Sequence and head-to-neck assessment

Examination sequence

The physical examination sequence is fairly standard; however, variations may occur, depending on the provider’s specialty, the reason for the examination, and the provider’s preference. Patients are more cooperative and less anxious if they understand what is expected of them. Start by giving the patient a brief explanation of the examination process. Many healthcare facilities provide the option for patients to have a chaperone present during physical examinations. Assemble all supplies and instruments needed for the examination before the provider enters the room. As the provider proceeds with the examination, make sure the patient remains unexposed by adjusting the drape and gown as needed. During the examination, the medical assistant assists by handing the provider the correct instruments and needed supplies. When the provider begins the examination, the medical assistant should keep conversation to a minimum and remain inconspicuous.

The examination usually starts with the patient seated at the end of the exam table or in the Fowler position if the patient needs support. If the provider uses reflected light, the light source should be behind the patient’s right shoulder. If illuminated instruments are used, standard overhead lights are sufficient. Take care not to shine a light directly into the patient’s eyes; this can be done by turning on lights while they are directed away from the patient and carefully moving the light toward the area.

Chaperones during physical examinations

It is becoming common for chaperones to be present during physical examinations. Having a third person in the exam room provides protection for both the patient and the provider. A medical assistant may be asked to be a chaperone.

A chaperone can reassure the patient about the professional character of the healthcare facility. The patient has the right to refuse to have a chaperone present in the room, but most are accepting. When the chaperone is another health professional, such as a medical assistant, she or he can serve two purposes: as a chaperone and as an assistant to the provider.

If a healthcare facility is going to have chaperones present, there should be a written policy that describes the role of the chaperone. This policy should allow for a private conversation between the patient and the provider.

General appearance

The provider starts the physical examination by observing the patient’s appearance, using an inspection technique. The general appearance explains whether the patient appears well and in good health (e.g., note whether the patient appears disoriented or in distress, well-nourished or undernourished, and answers questions with ease or confusion).

The patient’s gait often provides important information. The patient may limp, walk with the feet wide apart, have a shuffle step, or have difficulty maintaining his or her balance. Posture is also checked for indications of pain, stiffness, or difficulty with limb movement. The provider notes body build and proportions. Any gross (immediately obvious) deformities are recorded.

Sometimes abnormalities in height or body proportion may be caused by hormonal imbalances. If the medical assistant notices any of these or the patient reports any complaints, these should be documented in the patient’s health record, along with the vital signs, before the provider begins the examination.

Speech

Speech may reveal a pathological condition. Some basic speech defects are defined below.

Speech is also assessed in well-child checkups. A delay in speech development can indicate an issue (e.g., a neurologic deficit or possible autism spectrum disorder) and the need for a referral.

Skin

The skin’s condition can be a reflection of the patient’s nutritional status and hydration level. If dehydration is suspected, skin turgor is checked by pinching the skin on the posterior surface of the hands. The tissue is observed to see how quickly it returns to its normal location. A delay indicates a decrease in tissue fluid, confirming the diagnosis of dehydration. Extreme dryness, scaling, extended time for wound healing, or frequent breaks in the skin may indicate systemic disease.

Fingernails and toenails

Nails often give some indication of a person’s health. Brittle, grooved, or lined nails may indicate local infection or systemic disease. Clubbing of the fingertips is associated with some congenital heart or lung diseases. Spooning of the nail is seen in some patients with severe iron-deficiency anemia. Beau lines, deep grooved horizontal lines, appear after an acute illness but grow out and disappear. The provider may refer a patient with skin or nail findings such as these to a dermatologist for diagnosis and treatment.

Head

Once the provider makes the overall observations of the patient’s general condition, the physical examination typically begins with the head and face and moves downward to the feet. The face reflects the patient’s state and tells the provider a great deal about how the patient handles stress and illness. The skull, scalp, and face are palpated for size, shape, and symmetry. The distribution or lack of hair and hair texture may indicate hormonal changes. Excessive hair, especially facial hair in females, indicates a hormonal imbalance. As the head is palpated, the provider assesses possible nodules, masses, or signs of trauma.

Eyes

The pupils are checked for reaction by shining a light into one eye at a time. If the pupils are equal and round, constrict equally and smoothly to a light stimulus, and also constrict when the patient shifts focus from a distant object to a near one (accommodation), the provider documents “PERRLA” - pupils equal, round, and reactive to light and accommodation. If accommodation is not tested, “PERRL” is documented instead. The sclera is checked for color, which ranges from white to pale yellow. If the eye is inflamed, it will be evident in the sclera. A sclera with a yellow tone indicates liver disease. Movements of the eyes are tested by having the patient follow the provider’s finger. If eye movement is within average range, “extra-ocular movement (EOM) intact” is documented. The ophthalmoscope is used to examine the interior of the eye, including the retina and intraocular vessels. Some diseases, such as diabetes mellitus and hypertension, damage the blood vessels of the retina.

Ears

The ears are examined with an otoscope covered with a disposable speculum. The external ear is checked first for inflammation of the external auditory canal or cerumen (earwax). The tympanic membrane (eardrum) is examined and should appear pearly gray. Scars on the eardrum are frequently the result of earlier, chronic ear infections or perforations. The color of the eardrum is important to the diagnosis because it may indicate fluids such as blood or pus behind the eardrum in the middle ear. The patient may be asked to swallow several times to allow observation of movement of the tympanic membrane, which occurs because of pressure changes in the eustachian tube. The eustachian tube equalizes air pressure between the middle ear and the throat. The ability of the tympanic membrane to move is crucial to the hearing process.

Nose and sinuses

The mucosa of the nasal cavity is examined for color and texture. The sinuses cannot be seen, but the frontal and maxillary sinuses may be examined by firm palpation over the area and by transillumination. When disorders of the eyes, ears, nose, and throat are observed, and the provider believes that the condition warrants the attention of a specialist, the patient is referred to an ophthalmologist or an otorhinolaryngologist (ear, nose, and throat specialist).

Mouth and throat

The mouth, or oral cavity, is usually thought of in terms of oral hygiene and dental care. Dental hygiene includes the condition of the teeth, how the patient cares for the teeth and gums, and whether the teeth of the upper and lower jaws meet properly (occlude) for chewing. Healthy gums are pale pink, glossy, and smooth and do not bleed when pressure from a tongue depressor is applied. The palatine tonsils are usually visible. The provider may use a tongue depressor and a piece of gauze to grasp the tongue to examine it carefully. The floor of the mouth is examined by both inspection and palpation for enlarged lymph nodes, salivary gland function, and ulcerations. The insides of the cheeks and the gum line are also examined for any abnormal marks or color. The provider may use the otoscope light to help with the examination.

Neck

The neck is examined for ROM by having the patient move the head in various directions. The thyroid gland is given special attention for symmetry, size, and texture. The provider manually palpates the thyroid area while the patient swallows several times because this action elevates the thyroid lobes. The carotid artery is palpated and auscultated for possible bruits. The lymph nodes are palpated. Lymphadenopathy (enlargement of the lymph nodes) can occur if the patient has an infection of the face, head, or neck.