Skills HEENT & Thorax

Head:
□ Inspect the face, ears, and eyes for asymmetry, color (pallor, cyanosis), diaphoresis, deformities,
lesions
□ Palpate the head/scalp for lesions, deformities, and hair patterns.
□ Palpate Temporomandibular Joint with mouth closed and open
□ Palpate the supraorbital and infraorbital notches for tissue texture changes and tenderness
□ Palpate or percuss the frontal and maxillary sinuses for tenderness
□ Transilluminate the frontal and maxillary sinuses

Eyes:
□ Assess pupils for size, symmetry, shape, reaction to light and accommodation using penlight or
otoscope light
□ Assess extra ocular muscle movements
□ Assess Visual Acuity (using Rosenbaum card)

Ears:
□ Assess ear canals and TMs with otoscopic examination
□ Pneumatic Otoscopy
□ Assess hearing with either finger-rub or whisper test (student should learn both)

Nose:
□ Assess the nares with otoscope, first the vestibule then inside the nose.
Throat:
□ Assess the oropharynx, oral mucosa, tongue and teeth with tongue blade and otoscope or
penlight.

Neck:
While standing in front of the patient:
□ Inspect the neck for symmetry/deformities
□ Palpate the neck for trachea position, mobility or masses
□ Palpate lymph nodes in this order:
□ Preauricular
□ Postauricular
□ Occipital
□ Posterior cervical chain
□ Anterior cervical chain
□ Submandibular
□ Submental
□ Supraclavicular
□. Palpate and auscultate the Carotid arteries. (maybe done here or at beginning of thorax)

While standing behind the patient:

□ Palpate the thyroid gland and have patient swallow.
□ Palpate the cervical spine and upper thoracic spine (to T4) for TART
□ Temperature of skin
□ Superficial tissue texture assessment (skin drag)
□ Deep tissue texture assessment (Erythema Friction Rub)
□ Tissue texture abnormalities, such as hypertonicity
□ Asymmetry
□ Tenderness to palpation
□ Localize C2, C7 and T1. Confirm C7 and T1 with active forward neck flexion.
□ Describe how you would test active motion of the cervical spine and upper thoracic spine, while
localizing to C7/T1 for cervical motion and T4/T5 for upper thoracic motion, and demonstrate
what each of the motions are.
□ Flexion
□ Extension
□ Rotation
□ Side-bending
□ Describe assessment of cervical spine articular pillars for restriction of motion in either side-
bending or rotation.
□ Select the segment with the greatest TART findings and state that you would obtain a
segmental diagnosis.

Anterior Thorax: (perform procedures seated then supine. Don’t have patient move back and
forth)
□ Demonstrate proper draping and examination of anterior chest
□ Inspect anterior thorax for symmetry in movement, deformities, visible skin lesions, and chest
shape (Barrel/ flail, etc.)
□ Inspect anterior/posterior (A/P) diameter of the chest
□ Palpate the anterior chest for tenderness (seated or supine): costochondral junctions, anterior ribs,
sternum
□ Assess the thoracic inlet/outlet (May be done seated or supine)

□ Evaluate rib motion during breathing: upper, middle, lower, palpate for motion and
symmetry (seated or supine)
□ Palpate the PMI (seated/supine/left lateral decubitus are options; learn seated for exam
purposes)
□ Palpate for heaves or thrills
(Must ask patients with breast tissue to move their left breast up and to move breasts laterally)
□ Auscultate the heart – 4 listening posts with diaphragm and bell (Seated upright or supine)
□ Auscultate the anterior lung fields – apices and upper and lower aspects of lungs bilaterally
(Ladder fashion)
Posterior Thorax/Lumbar
□ Proper loosening/removing of gown if indicated
□ Inspect posterior thorax and lumbar spine for asymmetries, motion, deformities, and visible skin
lesions
□ Palpate for lung (posterior chest) excursion
□ Assess temperature, superficial tissue texture (skin drag) and deep tissue texture (erythema friction
rub)
□ Palpate paravertebral region for asymmetry of transverse processes (posterior), hypertonicity of
muscle, *warm and boggy or cool and fibrotic tissues
□ Palpate posterior ribs, thoracic and lumbar regions for tenderness (may combine with
assessment of asymmetry)
□ Evaluate active range of motion thoracic and lumbar spine (localize T12-L1 and L5-S1)
□ Auscultate 6 regions of lungs and RML (Ladder fashion)
□ Percuss 6 regions of lungs and RML (Ladder fashion)
□ Tactile Fremitus
□ Egophony
□ Whisper Pectoriloquey

□ Jugular Venous Distention

(Patient supine)
□ Hepatojugular reflux

NEURO Skills
□ Observe general condition and patient comfort
□ Mental Status:
Introduction
Determine age and gender (Informal)
□ Orientation to person, place and time (Formal)

Ask patient why they are here

Cranial Nerves: ( If you integrate your full exam, all CN would done within the HEENT exam)
CN I: bilateral smell (described)
CN II: Visual acuity with Rosenbaum card (as part of HEENT or in Neuro)
CN II: Fundoscopic exam
CNII: Screening Visual Fields by Confrontation (Both eyes open and temporal fields
assessed) (Also testing for visual extinction with Double Simultaneous Stimulation)
CN II,III:
Pupillary reaction to light and elements of the near reflex (Done in HEENT exam)
CN II,III,IV, VI: EOM (done in HEENT)
CN V: Facial sensation to temperature and light touch, motor
CN VII:
Facial symmetry (observed-done in HEENT)
CN VII: Formal testing of upper (lift eyebrows), vs lower face (smile, show teeth)
CN VIII: Hearing (Done in HEENT – whisper or finger rub)
CN IX, X: Palatal rise, swallow, speech
CN XI: Turn and hold head against resistance Sternocleidomastoid); Shrug shoulders
(Trapezius)

Motor: (Seated)
Upper Extremities (Muscle Bulk, Pulses, Tenderness):
□ Inspect upper extremity (upper arm, forearm, palm and dorsum of hand) for hypertrophy
or atrophy, lesions, masses, discoloration, edema, trophic changes, and skin integrity
□ Palpate palm and dorsum of hand for atrophy
□ Inspect lower extremity (thigh, calf, dorsum of foot) for hypertrophy or atrophy,
lesions, masses, discoloration, edema, trophic changes and skin integrity
□ Palpate dorsum of foot for atrophy
Muscle Tone (UE and LE):
□ Flex and extend relaxed arm at shoulder and elbow, pronate/supinate forearm, shake
forearm, assessing resulting movement of relaxed hand (for muscle tone)
□ Flex and extend relaxed leg at knee; shake knee and assess resulting movement of
relaxed lower leg, flex and extend relaxed foot at ankle; shake calf and assess resulting
movement of relaxed foot

Muscle strength (Stabilize the proximal joint when testing strength of distal muscles;
otherwise you are also testing proximal muscles in the limb):
□ Shoulder abduction
□ Elbow flexion/extension (STABILIZE)
□ Wrist extension (STABLIZE)
□ Finger abduction
□ Hand grip (finger squeeze)
□ Hip flexion/extension
□ Hip abduction/adduction
□ Knee flexion/extension
□ Ankle dorsiflexion/plantar flexion (STABLIZE)
□ Pronator Drift
Standing:
Range of motion (Active): Extremities
□ Scapulothoracic motion testing (during shoulder abduction, observe for which side
moves first)
□ Shoulder abduction/adduction; flexion/extension; internal/external rotation
□ Elbow flexion/extension; pronation/supination (active & passive – emphasize barrier
“end-feel” with passive)
□ Wrist extension/flexion
□ Lower extremities and rise from squat

Coordination, Gait, Postural Exam:

□ Observe position of tibial tuberosity in relationship to patella and assess for differences
in alignment with one side more medial or lateral than the other
□ Assess foot arches
□ Romberg
Gait:
□ Observe patient walking in usual way
□ Observe patient walking on heels
□ Observe patient walking on toes
□ Observe patient walking heel to toe (tandem)
□ Range of motion (Passive): Cervical, Thoracic and Lumbar Spine:

Seated:
□ Finger-Nose-Finger (FNF)
□ Heel-to -Shin

Rapid Alternating Movements (RAM)

□ UE: Hands alternating
□ Fine Finger Movements
□ LE: Toe to hand

Sensory (eyes closed)

Temperature Sensation and Light Touch
□ Assess temperature sensation of lateral upper arm (C5) and dorsum of hand radial side
(C6) and ulnar side (C8) bilaterally
□ Assess temperature sensation of medial (L4), central (L5), and lateral (S1) dorsum of foot
bilaterally
□ Assess light touch sensation of lateral upper arm (C5) and dorsum of hand radial side (C6)
and ulnar side (C8) bilaterally
□ Assess light touch sensation of medial (L4), central (L5), and lateral (S1) dorsum of foot
bilaterally
□ Stereognosis
□ Graphesthesia
Reflexes
Upper Extremities:
□ Test biceps tendon reflexes bilaterally
□ Test brachioradialis tendon reflexes bilaterally
□ Test triceps tendon reflexes bilaterally
□ Hoffman’s Reflex
Lower Extremities:
□ Test quadriceps/patellar tendon reflexes bilaterally
□ Test Achilles tendon reflexes bilaterally
□ Babinski Reflex
Abdominal Skills
Position Patient:
□ Position patient on table for exam in supine position (if not already done)
□ Make sure patient is comfortable
□ Inform patient that you are going to examine their abdominal area; obtain consent
□ Place patient’s drape and gown in proper position
□ Perform exam from patient’s right side
Inspection
□ Inspect the abdomen for shape, symmetry, distention, pulsations, scars, and/or visible
lesions
Auscultation
□ Auscultate in 4 quadrants for bowel sounds (once BS heard, do not need to auscultate
more quadrants)
□ Auscultate over aorta (bifurcation), renal, iliac, and femoral arteries for bruits
Assessment
□ Place hand just above the umbilicus and observe for visceral drag
□ Assess the thoracic diaphragm (May assess in seated position)
Percussion
□ Percuss the abdomen in 4 quadrants; assess for tenderness with percussion
□ Percuss the liver span at mid-clavicular line and assess liver size (cm or fingerbreadths
below costal margin)
Palpation (Start in area away from site of pain)
□ Position patient on table
□ Palpate the abdomen lightly for tenderness, guarding, muscle relaxation, masses, or bulges
– 4 quadrants and 3 regions
□ Always watch the patient’s face during light palpation for grimacing or signs of pain
□ Palpate the abdomen more deeply for tenderness, guarding, masses or bulges – 4
quadrants
□ Palpate for the liver and spleen
□ Murphy’s Test

Ascites:
□ Shifting Dullness
□ Fluid Wave

Peritoneal Signs:
□ Rebound Tenderness (direct and Indirect)
□ Rosving’s Sign
□ Obdurator Sign
□ Psoas Sign
□ Heel Tap
□ Cough Tenderness
Chapman’s Points (common)
□ Ribs 2 & 3 sternocostal junction (Esophagus)
□ Ribs 5-6 on left (stomach acidity)
□ Ribs 5-7 on right (liver/gallbladder)
□ Tip of 12th rib on right
(appendix)
□ IT band anterior, proximal to knee (transverse colon) (Right and/or Left)
□ Middle 3/5 th right thigh to anterior IT Band (ascending colon)
□ Middle 3/5th of left thigh along anterior IT band (Descending colon)

Patient returned to seated position:

□ Evaluate for costovertebral angle tenderness with percussion
□ Asterixes