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Physical Assessment Part IIIHead & Neck

Pulmonary & Cardiac(Lectures 2 & 3)

PHCL 326Hadeel Alkofide

April 2011

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Head & Neck

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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

Head & Neck

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Structure of the HeadHead & Neck

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

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Skull

Inspection Inspect the skull for size, shape &

evidence of traumaPalpation Palpate the skull for lumps, bumps &

evidence of trauma

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Hair

Inspection Inspect for quantity& distributionPalpation Palpate the hair for texture (fine, dry,

oily)

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Scalp & Face

Scalp Inspect scalp for lesions & scalesFace Inspect the face for expression,

symmetry, movement, lesions & edema

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NeckInspection 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

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NoseHead & Neck

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Nose

Inspection Inspect external nose for symmetry,

inflammation & lesionsPalpation Palpate the frontal, ethmoid & maxillary

sinuses for tenderness

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EarsHead & Neck

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EarsInspection 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 & perforationPalpation Palpate the external ear for nodules

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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

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HearingRinne 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

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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

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Mouth & PharynxHead & Neck

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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

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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?)

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EyesHead & Neck

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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

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Eyes

Inspection Test peripheral visual fields with the

confrontation technique Assess extraocular muscles movement

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Eyes

Inspection Inspect the pupil size, shape & equality Assess iris for abnormal pigments or

deposits Test pupil reaction to light

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Eyes

Inspection Inspect the retinal blood vessels & optic

disc,

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Chest & Pulmonary

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Pulmonary

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Chest & Pulmonary

Equipment needed Inspection Palpation Percussion Auscultation Pulmonary Function Test (Spirometry)

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Equipment Needed

Stethoscope Peak flow meter

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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

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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

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Percussion

Percuss over intercostal spaces to assess lung density

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Percussion

Percuss over intercostal spaces to assess lung density

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PercussionPosterior Chest Anterior Chest

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Percussion

Percussion Notes & Their Meaning

Flat or Dull Pleural Effusion or Pneumonia

Normal Healthy Lung or Bronchitis

Hyperresonant Emphysema or Pneumothorax

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AuscultationBreath 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

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AuscultationBreath Sounds: Normal Sounds

Trachea: tracheal Large central bronchi: bronchovesicular Small airways distal to central bronchi: bronchial Small lateral airways: vesicular

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AuscultationBreath 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

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AuscultationBreath 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

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AuscultationBreath 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)

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AuscultationBreath 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

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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

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Spirometry

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Spirometry

Abbreviation Name Description

FVCForced Vital

Capacity

The volume of air that can forcibly be blown out after full inspiration, measured in liters

FEV1

Forced Expiratory Volume in 1 Second

The maximum volume of air that can forcibly blow out in the first second during the FVC, measured in liters. Along with FVC it is considered one of the primary indicators of lung function

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Spirometry

Abbreviation Name Description

FEV1/FVC FEV1%

• The ratio of FEV1 to FVC• Normal: 75–80%• In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV1 is diminished because of increased airway resistance to expiratory flow and the FVC may be increased this generates a reduced value (<80%, often ~45%)• In restrictive diseases (such as pulmonary fibrosis) the FEV1 & FVC are both reduced proportionally & the value may be normal or even increased

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Spirometry

Abbreviation Name Description

PEFPeak

Expiratory Flow

The maximal flow (or speed) achieved during the maximally forced expiration initiated at full inspiration, measured in liters/second

FEF 25–75% or 25–50%

Forced Expiratory Flow 25–

75% or 25–50%

• The average flow (or speed) of air coming out of the lung during the middle portion of the expiration (also sometimes referred to as the MMEF, for maximal mid-expiratory flow)• In small airway diseases such as asthma this value will be reduced, perhaps <65% of expected value• This may be the first sign of small airway disease detectable

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Spirometry

Abbreviation Name Description

FIF 25–75% or 25–50%

Forced Inspiratory Flow 25–

75% or 25–50%

This is similar to FEF 25–75% or 25–50% except the measurement is taken during inspiration

FETForced

Expiratory Time

This measures the length of the expiration in seconds

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Cardiovascular System

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It was once said:

“The only things of interest are those linked to the heart”

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Cardiovascular System Inspection Palpation Auscultation (Heart Sounds)

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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

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InspectionJVP

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InspectionJVP

An indirect measure of right atrial pressure Measured in centimeters from the sternal angle

& is best visualized with the patient's head rotated to the left

Described for its quality & character, effects of respiration, & patient position-induced changes

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Palpation

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PalpationPhysical

Landmarks Suprasternal

notch Sternum Manubriosterna

l angle – Angle of Louis

Intercostals Spaces

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Palpation Palpate for (Point of Maximal Impulses) PMI;

easiest if patient sits up & leans forward Has a diameter of ≈ 2cm & located with 10 cm

of the midsternal line Palpate for general cardiac motion with

fingertips and patient in supine position Palpate for radial, carotid, brachial, femoral &

other peripheral pulses

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Palpation See figure 4-12 for peripheral pulses

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Auscultation With a stethoscope Use diaphragm to assess higher pitched sounds Needs a lot of practice & experience Listen in a quiet area or to close eyes to reduce

conflicting stimuli See also figure 4-10 for auscultatory Sites

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Auscultation: Auscultatory Sites

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Auscultation: Auscultatory Sites

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Auscultation: Auscultatory Sites

The auscultatory Sites are close to but not the same as the anatomic locations of the valves

Aortic area 2nd ICS at the right sternal border

Pulmonic 2nd ICS at the left sternal border

Tricuspid lt lower sternal border

Mitral cardiac apex

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Auscultation: Heart Sounds

Heart sounds are characterized by location, pitch, intensity, duration, & timing within the cardiac cycle

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Auscultation: Heart Sounds High-pitched sounds such as S1 & S2, murmurs of

aortic & mitral regurgitation, & pericardial friction rubs are best heard with the diaphragm

The bell is preferred for low-pitched sounds such as S3 & S4

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Heart Sounds – S1…(Lub)… S1: Closure of AV valves (mitral and tricuspid

valves: M1 before T1) Correlates with the carotid pulse Loudest at the cardiac apex Can be split but not often

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Heart Sounds – S2…(Dub)… S2: Closure of Semilunar valves (aortic &

pulmonic) Loudest at the base of the heart May have a split sound (A2 before P2)

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Heart Sounds – S2…(Dub)… S1 & S2 assessed in all four sites in upright and

supine position S1 precedes and the S2 follows the carotid pulse

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Extra Heart SoundsS3… S4…

Due to volume overload Due to Rapid ventricular

filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky)

Due to pressure overload Due to slow ventricular

contraction: atrial gallop S4-S1 — S2 (Ten-nes—

see)

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Extra Heart SoundsS3… S4…

Low-pitched sound Heard at apex of the

heart Caused by rapid filling &

stretching of the left ventricle

Characteristic of volume overloading, such as in CHF (especially left-sided heart failure), tricuspid or mitral valve insufficiency

A dull, low-pitched postsystolic atrial gallop

Caused by reduced ventricular compliance

Best heard at the apex in the left lateral position

Present in conditions such as aortic stenosis, hypertension, cardiomyopathies, & coronary artery disease

Less specific for CHF than S3

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Murmurs Turbulent blood flow across a valve or a disease

such as anemia or hyperthyroidism Listen for murmurs in the same auscultatory

sites APETM Systolic b/w S1 & S2 Diastolic b/w S2 & S1

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MurmursThey are classified by

Timing & duration within the cardiac cycle (systolic, diastolic, & continuous)

Location Intensity Shape (configuration or pattern) Pitch (frequency) Quality, & radiation

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Murmurs Grade I: barely audible Gr II: audible but quiet and soft Gr III: moderated loud, without thrust or thrill Gr IV: loud, with thrill Gr V: louder with thrill, steth on chest wall Gr VI: loud enough to be heard before steth on

chest

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Thank You