Physical Exam Pearls – 2 (HENT)

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More in our series of random tips on performing physical exam.  Last time we discussed the Eye.  Moving on down (and around)…

HEAD

1.  We chart “atraumatic,” only because there’s nothing else to say about the adult head (we never chart “Chest, atraumatic,” etc.!!!)

2.  In the case of head trauma with normal mental status or slight disorientation, examine for subtle signs of basilar skull fracture:

  • Battle’s Sign: ecchymosis over mastoid process
  • Raccoon Eyes:  blood pooling at lower lids (also occurs with mild forehead trauma)
  • Hemotympanium:  blood behind TM (or leaking from ruptured TM)
  • CSF Rhinorrhea / Otorrhea:  Clear fluid leaking from nose / ear

EARS

1.  Hold the otoscope properly:

  • Your right hand for their right ear, left for left
  • Choke up on the handle, so your hand is right up near the light source
  • That way you can brace your 4th & 5th fingers against patient’s jaw or cheek.  This is essential in pediatrics, lest the child wiggle, jamming their ear into the otoscope speculum

2.  Tug on the pinna to straighten the canal; be as aggressive as you need.  I’ve seen countless students find a “red TM” when all they were seeing was the canal wall.

3.  Seek bony landmarks every time you examine the TM.  Can’t evaluate it otherwise.  Presence / absence of landmarks is much more important than the color when it comes to Otitis Media.

  • Increased vascularity of TM along the bony landmark looks “red,” but is NOT Otitis Media.
  • Cone of light not as important in adults, since old infections may have distorted it.

4.  A single reddish spot on TM is probably pasted-on wax, but stare at it carefully.  If it pulsates, it’s a rare vascular tumor [have never seen one].

5.  Seek out a cholesteatoma — white lesion / nodule usually at the superior aspect of TM.  Needs ENT evaluation, since it can erode into bone.

6.  Ear Pain & too much wax / gook to visualize the TM — tug on pinna & push on tragus.  If these maneuvers are tender, it’s Otitis Externa.  If not, then no Externa (so maybe Media, if the pain is significant).

7.  Weber Test (tuning fork)  —  Explain to patient, “I’m going to hit the fork to make a tone, ‘Buzzzz,’ put it on your head, & you tell me, is it louder in this ear [point] or that one [point].”

8.  Rinne Test (tuning fork): the easiest & quickest way:

  1. Explain to pt: “I’m going to put the fork here, ‘#1’ [on mastoid], then here, ‘#2’ [by auditory meatus], & you tell me which is loudest.”
  2. Hit the fork, press it to mastoid process, ask, “Which is louder, #1, [then move it to the meatus] or now, ‘#2’?”

9.  Know how to interpret Weber & Rinne (distinguishing conductive from sensorineural hearing loss):

  • First test hearing by whisper test to determine which ear has a deficit.
  • Principle:  Bone Conduction (BC) greater than Air Conduction (AC) = conductive hearing loss (external or middle ear, NOT the nerve)
  • Weber lateralizes to R = R conductive deficit, or L sensorineural deficit.  Knowing where the deficit is from whisper test lets you distinguish.
  • Rinne:  BC > AC in an ear = conductive deficit; AC > BC is normal (or, if hearing loss in that ear, a sensorineural deficit)
  • Weber & Rinne are not absolute, but very useful if everything fits together.  Click link for an in-depth description.

NOSE

1.  Testing for Sinus Tenderness isn’t very reliable.  Only useful if dramatic difference from one side to the other.

2.  Transilluminating sinuses isn’t reliable at all.

3.  When considering Allergic Rhinitis as a diagnosis, don’t forget to observe for “Allergic Salute” (horizontal crease across tip of nose, from frequent wiping) and “Allergic Shiners” (darkened lower lids, like ‘black eyes,’ from venous congestion).

  • Also examine interior nares for “pale, boggy mucosa”
  • Chronic nasal congestion, look for polyps way inside protruding into turbinates

4.  Epistaxis — if unilateral, seek an anterior bleeding point that can be cauterized.

5.  Unilateral anterior nasal pain — seek an occult furuncle in the nasal vestibule.

6.  Deviated nasal septum is important because it can make an otherwise mild allergy feel quite uncomfortable on the narrow side.

MOUTH

1.  Routine PE for heavy smokers or chewless-tobacco users: palpate under tongue for nodules (cancer)

  • I’ve had several patients worry about “tongue cancer,” when they’d happen to notice normal papillae way in the back of their tongues.  Though I usually don’t reveal personal information to patients, I do stick out my own tongue as reassurance.

2.  Every time I examine the mouth & throat, I look for stigmata of occult undiagnosed HIV.

  • Examine the buccal mucosa for thrush.
  • Seek oral Kaposi’s Sarcoma on the palate.
  • Check sides of tongue for vertical white corrugated streaks = Hairy Leukoplakia (pathognomonic of advanced HIV).  Simply say, “Point your tongue to this side [point].  Now the other.”
  • Click for pictures.

3.  Diagnose dental infection by percussion.

  • Single tooth tender suggests root infection
  • All maxillary teeth tender on one side suggests sinusitis

THROAT

1.  A great way to visualize the throat is to ask patient to “Yawn”.  Most can do so on cue (especially if they’d been waiting a long time already).

2.  Don’t confuse round white circles on tonsils with exudate.  It’s just gunk stuck in crypts (scars from old tonsillitis).  Exudate appears more pasty or slapped-on.

3.  When examining pt. w/ “sore throat,” r/o early Peritonsilar Abscess by documenting,“Uvula in midline.  No swelling of soft palate.”

LYMPH NODES

1.  Remember there are 10 groups of cervical nodes to check; I think in terms of 3 areas:

  • Ant. Auricular, Post. Auricular, Suboccipital
  • Tonsillar, Submandibular, Submental
  • Ant. Cervical, Post. Cervical, Deep Cervical (hook fingers under sternocleidomastoid), Supraclavicular

2.  Think “occult HIV” if you find post. cervical or suboccipital nodes

  • Also think “occult HIV” for Axillary and especially for Epitrochlear (I always check these along with cervical nodes)
  • Consider breast cancer too if you find an Axillary node

3.  Pay special attention to Left Supraclavicular area — most ominous node in the body.

4.  Inguinal nodes so common & non-specific, not worth examining

  • Swell from asymptomatic foot infections & pubic/perineal folliculitis
  • When AIDS was first identified & defined, inguinal adenopathy was excluded from consideration!

NECK

1.  For the uncommon complaint of “Swollen Neck”:

  • Palpate for crepitus = subcutaneous air [send to ER; ruptured lung / mediastinum]
  • Palpate for enlarged thyroid, nodes & masses
  • Order Chest X-Ray for upper lobe masses compressing veins

2.  The Hyoid Bone can often be balloted back & forth just superior to the thyroid cartilage.  Get used to thinking about it, so you don’t order an unnecessary CT for supposed “neck mass”

3.  Thyroid  —  Makes beginning clinicians nervous, because a normal thyroid gland often isn’t palpable.  So like normal ovaries & a normal spleen, don’t worry if you can’t identify it.

  • Some clinicians approach from behind, others from in front
  • If you indeed do feel it rising as patient swallows, don’t worry as long as it’s barely palpable, and bilaterally symmetrical
  • A tender thyroid is “thyroiditis” (see posting Hyperthyroidism)
  • An asymmetric thyroid warrants an ultrasound to r/o nodule (i.e. cancer)
  • A non-tender diffusely smooth thyroid suggests for Graves.  If TSH & Free T4 are normal, it’s Euthyroid Goiter, but warrants an ultrasound for occult nodules (see “Nodules” at end of Hyperthyroid posting)

4.  Jugular Venous Distention (JVD)  —  Really part of the Cardiovascular Exam; will address later

  • Much better to organize your thought in terms of organ systems, instead of saying, “Here I am at the neck, let’s look for JVD.”

5.  Carotid Bruits — I never listen for them; just gets me in trouble

  • Find one in an asymptomatic patient, logically you get an ultrasound.
    • Studies of endarterectomy for asymptomatic carotid stenosis show stroke reduction of 1% per year, but up to 3% risk of perioperative stroke / death
  • If pt. symptomatic for carotid-area TIAs, do the ultrasound even if no bruit

6.  Carotid “Aneurysm”  —  my mother’s right carotid bulged with each pulsation!

  • Ultrasound was normal
  • Pub Med search found no mention of carotid aneurysms outside of trauma
  • One series found normal tortuous carotids, mostly on the right.  Ignore them!!!

Moving on down the body next posting.

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One response to “Physical Exam Pearls – 2 (HENT)

  1. Thank you! I appreciated the pictures in the mouth.

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