Terminal Learning Objective - JSOMTCInvoluntary movements Edema ... Extraocular movements ......

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Slide 1JSOMTC, SWMG(A)

SOCMPhysical Exam of the Head and Neck

PFN: SOMPYL0N

Hours: 2.0


Terminal Learning Objective Action: Communicate knowledge of “Physical Exam of the Head and Neck”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet


References

Bates’ Guide to Physical Examination And History Taking (11th Edition, Lynn S. Bickely)

Essentials of Anatomy & Physiology (6th

Edition, Martini/Bartholomew)

Examination of the Head, Eyes, Ears, Nose and Throat Video, Learning Management System (LMS)

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Reason

As a SOF Medic your ability to understand and perform an HEENT exam will play a key role in proper diagnosis of some conditions your patients may have. Although HEENT exams are exciting, this is an area in which you can make a big difference in optimizing your teammates’ performance.


Agenda

Define the key terms and identify anatomy and physiology related to the physical exam of the head and neck

Communicate the examination techniques of the head

Communicate the examination techniques of the eyes

Communicate the examination techniques of the ears


Agenda

Communicate the examination techniques of the nose and para‐nasal sinuses

Communicate the examination techniques of the mouth and pharynx

Communicate the examination techniques of the neck

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The Examination Techniques of the Head


Head Exam

Examination

Important areas

• Hair

• Scalp

• Skull

• Face

• Skin


Head Exam

Inspection

The skin

• Observe

Color

Lesions

Texture

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Head Exam

Inspection

The face

• Observe facial expressions for

Asymmetry

Involuntary movements

Edema and masses


Head Exam

The head

The skull

• Observe: size and contour

• Palpate all bones and prominences

Note: deformities, depressions, lumps, or tenderness

• Palpate temporal arteries

Note: thickening, hardness, and tenderness


Head Exam

The head

The hair

• Inspect: quantity, distribution, texture, pattern of loss

• Note: loose flakes, white ovoid granules (eggs)

• Fine vs. coarse hair

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Head Exam

Inspection

The scalp

• Part the hair and observe for: erythema, scaling, lumps, nevi, edema

Seborrheic dermatitis

Psoriasis


Head Exam

Palpate facial bones

Frontal

Nasal

Maxillary

Mandible

Note any tenderness, instability, or deformities


Head Exam

Palpate the TMJ

Find the TMJ

Ask patient to slowly open and close mouth

Note any clicking or popping

Note any deviation of the mandible to the left or right

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Head Exam

The nose and paranasal sinuses

Palpate:

• Assess for sinus tenderness

Frontal sinus

Maxillary sinus


Head Exam

Inspect CN VII Facial (motor branch) innervation

Ask the patient to:

Wrinkle forehead

Smile

Frown

Puff out cheeks


Head Exam

Test sensation to light touch

Stimulate all sensory branches of CN V Trigeminal

Ask patient if there is a difference in sensation

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Head Exam

Alternate test for CN V Trigeminal; The corneal reflex

Ask patient to look away

Lightly touch patient’s cornea with sterile cotton wisp

Patient should blink with both eyes


The Examination Techniques of the Eyes


Examination Techniques – The Eyes

Important areas of examination

Visual acuity

Visual field

Conjunctiva and sclera

Cornea, lens, and pupils

Extraocular movements

Fundi

• Optic disc and cup

• Retina

• Retina vessels

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Eye Exam

The eyes

Visual acuity

• Snellen eye chart

• 20 feet

• 20/30 ???

20 distance of patient

30 distance of normal vision

• Special hand‐held card

Near vision

45 y/o plus, 14 inches

Bedside


Key Definitions

Hyperopia ‐ Farsighted

Acuity example (20/10)

Myopia ‐ Nearsighted

Acuity example (20/200)


Eye Exam

The eyes

Fields of Vision

• Screening

Temporal fields

– Two eyes

Further testing

– One eye at a time

– Blind spots

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Eye Exam

The eyes

Position and Alignment• Inspect

Eyebrows

– Quantity, distribution, scaliness

Eyelids

– Width of palpebral fissures

– Edema of lids. Color of the lids

– Lesions, and condition/ direction of the eyelashes

– Adequacy in which the eyelids close


Eye Exam


Eye Exam

Inspection of the upper palpebral conjunctiva

Exam to search for foreign bodies thru eversion of the upper eyelid

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Eye Exam

The eyes

Lacrimal apparatus

• Inspect

Lacrimal gland, and lacrimal sac

– Swelling

– Excessive tearing or drying


Eye Exam

The eyes

Conjunctiva and sclera

• Inspect

Color

Clarity


Eye Exam

The eyes

Cornea and lens

• Inspect

Scaring

Cataracts

Arcs

Thickening

Erythema

Edema

Opacities

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Eye Exam

Exopthalmos –Protruding eyes

Inspection

• Viewed from behind the seated patient

• Draw upper eyelids

• Measure the distance in relation of the cornea to the lower eyelids

• Abnormal readings 18mm from orbit require further evaluation


Eye Exam

Pupil assessment = PERRLA

Pupils Equal (in size)

• Inspect

Size

– (>5mm) large, (<3mm) small

Shape (should be Round)

Symmetry


Key Term

• Anisocoria – An unequal pupil size

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Eye Exam

Pupils

Should be Reactive to Light (bilaterally)

• Test

Reaction to light (obliquely)

– Darken the room

– Distant gaze

• Observe

Direct and consensual constriction


Eye Exam

Pupils

Accommodation

The ability for the lens to change shape

Provides near and far focus

Test by having patient look at a near object, then far object, observing the change in pupil size


Eye Exam

A check for Glaucoma

Use oblique lighting technique

•Observe for shadows on iris

Use white light from temporal side

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Eye Exam

Checking alignment

Extraocular muscles choose direction

• Assess corneal reflection (small light on cornea)

Deviations vs. normal alignment

–


Eye Exam

The eyes

Extraocular muscle test

• Six EOMs

Finger or pencil

Sweeping motion from right to left in a wide “H”

Distance depends on age of patient


Eye Exam

Extraocular muscle test

Looking for nystagmus – fine oscillating movement

• Evaluated in the binocular field of vision

• Tested on multiple planes (horizontal, vertical, rotary)

• Slow phase

Pendular

• Fast phase

Left / right‐beating nystagmus

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Key Term

Nystagmus

A fine oscillating movement of the eyes


Eye Exam

Extraocular muscle

Test for convergence

• Using an object

Move towards the bridge of the nose stopping approximately 5‐8 cm off the bridge of the nose


Eye Exam

The eyes

Ophthalmoscopic examination

• 15 degree from patient’s line of vision

• “Red light” reflex

• Pupil dilation – mydriatic eye drops

View more peripheral structures

Evaluate macula last

Investigate unexplained visual loss

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Eye Exam

Inspect

The optic disc


Eye Exam

Inspect

The optic disc

• Inspection:

Sharpness

Color

Size

Symmetry


Eye Exam

Inspect

The retina – arteries, veins, fovea, and macula

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Eye Exam

The eyes

The retina ‐ arteries, veins, fovea, and macula

• Inspection: the retina

Arteries vs. veins

– Color: light vs. dark

– Size: small vs. large

– Light reflex: bright vs. absent

– Lesion measurements


Eye Exam

Inspection

The anterior surfaces

• Vitreous or lens

The fovea and macula

• Ask patient to look directly at the light

• Observe for “light reflection”


Eye Exam

Saccadic insufficiency Similar to extraocular

test

Hold two objects in view

Ask patient to look at one then the other moving them up and down

A saccadic insufficiency is a sign of TBI

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The Examination Techniques of the Ears


Ear Exam

Important areas

Inspection and palpation of the external ear

Inspection of the auditory canal

Inspection of the tympanic membrane

Test mobility of tympanic membrane

Assess hearing


Ear Exam

Inspect

The auricle

• Tissues for deformities, lumps, lesions or discharge

• Palpation

Tug test – R/O otitis externa

– Lift auricle up and down

– Press tragus

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Ear Exam

Otoscopic Exam

Ear canal and drum

• Pull up and back on auricle


Ear Exam

Otoscopic Exam

Ear canal and drum

• Inspection

Ear canal

– Discharge, foreign bodies, erythema, edema

– Cerumen (ear wax)

Eardrum

– Note color and contour

– “cone of light”


Ear Exam

Otoscopic Exam

Ear canal and drum

• Inspection

Malleus handle and short process

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Ear Exam

Otoscopic Exam

Ear canal and drum

• Inspection

Perforation

Purulent effusion


Ear Exam

Assess TM mobility

Ear canal and drum

• Assess mobility by having patient perform valsalva maneuver


Ear Exam

The ears

Auditory acuity

• Hearing tests

• Estimation tests

Air and bone conduction

•Weber test

Lateralization

• Rhine Test

AC vs. BC

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Ear Exam

The ears

Air and bone conduction

• Unilateral conductive hearing loss

Sound heard in impaired ear

– Acute otitis media, perforation, obstruction

BC = AC or BC > AC

• Unilateral sensorineural hearing loss

Sound heard in good ear

AC > BC


The Examination Techniques of the Nose and Paranasal Sinuses


Nose Exam


Inspect symmetry of the nose

Determine patency of each nostril

Inspect nasal mucosa

Assess CNI olfactory

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Nose Exam


Inspect: anterior and inferior surfaces of the nose

View each nasal vestibule

• Pressure on nose tip

• Use penlight or otoscope to view

Test for nasal obstruction

• Palpation of ala nasi


Nose Exam


Inspect the inside of the nose


Nose Exam


Observe

• Nasal mucosa

Note: color, edema, bleeding (epistaxis), or exudate (rhinorrhea)

• Nasal septum

Note: deviation, edema, perforation

• Abnormalities

Note: ulcers or polyps

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Nose Exam

Assess olfactory function (CN I) Olfactory

Patient should close both eyes

Occlude one nostril

Present a familiar non‐noxious odor; (e.g., coffee)

Ask patient to identify

Test other nostril


The Examination Techniques of the Mouth and Pharynx


Examination Techniques


Inspection of lips

Inspection of the oral mucosa including the tongue and teeth

Assess motor of tongue

Inspect posterior pharynx

Assess gag reflex

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Mouth and pharynx

The lips

• Observe

Color

Moisture

Lumps

Ulcers

Cracking

Scaliness



Mouth and pharynx

The oral mucosa

• Inspection

Color

Ulcers

White patches

Nodules



Mouth and pharynx

The gums

• Inspection

Color

Margins

Interdental papillae

Edema

Ulcers

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Mouth and pharynx

The teeth

• Inspection

Number

Color

Position

• Palpation

Looseness



Mouth and pharynx

The roof of mouth

• Inspection

Color

Architecture



Mouth and pharynx

The tongue and floor of the mouth

• Inspection

Symmetry (CN XII)

Color

Texture

• Palpation

Pull left and right

Induration

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Mouth and pharynx

The pharynx

• Inspection

“ah” or “yawn” (CN X)

Rise of soft palate

Color

Symmetry

Exudate

Tonsillar enlargement

Edema

Erythema


The Examination Techniques of the Neck




Inspect for symmetry of the neck

Inspect tracheal position

Inspect and palpate the thyroid

Assess CN XI spinal accessory

Palpate lymph nodes

Assess cervical range of motion

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Inspect for symmetry of the neck and thyroid



The neck

The trachea

• Inspection and palpation

Trachea for deviations

•



The neck

The carotid arteries and jugular veins

• Defer to the cardiovascular examination

Inspect the patient while supine

• JVD – Jugular vein distention

May be visible in sitting position

• Carotid Arteries

Observe for prominent pulsations

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The Neck

The thyroid gland

• Inspection (at rest)

Below the cricoid cartilage

•



The Neck

The thyroid gland

• Inspection (swallowing)

Below the cricoid cartilage

•



The Neck

The thyroid gland

• Palpation

Locate the thyroid isthmus

•

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Assess trapezius and sternoclidomastoidmuscle strength (CNXI)



The Neck

The lymph nodes

• Inspection

Size

Shape

Delimitation

Mobility

Tenderness

• Palpation

From top to bottom

Pads of index and middle finger

Neck: relaxed, slightly forward, toward examiner


Examination Techniques The neck

The lymph nodes

1 Preauricular

2 Posterior auricular

3 Occipital

4 Tonsillar

5 Submandibular

6 Submental

7 Superficial cervical

8 Posterior cervical

9 Deep cervical chain

10 Supraclavicular

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Cervical range of motion


Questions?


Terminal Learning Objective

Action: Communicate knowledge of “Physical Exam of the Head and Neck”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards

30


Agenda

Define the key terms and identify anatomy and physiology related to the physical exam of the head and neck

Communicate the examination techniques of the head

Communicate the examination techniques of the eyes

Communicate the examination techniques of the ears


Agenda

Communicate the examination techniques of the nose and para‐nasal sinuses

Communicate the examination techniques of the mouth and pharynx

Communicate the examination techniques of the neck


Reason

As a SOF Medic your ability to understand and perform an HEENT exam will play a key role in proper diagnosis of some conditions your patients may have. And although HEENT exams are not very exciting, this is an area in which you frequently can make a big difference in optimizing your teammates performance.

31


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Terminal Learning Objective - JSOMTCInvoluntary movements Edema ... Extraocular movements ......

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