PHYSICAL EXAMINATION

OF HEENT & LGS

BY:- Dr Solomon Gezie
 Guide for P/E
• General appearance
– Severity of illness, nutritional status, cardio-
respiratory distress, mental status
• Vital signs
– Blood pressure(Rt. or Lt. arm, supine or erect ,
– pulse rate, per min
– respiratory rate, per min
– Temprature (site taken) , in celicius or farheniet
• Weight & Height
 HEAD
• Abnormalities covered by the hair are easily missed,
• Ask if the patient has noticed anything wrong with the scalp or
hair. If you detect a hairpiece or wig, ask the patient to remove
it.
Examine:
 The Hair. Note its quantity, distribution, texture, and any
pattern of loss.
Eg. Fine hair is seen in hyperthyroidism;
coarse hair in hypothyroidism.
Tiny white ovoid granules that adhere to hairs may be nits
(lice eggs).
 The Scalp. Part the hair in several places and look for
scaliness, lumps, nevi, or other lesions.
 HEAD
 The Skull.
 Observe the general size & contour of the skull.
 Note any deformities, depressions, lumps, or tenderness.
 to recognize the irregularities in a normal skull, such as those
near the suture lines between the parietal and occipital bones.
• The Face.
 Note the patient’s facial expression and contours.
 Observe for asymmetry,
 involuntary movements, edema, and masses.
• The Skin.
 Observe the skin,
 noting its color,
 pigmentation, texture, thickness, hair distribution, and
any lesions.
 EYE
• Components of the eye examination
 Visual acuity by SNELLEN’S CHART
 Visual field
 Color vision
 Fundus by Ophthalmoscope
 Front part of the eye
 Pupils
 EYE
• Pupils equal round and react to light and
accommodation (PERRLA);
• extra ocular movements intact (EOMI),
• and visual fields.
• Funduscopy (papilledema, arteriovenous
nicking, hemorrhages, exudates);
• scleral icterus,
• ptosis
 EYE
• Xanthelasma or corneal arcus indicates
hyperlipidemia
• Pallor of the conjunctiva indicates anemia
• Icterus may be found in acutely congested
liver
• Exophthalmus may be seen in
thyrotoxicosis
 EYE
• Causes of Dilated Pupils
1-Mydriatic
2-Parasympathetic palsy
3-Glaucoma
4-Trauma
Causes of Constricted Pupil
1-Miotic
2-Sympathetic nerve palsy
3-Iritis
 The Ears

• The Auricle
• Inspect each auricle and surrounding tissues
for deformities, lumps, or skin lesions.
• -If ear pain, discharge or inflammation is
present,
o move the auricle up and down,
o press the tragus, and
o press firmly just behind the ear.
Ear Canal and Drum ƒ
• To see the ear canal and drum, use an
otoscope with the largest ear speculum that
the canal with accommodate position the
patient’s head so that you can see
comfortably through the instrument.
 Some pathologic findings
• Non tender nodular swellings covered by
normal skin deep in the ear canals suggest
exostoses.
• These are nonmalignant over- growths,
which may obscure the drum.
• Cerumen, which varies in color and
consistency from yellow and flaky to brown
and sticky or even to dark and hard,
• In acute otitis externa, the canalis often
swollen narrowed, moist, pale, and tender.
It may be reddened.
• In chronic otitis externa, the skin of the
canal is often thickened, red, and itchy
 The Nose
• Inspect the anterior and inferior surfaces of
the nose. ƒ
• Gentle pressure on the tip of the nose with
our thumb usually widens the nostrils and,
with the aid of a penlight or otoscope light,
you can get a partial view of each nasal
vestibule ƒ
• Tenderness of the nasal, tip or alae suggests
local infection such as a furuncle.
• ƒNote any asymmetry of deformity of the
nose
 Observation
• 1. The nasal mucosa that covers the septum
and turbinates. Note its color and any
swelling, bleeding, or exudates. If exudate
is present, note its character: clear,
mucopurulent, or purulent. The nasal
mucosa is normally somewhat redder than
the oral mucosa.
• 2. The nasal septum. Note any deviation,
inflammation, or perforation of the septum.
The lower anterior portion of the septum is
a common source of epistaxis nosebleed.
• 3. Any abnormalities such as ulcers or
polyps. Polyps are pale, semi translucent
masses that usually come from the middle
meatus.
 Para nasal sinuses
• Palpate for sinus tenderness.
• Press up on the frontal sinuses from under
the bony brows, avoiding pressure on the
eyes.
• Then press up on the maxillary sinuses.
• Local tenderness, together with symptoms
such as pain, fever and nasal discharge,
suggests acute sinusitis involving the frontal
or maxillary sinuses.
• Transillumintion may be diagnostically
 The Mouth
• Observe the color, moisture, and note any
lumps, ulcers, cracking, or scaliness
• Look in to the patient’s mouth and, with a
good light and the help of a tongue blade.
• Inspect the oral mucosa for color, ulcers,
white patches, and nodules.
• Note the color of the gums, normally pink.
Patchy brownness may be present,
especially but not exclusively in black
people
• Inspect the gum margins and the interdental
papillae for swelling or ulceration.
• Inspect the teeth. Are any of them missing
discolored, misshapen, or abnormally positioned?
You can check for looseness with your gloved
thumb and index finger.
• Inspect the color and architecture of the hard
palate, which makes the roof of the palate
• To examine tongue ask the patient to put out his
or her tongue. Inspect it for symmetry- a test of
the hypoglossal nerve. Note the color and texture
of the dorsum of the tongues
 Pharynx
• Made by the anterior and posterior pillars,
tonsils and uvula and pharynx.
• - Note the color, symmetry, exudate,
swelling, ulceration and tonsillar
enlargement.
 EXAMINATION OF THE LYMPHO
GLANDULAR SYSTEM
• The accessible lymph node groups in our
body for physical examination are: ƒ
Cervical lymph node groups
ƒAxillary lymph node groups ƒ
Supraclavicular lymph node groups ƒ
Inguinal lymph node groups ƒ
 Para aortic lymph node groups and others
• Cervical lymph node group: are affected
usually by neck and face pathologies.
Matted together e.g. Tuberculosis ƒ
Discreetly enlarged. Lymphomas ƒ
Hard or soft in consistency depending up on the
pathology ƒ
Small or big size ƒAssociated with discharge
• Cervical lymph group are also divided as: ƒ
Anterior
 ƒPosterior ƒ
Deep or Superficial
 Groups of lymph node found in
the neck region are
• Groups of lymph node found in the neck
region are following
• Examination of axillary lymph nodes is
done ƒ
The patient being best in sitting position ƒ
Pectoralis muscles should be relaxed, ƒ
Examiner sitting on the same side of the axilla then
ƒPalpate systematically the five groups of lymph
nodes.
 Other groups:
• Examination of the inguinal lymph nodes:
– The inguinal lymph nodes are found along the inguinal
canal.
– Most of them are palpable as they are check point for the
lower extremit

• Para aortic lymph nodes:

– these nodes are not usually accessible to physical
examinations unless the patient is thin or wasted.
Colorectal carcinoma metastasizes to these lymph

• ƒPre trochlear nodes:

– Are located close to the elbow joint and affected by
syphilis
 Examination of the Thyroid
Gland
• Inspection ƒ
 Size of the thyroid if it is enlarged, (minimally,
moderately or severely) ƒ
Movement with swallowing ƒ
Any dominant or solitary nodule ƒ
For scars, sinuses and change in color of the
skin
 Palpation
• Palpation from in front
• This is done by the palmar side of the fingers, ƒ
• ask the patient to swallow and feel for trachea
• ƒthen feel each lobe (right, left) by palpating the
anterior boarder of the sternomastoid muscles by
flexing the neck ƒ
• measure the size ƒ
• look for tenderness ƒ
• assess for mobility and
• attachment ƒtry to palpate the lower boarder of the
thyroid gland and the trachea
• Percussion:
– upper part of the chest for possibility of
retrosternal extension
• Auscultation:
– This is done for detecting bruit which may be
heard during hypervascularity of the thyroid
gland
 Examination of the Breast
GENERAL PRINCIPLE
• Should be done in a private place with good
illumination ƒ
• Is more informative if done just after the end of
menses ƒ
• patient should be in a semi sitting position ƒ
• expose the whole of the upper half of the body ƒ
• always start from the normal breast ƒ
• examine systematically, quadrant by quadrant
• Specific goals of examination are to: ƒ
• detect and characterize breast mass or masses
• ƒelicit discharge from the nipple
• ƒrelate pain compliant to a specific breast finding ƒ
• detect skin changes ƒ
• detect enlarged axillary, supraclavicular or
infraclavicular lymph nodes ƒ
• detect metastasis (If breast cancer suspected)
• Inspection:
• Stand in front of the patient. Look at the:
– size of breast
– symmetry and contour of breast
– nipple & areola for absence, symmetry,
retraction, discharge
– skin for retraction, discoloration, “peau d’
orange” appearance nodules and ulceration
 Palpation
Palpate with the palmar surface of your
fingers ƒ
• Roll the breast tissue between the chest wall
and your hand ƒ
• Palpate the whole breast quadrant by
quadrant ƒcheck for
• skin temperature
• consistency of breast, nodularity
• tenderness
• nipple discharge (expression)
• axillary, infra and supraclavicular lymph nodes
should always be examined together with the breast
• Mass
• discrete or indiscrete? ƒ
• position in the breast ƒ
• number ƒshape & size
• ƒsurface & consistency ƒ
• tenderness and hotness of overlying skin ƒ
• fixation to skin, pectorals fascia or chest wall
 10 Q

• The end