpate
 Normal: <1cm, rubbery, mobile - should be able to roll them up/down & side to
side
 Pathological :
 Localized & tender – infection w/in drainage area
 Generalized – HIV, TB, SLE, meds (phenytoin)
 Malignancy – nontender, firm, fixed nodes
 Using pads of fingers, massage in circular motion applying enough pressure to
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only engage skin
Cervical : preauricular, postauricular, occipital, tonsilar, submandibular,
submental, superficial cervical, deep cervical, supraclavicular, infraclavicular
Axillary : [wear gloves] anterior fold, chest wall – medial, posterior fold, medial
arm – lateral
Epitrochlear : not normally palpable, if arm infected or axillary swollen; located
above medial epicondyle [local or systemic infection if epitrochlear rather than
breast malignancy ]
Inguinal : lift garment, want to look to make sure you’re not going haywire but
keep drape over patient, stand at hip level
Neck & Lymph
 Special Testing – Meningitis
 Symptoms associated: Neck pain, stiff neck, headache, fever,
photophobia, mental status change, nausea and vomiting
 Physical findings: Appears acutely ill, often in distress,
confused or obtunded, febrile, tachycardia, tachypnea,
occasional rash
 Palpate for Nuchal Rigidity
 With the patient in the supine position, palpate the nuchal cord
(nuchal ligament) from occiput to C7 for nuchal rigidity
 The nuchal cord is firm and bandlike but softens with extension of
the neck and is not typically tender
 Meningeal irritation can cause the patient to attempt to hold the
head still, resulting in contraction of the neck muscles and rigidity of
the nuchal cord that does not relax with extension of the neck
 Brudzinski’s Sign (passively flex patient’s neck): pain =
positive, person may flex hips to relieve pain
 Kernig’s Sign (patient supine, flex their hip 90º then extend
their lower leg): pain = positive
ENT
 Ear
 History : hearing problems (unilateral, bilateral – sensory or
conductive), assoc. problems (tinnitus, vertigo, otorrhea),
duration, family Hx, noise exposure
 Vertigo  CN VIII
 Presbycusis – progressive, bilateral sensory loss, high frequency
 Syphillis, Rubella, Meningitis,
 Gross Hearing Test: finger rub, whisper 2 syllable test tuning
forks
 Weber [fork in middle of head or forehead]– lateralization, where they
hear it louder = conductive loss side (or sensory hearing loss is louder in
better ear)
 Rinne [start on mastoid (BC) until can’t here then move to in front of
canal (AC)] – AC > BC = sensory hearing loss ; BC=/> AC = conductive
hearing loss **louder in air is normal**
ENT
 Ear Physical Exam
 External ear
 Auricle - cartilage covered by skin
 Meatus – entrance into the ear canal.
 Mastoid – temporal bone located behind the ear
 Ear canal – bony and cartilaginous portions, contains cerumen glands. The site of
infection in otitis externa
 Adult: pull ear up and back to straighten the ear canal
 Child: pull ear down and back to straighten the ear canal
 “Tug test” – movement of auricle and tragus is painful in otitis externa, not in otitis
media
 Middle ear
 Tympanic membrane – lateral limit of ME. Examine with the largest speculum
possible
 Umbo – where malleus meets the TM
 Pars flaccida – above the short process of the malleus
 Pars tensa
 Ossicles (Malleus, Incus, Stapes)
 Eustachian tube
 Mobility tested with pneumatic otoscope
 Inner ear
 Cochlea, Semicircular Canals (balance, position/movement), CN VIII
ENT
 Ear
 Tube Placement for recurrent otitis media : 5+ infections in a year, 3+
infections in 6 months, infection that does not respond to oral
antibiotics, chronic middle ear fluid with conductive hearing loss,
acute mastoiditis
 Placement: anterior inferior
 Tympanic membrane perforations may heal over time (central or
marginal, water precautions)
 Cholesteatoma: epithelial doposition in middle ear, in pars flaccida,
can be acquired or congenital
 Ball of skin keeps growing, can erode ossicles
 Etiologies congenital, chronic eustachian tube dysfunction with retraction or
perforation
 Rx: surgical excision of cholesteatoma & all of the debris
 Ear Exam:
 L hand with L ear, R hand w. R ear
 Stand behind patient, your hand resting on their zygomatic arch
 Otoscope held upside down, pointy end facing patient
 How to tell which side of ear: MALLEUS at 2:oo = R ear, 10:00 = L ear
ENT
 Nose
 Hx: rhinorrhea, congestion, epitaxis (U/L, B/L), trauma, duration,
medications (chronic afrin), allergy, adenoid removal
 Anatomy: nasal turbinates humidify air & remove debris, nasal
lacrimal duct drains into inferior meatus,
 Exam: Inspect the external nose, look for asymmetry or deformation
 Test for nasal obstruction by blocking one nostril at a time and asking the
patient to breathe in
 Look inside the nose with either a large otoscope speculum or with a nasal
speculum and headlight
 Touch nose edge, go in (can tilt head back slightly), then look around
 Nasal mucosal color, crusting, swelling, exudate
 Nasal septal deflection, perforation (cauterization, nose picking, nasal
packing, afrin, granulomatous disease), crusting, polyps
 Normal: pink, dense [Polyps are clear, jelly-like]
 Sinuses
 Transillumination (one brighter than other)
 Percussion: maxilla & frontal, do L then R looking for symmetry, use
tip of finger & hit at 90º movement only at the wrist
ENT
 Mouth & Pharynx
 Anatomy:
 Lips – muscular folds, entrance to mouth
 Gingiva – mucosa, firmly attached to teeth and maxilla or mandible
 Labial frenulum – connects lips and gingiva
 Alveolar mucosa – mucosa adjacent to gingiva
 Labial mucosa – mucosa of the inner lip
 Tongue [CN XII paralysis – to same side]
 Uvula [CN X paralysis = to opposite side]
 Teeth (32 adult)
 Lingual frenulum
 Wharton’s ducts (submandibular)
 Palate – hard and soft
 Buccal mucosa – lines the cheeks
 Stenson’s ducts (parotid)
 Tongue Anatomy:
 Circumvallate papillae (Large, v-shaped pattern in posterior tongue, taste via CN IX to
nucleus solitarius)
 Foliate papillae (Lateral tongue)
 Filiform papillae (No taste function)
 Fungiform papillae (Diffuse, taste via lingual nerve (V3) to chorda tympani and nucleus
solitarius)
ENT
 Mouth & Pharynx Exam
 Ask patients to remove dentures
 Look at the color of the lips, oral cavity
 Grasp the tip of the tongue with gauze to inspect the sides and
posterior tongue
 Palpate the body and base of the tongue
 Ask patient to open the mouth, leave the tongue in and say
“ah” (or with children, ask them to “pant like a puppy”)
 Use a tongue blade to press down the anterior half of the
tongue
ENT
 Tongue Disease:
 Fissured tongue – dry, cracked
 Geographic tongue
 Atrophic glottis – tongue more red, smooth, lack papilla
 Anemia, pellegra, Vit B/folate/Fe deficiencies, Celiac & Lichen planus
 Ankyloglossia – tongue tied, frenulum tethers tongue
 Mouth Disease:
 Oral thursh: white placks on mucus membrane (Candida albicans)
 Leukoplakia: white plaque (precancerous lesion, hyperkeratotic lesions), <10%
carcinoma, from irritation
 Chancer sore: shallow ulcer, painful, tingling sensation from tissue injury, Celiac
or Crohn’s disease
 Cold sore: outside on lips, Herpes simplex virus – exaberated by sun, stress,
hormones
 Oral Pemphigus – autoimmune bollus disease
 Nikolsky sign: top layer of lesion can be rubbed off w. light pressure
 Tonsilitis: red swollen w. white spots
 Monotonsilitis – Epstein barr virus, both are covered in white, palate petechiae,
hepatomegaly & jaundice
 Ludwig’s Angina : dental infection in floor of mouth, requires surgical drainage
of abscess
ENT Exam
 Head
 Symmetry, trauma, palpate for tenderness/lesions/deformity
 Facial expressions to test for CN VII (facial n.) – compare
symmetry [UMN lesion(central) – contralateral lower
portion of face; LMN lesion(peripheral) – ipsilateral half of
face]
 Test orbicularis oculii m. – patient closes eyes and attempts to keep
them closed as you pull up on their eyebrows
 Palpate face with tissue to test CN V (trigeminal n.) sensory
portion, have patient clench their teeth to test CN V motor
 Patient’s eyes closed, look for symmetry between sides, don’t do angle
of jaw [innerv. Great auricular n.)
 Sinuses: transillumination (dullness = sinusitis), palpation
(apply firm pressure w. thumbs simultaneously for
tenderness), percussion (tip of middle finger at 90º over frontal
& maxillary sinuses; pain/discomfort = sinusitis )
ENT Exam
 Nose
 Check symmetry of breathing thru nose , ask to inhale (pain?) block
one nostril at a time
 Hold speculum like a pencil, edge on tip of nose, look in then proceed
into nose, move speculum around to visualize parts of nose
 Ear
 External ear inspection, behind ear – look for symmetry, piercings
 Adult: pull ear up & back, Child: pull ear down & back
 Hold speculum upside-down, your hand resting on their zygomatic
arch, place speculum in until can’t see tip then look inside and
proceed… visual canal & TM (superior  inferior & anterior 
posterior)
 Malleus location: 2:00 – R ear, 10:00 L ear
 If whisper & finger rub tests okay, don’t need to go further
 Dysfunction: use 512Hz tuning fork for Weber (lateralization, conduction loss
in louder ear, sensory hearing loss louder in better ear) & Rinne (sensory
hearing loss AC > BC, conductive hearing loss BC=/> AC)
ENT Exam
 Mouth/Throat
 Outside first
 Buccal area – anterior  posterior
 Palpate for masses within the skin of cheek, floor of mouth
 Remember which finger you used so you don’t place that wet finger on patient’s
face when switching sides !!
 Teeth – upper then lower
 Hard palate, soft palate
 Uvula
 CN X lesion – uvula deviates to OPPOSITE side of lesion
 Tonsils
 Pharynx
 Gag reflex : sensory stimluation via CN IX, motor response via CN X
 Tongue – top & under
 CN XII lesion – tongue deviates to SAME side as lesion
 Gums
** Always say please & thank you! **
Vitals Review
 BP: <120/<80
 Shirt off, place cuff above antecubital fossa lined up with brachial
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artery (find via palpation – more medial side)
Find radial pulse, pump quickly to 100 then increments of 10 until
pulse is obliterated , deflate quickly
Reinflate to that number + 20
Slowly deflate, 1st sound: systolic, 2nd sound: diastolic
Sounds of Korotkoff: intial tapping, sounds increase intensity, hits
max, sounds muffled then disappear
Ausculatory gap: period of silence during ascultation where the first
beat is heard, period of silence follwed with a return of audible pulse
then second disappearance being diastolic
 RR: 12-20; depth, pattern
 Pulse: 60-100bpm, normal 2/4 strength, rhythm
 Temp: 98.6ºF
 BMI : healthy 18.5-24.9 (kg/m2)
 Dermatology
 Skin types
 1: always burn easily, never tans,
 2: burns easily, tans slightly
 3: sometimes burn, tans gradually & mod.
 4: burns minimally, always tans well
 5: burns rarely, tans deeply
 6: almost never burns, deeply pigmented
 Pallor = reduced oxyhemoglobin, Hypopigmentation – lack of sun
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exposure
Brown – pituitary or adrenal disorder, hemochromatosis
Skin mobile in certain directions – follow directions for best cosmetic
results (O to T closing of subcutaneous sutures)
Most common skin cancer – basal cell carcinoma [white n dome
shaped] , second most squamous cell carcinoma [scaly red] ;
melanoma [ABCDE]
Nails
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Paronychia – infection
Vertical split – damage to the matrix
Onychomycosis – fungal infection
Onycholysis – nail splitting
 Eye:
 Drusen: small collections found on the retina & optic n. often
occuring w. macular degeneration & again
 Exudates: fluid collection sin the retina resulting from damaged
blood vessels
 Retinopathy: non-inflammatory pathology of the retina
 Mouth
 Black hairy tongue – poor oral hygeine, thursh, antibiotic use
 Geographic tongue – normal variation
 Ear
 Insufflation: assessment of the mobility of the TM in the
evaluation of fluid & middle ear pressures by forcing air against
it through the use of an insufflation bulb attached to an
otoscope