Physical Exam Information


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Your Head, Neck, Heart, and Lung Exam


The Doctor Checks Janet's Head and Neck

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Begin by asking about the nose and paranasal sinuses. The examiner should inquire about the presence and duration of trauma, nosebleeds, drainage, facial aching, congestion, or previous surgery. The type and severity of trauma, a description of the type of drainage, and the degree of pain or swelling should be carefully noted. Associated congestion in the nose and records of all previous nasal or head and neck surgery should be recorded. Frequent occurrence of colds, hay fever reactions, and seasonal exacerbation of these problems should be recorded. Snoring, the use of intranasal drugs such as cocaine or crack, or prolonged use of nasal sprays and the intake of other decongestant medications should be documented. Frequent redness or swelling of the eyes should be noted also.

Next consider the oral cavity and salivary glands. The examiner should inquire about the presence and duration of the following lesions in and about the mouth and lips: ulcers or canker sores, tender gums or painful teeth, xerostomia (dry mouth), fissures at the corner of the mouth or the tongue, and the presence of blood in saliva. The patient should be asked about tongue soreness, recent dental work, difficulty chewing, excess saliva or thick saliva, the chronic use of tobacco, and unusual habits such as bruxism or nocturnal grinding of the teeth. The patient should be asked about the possibility of previous swelling or tenderness under the jaw, in the preauricular area, in the palate or on the tongue, or any limited or painful jaw motions.

For the jaw and temporomandibular joints, a history should be taken to document the presence and duration of the following: trauma, braces or orthodontic treatment, clicking or crunching sounds when opening the mouth, preauricular swelling, tenderness to palpation, teeth grinding at night, frequent clenching of teeth during the day, or pain or discomfort into the temple or down the side of the neck. The patient should also be asked about ringing in the ear or tinnitus, associated sensations of dizziness or unsteadiness, and the presence of ear fullness. The use of dentures or bridges should be documented, and the patient's history concerning excision of third molars (wisdom teeth) or other extractions should be documented.

For the pharynx, larynx, and thyroid gland, the examiner should inquire about the presence and duration of sore throats and previous antibiotic treatment for pharyngitis or mouth ulcers. Questions should be asked about difficulty swallowing, the presence of gland or node enlargement in the neck, the presence of hoarseness, or the presence of blood in the sputum (hemoptysis). Occupational exposures to chemicals, dust, or various gases should be documented. Any known respiratory allergens should be recorded. Tobacco use should be documented, and the number of years of usage recorded. Unusual use of the voice, such as professional singing or talking consistently above a noisy environment, should be noted. The presence of an irritative cough, tenderness or fullness under the collar, or consistent clearing of the throat should be documented. The patient should be asked about pain on neck motion. The regular use of any prescription drugs should be recorded. Because almost one-third of AIDS patients present with head and neck disorders, any history of risk factors for the disease should be investigated (high-risk sexual practices, use of intravenous drugs with shared needles, blood transfusions).

In collecting information about problems involving the face, the patient should be asked about discomfort in the cheek or forehead, unusual pains following dental procedures, or unusual sensitivity to sunlight. Inquiries should be made about prolonged occupational exposures to sunlight, chemicals, or dust. Patients should be asked if they have used protective hats or masks when around these substances. Questions about the severity of acne in adolescence or recurrent skin infections should be noted. The patient should be asked about visual disturbances related to sagging eyelid or the presence of any double vision, which indicates obstruction of vision.

For evaluation of the ears and hearing, the patient should be asked about awareness of decrease in conversational hearing, and the effect that background noise has upon hearing. The history of childhood ear disease should be documented along with head, facial, or ear trauma, exposure to ototoxic drugs, previous ear surgery, or ear treatment, and the presence of any severe febrile ear illnesses during childhood. A careful family history for hearing impairment, the use of hearing aids, or known ear surgery should be documented. The patient should be asked about recent respiratory infections or allergy, and medical treatment for severe allergy should be recorded. Questions about ear drainage or discharge, or the presence of excessive wax, should be asked. An occupational and recreational history should be taken, particularly relating to exposure of the patient to excessive noise. The quality, duration, and type of noise should be documented, and the patient's hunting experience or other exposure to gunfire should be recorded. The frequency of aircraft exposure or scuba diving needs to be documented.

Symptoms related to the ear such as ringing in the ear, or tinnitus, are very common, and specific questions should be asked about duration, intensity, unilateral or bilateral presence, and pulsating or throbbing quality. Fullness in the ear should be documented, and balance disorders or vertigo require particular elaboration. Frequent probing of the ear for wax removal or itching, or the placement of foreign bodies in the ear, should be documented. The presence of persistent pain in the ear, or otalgia (Chapter 122), or knowledge about drum perforations in the past, is needed. Questions relating to unusual sensitivity to sudden or loud sounds, particularly those associated with or related to other ear symptoms such as tinnitus, vertigo, fullness, or fluctuant hearing loss, need to be recorded. Intermittent, changing, or fluctuant hearing loss may be present.

The Doctor Checks Janet's Heart and Lungs

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Auscultation of the heart and lungs are integral parts of physical examination of a patient. Blood flowing across the heart valves is laminar flow so that no sound is produced. The sounds heard on auscultation are the sound of the valve cusps snapping shut at the end of diastole (when the AV valves shut producing the 1st heart sound) and at the end of systole (when the Aortic & Pulmonary valves shut producing the 2nd heart sound).

These sounds are conducted to the surface of the body and can be heard with the aid of a stethoscope. There are specific places on the anterior chest wall where the sound from each of the 4 valves can best be heard. These are not the surface markings of the valves but rather the points where the sounds are best conducted to. They are as follows:
• Aortic Valve – R 2nd ICS
• Pulmonary Valve – L 2nd ICS
• Tricuspid Valve – L sternal border
• Mitral Valve – 5th ICS MCL

The stethoscope comprises a bell and a diaphragm. The bell is designed to hear low pitched sounds and the diaphragm is designed to hear high pitched sounds. They are connected via rubber tubing to the ear pieces. These should be worn facing forward as the ear canals run anteriorly.

The main sounds of the lungs include wheezes, crackles, pleural rub and normal lung sounds.

Crackles (rales) are caused by excessive fluid in the airways. It is caused by either an exudate or a transduate. Exduate is due to lung infection e.g pneumonia while transduate such as congestive heart failure. A crackle occurs when a small airways pop’s open during inspiration after collapsing due to fluid or lack of aeration during expiration. Crackles are much more common in inspiratory than in expiratory.

Crackles are high-pitched and discontinuous. They sound like hair being rubbed together. There are three different types; fine, medium and coarse.

Fine are typically late inspiratory and coarse are usually early inspiratory
Fine crackles are high pitched, very brief and soft. It sounds like rolling a strand of hair between two fingers. Fine crackles could suggest an interstitial process; e.g pulmonary fibrosis, congestive heart failure.
Coarse crackles are louder, more low pitched and longer lasting. They sound like the separation of Velcro. Coarse crackles could suggest an airway disease, chronic bronchitis.

Listen to Wheezes

Wheezes are an expiratory sound caused by forced airflow through collapsed airways. Due to the collapsed or abnormally narrow airway, the velocity of air in the lungs is elevated. Wheezes are continuous high pitched hissing sounds. They are heard more frequently on expiration than on inspiration. If they are monophonic it us due to an obstruction in one airway only but if they are polyphonic than the cause is a more general obstruction of airways. Where the wheeze occurs in the respiratory cycle depends on the obstructions location, if wheezing occurs in the expiratory phase of respiration it is usually connected to broncholiar disease. If the wheezing is in the inspiratory phase, it is an indicator of stiff stenosis whose causes range from tumours to scarring. One of the main causes of wheezing is asthma other causes could be pulmonary edema, interstitial lung disease and chronic bronchitis.

Pleural Rub
Pleural Rub produces a creaking or brushing sound. These occur when the pleural surfaces are inflamed and as a result rub against one another. They are heard during both inspiratory and expiratory phases of the lung cycle and can be both continuous and discontinuous. Pleural rub can suggest pneumothorax or pleural effusion.



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