1145 Head, face & neck
What are 5 parts that make up the head?
1. Cranial bones
3. Facial bones
4. Facial muscles
5. Salivary glands
What are 3 parts that make up the neck?
1. Neck muscles
2. Anterior and posterior triangles
3. Thyroid gland (usually don't exam)
What happens when you massage a thyroid mass?
It will release T3 and T4 which will create a hyperthyroid state
What is the lymph node called that is behind the ear? What kind of infection would swelling indicate?
Posterior auricular. Bug bite or cellulitis on the scalp, ear infection
What is the lymph node called that is in front of the ear?
What is the lymph node called that is at the base of the head?
What is the lymph node called that is right below the ear on the neck?
Jugulodigastric (right next to jaw)
What are the lymph nodes called that are below the ear on the sternocleidomastoid?
What are the lymph nodes called that are on the posterior of the lower neck?
Posterior cervical (between sternomastoid & trapezius
What are the lymph nodes called that are on the clavicle?
What are the lymph nodes called that are under the mandible?
What are the lymph nodes called that are under the tongue?
What are the lymph nodes called that are on the anterior of the neck?
deep cervical chain
What lymph nodes swell when you have an ear infection or dental infection?
what is the most common reason for pts coming to the ER?
What can cause dizziness?
Meds, loss of fluid, upon standing
What are some causes of neck pain or limitation of motion?
Elderly/arthritis, Motor vehicle accident
What are 6 health history questions?
Do you have any:
Neck pain or limitation of movement
Lumps or swelling
Hx of head or neck injury
What additional hx must be obtained from an aging adult?
Hx of dizziness and neck pain (arthritis). Med side effects can cause dizziness and makes them a fall risk.
Head - Inspect and palpate:
The skull, size and shape, temporal area (pulses, tenderness & pain). Notice symmetry and have them grimace and smile
Inspect the face:
facial structures, symmetry (have them grimace or smile)
Neck - Inspect and palpate:
Symmetry, ROM, Lymph nodes, trachea, thyroid glad
Thyroid gland - 3 different ways to inspect and palpate:
What is hydrocephalus?
Fluid buildup in the head, in kids up to 2 years of age. Measure the head
What is acromegaly?
Growth hormone excess due to an anterior pituitary enlargement.
- enlargement of head, jaw (↑ cartilage), hands, heart
What is torticollis or wryneck?
A parotid gland enlargement is usually:
Unilateral (side of neck)
What is a goiter?
An enlarged thyroid
Hypothyroidism ↓ T3 & T4
Hyperthyroidism ↑ T3 & T4
What causes a goiter due to hypothyroidism?
It can't produce enough T3 and T4 so it grew to compensate. TSH (thyroid stimulating hormone)
What is Hashimoto's thyroiditis?
Autoimmune disease of the thyroid that causes hypothyroidism
What causes a goiter due to hyperthyroidism? What are signs and what kind of treatment?
Excessive T3 and T4. Bulging eyes, radioactive iodine or remove thyroid.
What are s/s of Parkinson's?
What is Cushing's syndrome?
Excessive production of corticosteroids, which are produced in the adrenocortex. Prednisone can cause false s/s - moon face.
What is Grave's disease?
Hyperthyroidism - bulging eyes
What is myxedema?
What is Bell's palsy?
Facial nerve paralysis. Autoimmune or virus. Short term paralysis
What is a brain attack or CVA?
Stroke or cerebrovascular accident
What is a cachetic appearance?
What is the palpebral fissure on the eye?
The opening of the top and bottom eyelids, when eyes are open
What is the limbus on the eye?
Border between the cornea and sclera
What direction does the superior rectus muscle move the eye? What CN?
Up and out on a diagonal. CN III - Oculomotor
What direction does the inferior rectus muscle move the eye? What CN?
Down and out on a diagonal. CN III - Oculomotor
What direction does the lateral rectus muscle move the eye? What CN?
Out and to the side. CN VI - Abducens
What direction does the medial rectus muscle move the eye? What CN?
In and to the side. CN III - Oculomotor
What direction does the superior oblique muscle move the eye? What CN?
In and down at a diagnonal. CN IV - Trochlear
What direction does the inferior oblique muscle move the eye? What CN?
Down and to the side at a diagonal. CN III - Oculomotor
How would you see brain damage on one side of the brain?
It would be reflected on the opposite side. Because of crossing optic nerves. Possibly stroke. Ex. right sided stroke → hard time seeing on left side, so encourage patients to turn their head
Visual pathways and visual fields:
Refraction of light rays and crossing of fibers at the optic nerve.
To see something distant our eyes...?
To see something close up our eyes...?
What will pupils do in a deeply comatose patient?
They won't dilate
What is different about elderly pupils?
They are smaller. Keep the room dark
What is a fixed pupil?
A pupil that is stuck in dilation/constrict. sometimes too bright in room so dim light, close shades and try again
Accommodation of the eye is:
Constriction when there is light and dilation when it is dark.
Dilate when looking in the distance and constrict when looking up close
What is the most common surgery for medicare patients?
What is the cause of cataracts?
Sun exposure, cigarette smoke, diabetes
What does PERRLA stand for?
Pupils are Equal, Round, and React to Light and Accommodation
What is macular degeneration?
Occurs in aging adults - eye disorder that damages the macula and causes vision problems.
What is glaucoma?
Eye disorder that damages the optic nerve and causes blindness
What is strabismus?
Wandering eye. Both eyes are not directed at the same object or point. sometime use patch to correct.
What is diplopia?
What are some health history questions to ask a patient?
Vision difficulty, decreased acuity, blurring, blind spots, pain, strabismus, diplopia, redness, swelling, watering, discharge, glasses, contact lenses, self-care behaviors
What is a self-care behavior regarding the eyes?
What affect does hypertension have on the eyes?
Dilation of the blood vessels in the eye, changes within the retina
What are some health history questions to ask the elderly?
Visual difficulty, Glaucoma test, cataracts, eye dryness, decreased activity due to eye problems
What equipment would you use to examine the eyes?
Snellen eye chart, handheld visual screener, opaque card or occluder for confrontation test, penlight, applicator stick, opthalmoscope
What would you do to test central visual acuity?
The Snellen chart, and the handheld chart for near vision
What test would you use to test visual fields?
Confrontation test (peripheral test)
How would you test extraocular muscle function?
Cardinal directions test, corneal light test (Hirschberg test), cover/confrontation test
What is the corneal light test (Hirschberg's test)
Shine penlight at the bridge of the nose at a distance of 12-15in. Light reflections should be symmetrical. Asymmetric - weak extraocular muscles.
What test should you perform if there is an imbalance in the corneal light reflex test?
The cover-uncover test.
What would you inspect for the eye exam?
• Eyebrows (symmetry)
• Eyelids and lashes
• Conjunctiva (pale pink) and sclera
• Eversion of the upper lid
• Lacrimal apparatus - goopy, excessive tearing
What would you inspect for the anterior eye?
• Cornea and lens
• Iris and pupil
- Size and shape
- Pupillary light reflex - only once
What are some extraocular muscle dysfunctions? (4)
Strabismus - Wandering eye
Esotropia - In
Exotropia - Out
Paralysis - Bell's palsy
What is esotropia?
Wandering eye in (strabismus)
light on lateral side
What is exotropia?
Wandering eye out (strabismus)
light on medial side
What is periorbital edema and it's causes?
Fluid buildup under the eye. Huge bags under the eyes. Caused by renal or HF
What is exopthalmos and it's cause?
Protruding eyes - Grave's disease - hyperthyroidism
What is enothalmos?
What is ptosis?
Drooping of the eye lid
What is conjunctivitis?
Pink eye - could be an allergy or bacteria. Not always contagious
What is a subconjunctival hemorrhage?
Caused by high pressure from coughing, vomiting, or childbirth
What is a corneal abrasion?
Scratch on the cornea - can be caused by contacts
What is hyphema?
Blood in the anterior of the eye
What is osteogenesis imperfecta and what does it do to the eyes?
Brittle bone disease. Turns the whites of the eyes blue
What are the parts of the external ear?
External auditory canal and the tympanic membrane
What are the parts of the middle ear?
Malleus, incus, and stapes, Eustachian tube
What are the parts of the inner ear?
The vestibule and semicircular canals, cochlea
What are the levels of the auditory system?
Peripheral, brainstem, cerebral cortex
What are the pathways of hearing?
Air conduction, bone conduction
Hearing loss is due to problems with what?
Conductive problems, sensorineural (perceptive) problems
What issues can you have with equilibrium changes?
What is otitis media?
Middle ear infection
What is otitis externa?
External ear infection
What are some health history questions to ask about the ears?
Earaches, infections, discharge, hearing loss, changes, tinnitus (common in elderly males-loud noises), vertigo, self care behaviors
What are some self care behaviors for the ears?
Wearing ear plugs and protecting ears from loud noises
What equipment would you use for an ear exam?
Otoscope w/bright light, Pneumatic bulb attachment (sometimes used in infants and children, Tuning forks in 512 and 1024 Hz
What would you inspect for the external ear?
• Size and shape (symmetric)
• Skin condition
• External auditory meatus
What would you look for in the external canal?
What would you look for with the tympanic membrane?
- Color and characteristics - pearly gray
- Integrity of membrane - intact, scarring
How do you look in an adult's ear and child's ear with an otoscope?
Adults - pull ear up
Children - pull ear down
How would you test hearing acuity?
- Conversational speech
- Whispered voice test or rubbing fingers together
- Tuning fork tests
• Weber test
• Rinne test
What is the Weber test?
Put vibrating tuning fork on the top of the head. Ask which ear can hear the loudest. Abnormal - lateralization of sound - conductive hearing loss
What test should be done on every elderly person?
Romberg test, but be careful to catch them
What is the Romberg test?
Testing for dizziness. Close eyes and see if they are going to fall over
What are some abnormalities of the external ear? (3)
• Otitis externa ("swimmer's ear") → ear drops
• Cerebrospinal fluid otorrhea - CSF leaking through ear - clear, sometimes w/ring of blood
What is Otitis media with effusion (OME)?
Bulging tympanic membrane. Can perforate
What is acute (purulent) otitis media?
Ear infection - fluid underneath often caused by antibiotics??? often caused by a virus
Sensorineural hearing loss:
Cochlear damage, meds, wax or foreign body
What is the exam that is the most neglected during a physical exam?
What are the 4 paranasal sinuses?
What are the parts of the mouth?
• Hard and soft palates
What are the different salivary glands?
What are the 3 parts of the throat?
Three ENT issues pregnant women have are:
- Nasal stuffiness
- Epistaxis = bloody nose
- Hyperemic gums - swollen
Three ENT issues that the elderly have are:
- Diminished smell and taste
- Atrophic tissues
- Dental changes - eat less, receding gums, loose teeth
Health history questions for the nose: (7)
• Frequent colds = how often
• Sinus pain
• Epistaxis = nose bleed
• Altered smell = changes
Health history questions for the mouth and throat: (9)
• Sores or lesions
• Sore throat
• Bleeding gums
• Altered taste
• Smoking, alcohol consumption
• Self‐care behaviors
Health history questions about the mouth for the elderly: (5)
• Mouth dryness
• Tooth loss
• Care of teeth, dentures
• Taste, smell
What will you inspect in the nasal cavity with the otoscope?
What will you inspect in the mouth?
• Teeth and gums
• Buccal mucosa
• Palate and uvula
How do you evaluate the sinus areas?
Palpate the frontal and maxillary sinuses
Transilluminate the sinuses
What is the scale for grading the tonsils?
1+ - visible
2+ - halfway between tonsillar pillars and uvula
3+- nearly touching the uvula
4+ - touching each other
-colds, virus, bacterial infections make them swell
What are some abnormalities of the nose?
• Acute rhinitis
• Allergic rhinitis
• Nasal polyps → can cause snoring
What do you inspect in the throat?
• Tonsils grading
• Use of tongue blade
• Posterior pharyngeal wall
What are some abnormalities of the lips? (2)
• Cleft lip
• Herpes simplex I
What are some abnormalities of the tongue? (4)
• Black hairy tongue - not hair - bacterial infection
• Enlarged tongue (macroglossia)
• Fissured or scrotal tongue
• Smooth, glossy tongue (atrophic glossitis) = anemia or vitamin deficiency
What is macroglossia?
What is thrush?
Candida infection of the mouth
What are some abnormalities of the oropharynx?
• Cleft palate
• Acute tonsillitis and pharyngitis
What is leukoplakia?
Pre cancer of the mouth