Head and Neck

Anatomy: Salivary glands: Parotid -superficial/behind the mandible; Submandibular- deep to mandible Eye a. Conjunctiva- clear mucous memb: Bulbar(covers most of the anterior eye) & Palpebral(lines eyelids) conjunctivas b. Lacrimal Gland- fluid protect eye; drain into lac puncta lac sac nasolacrimal duct c. Aqueous Humor- fill ant/post chambers of eye, drain into canal of schlemm d. Fundus- post part of eye seen through ophthalmoscope e. Optic Disc- where optic nerve w/retinal vessels enter eyeball f. Fovea- w/ macula around it Visual Fields a. Blind Spot- 15 deg temporal to line of gaze; lack retinal receptors. Created by the optic disk. b. Binocular- where field of vision overlaps Pupillary Reactions a. Light Reaction- shining light/constriction into one eye (direct reaction), cause constriction in other eye (Consensual reaction); mediated by CN 3 b. Near Rxn- as things get closer, pupils constrict; mediated by CN 3; should have convergence (inward movement of both eyes, extraocular movement)/accommodation (increased convexity of the lenses, ciliary muscles). c. Sympathetic- cause pupillary dilation; Parasympathetic- pupillary constriction d. Extraocular Movements- CN 3 most; CN IV (Sup Oblique); CN VI (Lateral Rectus) Cardinal Directions of Gaze:

1. 2.

3.

4.

5.

(draw image)

6. Ear a. Mastoid Process- palpable behind the lobule; lowest portion of temporal bone b. Eardrum- oblique membrane; short process/handle of malleus; have pars flaccid (above the short process of the malleus) and pars tensa i. Cone of Light- anteroinferior; Umbo- meets tip of malleus c. Conductive hearing loss- external ear through middle ear. d. Sensorineural hearing loss- cochlea and the cochlear n. e. Bone conduction- stimulates the cochlea directly. Normally, air conduction is more sensitive then bone. 7. Nose a. Inspection is limited to vestibule, ant. septum, and lower and middle turbinates. b. Paranasal sinuses- only frontal and maxillary are papable 8. Mouth a. Lingual Frenulum- Submandibular glands ducts open on either side b. Ant/Post Pillar (tonsils in between); hard/soft palate c. Parotid duct- opening at upper second molar. 9. Neck a. Anterior Triangle- mandible; SCM; Neck midline; Posterior Triangle- SCM; Trapezius; Clavicle

b. Great Vessels- Carotid Artery; Internal/External Jugular Vein deep to SCM c. Midline struct: Hyoid bone; thyroid cartilage; cricoids cartilage; trach rings; thyroid gland 10. Lymph Nodes: tonsillar, submandibular, & submental nodes drain portions of mouth/throat & face

Health History: 1. Head a. Headache- common; point to area of pain; Tension (temporal region)/migraines most common recurring. i. Most important attributes: chronologic pattern/severity; Inc chance of tumor, abscess or other mass. ii. Extremely severe: subarachnoid hemorrhage/meningitis iii. Visual aura/scintillating scotomas; migraine iv. Nausea or vomiting; migraine/brain tumor/subarachnoid hemorrhage 2. Eyes a. Refractive errors common cause blurring; High blood glucose may cause blurring b. Sudden visual loss: retinal detachment; vitreous hemorrhage; occlusion of retinal aa c. Hyperopia (Farsightedness)/ Presbyopia (Aging)- difficulty close; Myopia/Nearsightedness- distance d. Diplopia- double vision (horizontal vs. vertical) e. Slow Central loss: Cataracts(examine lens and fundi for clouding of lens); Macular Degeneration(retinal pigmentation/subretinal hemorrhage/excudate), Peripheral loss in advanced open angle: Glaucoma (change in size/color of optic cup/gradual vision loss/ocular hypertension), one sided loss: hemianopsia/quadrantic defects i. Glaucoma- major cause of blindness; Inc intraocular pressure 3. Ears a. Sensorineural loss(Inner Ear)- have trouble understanding speech; noisy environments worse; Conductive loss (External/Middle Ear)- noisy environments may help b. Tinnitus- perceived sound w/no external stimulus; ringing in one or both ears; Vertigo-spinning feeling, CN VIII c. Pain- problem associated w/ otitis externa; with respiratory infection associated w/ otitis media. May be referred from mouth throat, or neck. 4. Nose/Sinuses a. Rhinorrhea- drainage from nose, often assoc w/ nasal congestion i. Cause: allergic rhinitis hay fever assoc w/ itching or vasomotor rhinitis or rhinitis medicamentosa assoc w/ excessive use of decongestants; drugs can worsen ii. Congestion limited to one side deviated nasal septum, foreign body, tumor. iii. Sinusitis- accompany w/ tenderness/pain 5. Mouth/Neck a. Sore Throat- acute upper resp symptoms; Strep Throat- fever, pharyngeal exudates (exudate = any fluid that filters from the circulatory system into lesions or areas of inflammation, ant. lymphadenopathy w/o cough b. Sore Tongue- local lesions or systemic illness or nutritional deficiencies c. Bleeding Gums- most often cause by gingivitis

d. Hoarseness- overuse of voice/acute infections; also chronic causes (smoking, allergy, voice abuse, etc). More than 2 wks, visual examination of the larynx by indirect or direct laryngoscopy is advisable. e. Thyroid- enlarged/goiter, evaluate temperature intolerance and sweating. Cold intolerance = hypothyroidism. Heat intolerance/weight loss/palpitations = hyperthyroidism. Techniques of Exam: 1. Head: Hair; Scalp; Skull (suture lines); Face; Skin a. Hair- Fine; hyperthyroidism, course; hypothyroidism b. Scalp- redness and scaling; seborrheic dermatitis/pilar cyst/psoriasis c. Skull- enlarged; hydrocephalus/Paget s disease d. Face- observe asymmetry, invol movements, edema, masses e. Skin- color, pigment, texture, thickness, hair distribution, lesions. i. Hirsutism- excessive facial hair, in some women with polycystic ovary syndrome. 2. Eyes: 20/200 or less in the better eye corrected with glasses or constricted field of vision 20 degrees or less in better eye is legally blind. a. Visual Acuity- central vision; Snellen chart (20 ft.); 20/40 i. Top number = dist from chart, bottom number = dist at which a normal eye can read that line. b. Visual Fields: Screening (temporal fields; glass bowl around head, hands 2 ft apart test all quadrants. Normally, patient should see both sets of fingers at the same time.) i. If you find a defect, establish its boundaries. Test one eye at a time. Record in the patient s point of view. FYI, temporal defect in of one eye = nasal defect in opposite eye. ii. Homonymous hemianopsia- Lt. (draw image) Rt. iii. Bitemporal hemianopsia- (draw image) iv. Quadrantic defects- (draw image) c. Lids- blepharitis (inflammation/redness) d. Conjunctiva/Sclera- depress lower lid with thumb, note color/vascular pattern/nodules/swelling Jaundice- yellow sclera sign e. Cornea/Lens- with oblique lighting, look for opacities f. Iris- with light shining directly from the temporal side, look for crescentic shadowon medial side (flat iris = no shadow, normal. Abnormally far forward iris = shadow, narrow-angle glaucoma) g. Pupils- size, shape, and symmetry. (>5mm, large <3mm, small) i. Miosis- constriction. ii. Mydriasis- dilation. iii. Anisocoria- Pupillary inequality <0.5mm; benign if papillary rxns normal (Direct & Consensual). iv. If papillary rxn is abnormal, test near reaction (hold a pencil 10cm away from pt eye. Have pt look at pencil then a distance directly behind it. Constrict = focus is near; Dilate = focus is far.) h. Extraocular MM/Mvmt- norm conjugate movement (6 cardinal directions; Large H); Nystagmus (fine rhythmic oscillation); Lid Lag (associated w/ hyperthyroism) and Convergence; Left infranuclear opthalmoplegia (paralysis of CN VI/abducents n, eyes are conjugate in right lateral gaze but not in left lateral gaze) i. Ophthalmoscope- Start @ 0 diopter; use right hand and right eye for examination of right eye of patient. Patient should look slightly up and over your shoulder at a point directly ahead on the wall. 15in away from patient at 15 deg lateral to patients line of vision. Orange glow = red reflex; absence indicates

opacity of lens/cataracts/retinoblastoma in children. Thumb on patients eyebrow. Move in slowly at 15 deg angle. i. Optic Disc- yellow orange to creamy pink oval, follow BV if can t find; you and patient no refractive errors = diopter is 0; if patient is myopic use minus diopters; presbyopic (pos) 1. Inspect sharpness/clarity of disc outline, color, size of physiological cup, comparative symmetry. 2. Papilledema- elevation/swelling of optic disc. Difference between diopters of the elevated disk and uninvolved retina. 3 diopter= 1mm a. Indicates increased intracranial pressure, meningitis, subarachnoid hemorrhage, trauma, and mass lesions. ii. Inspect Retina- size, shape, color, distribution of vessels iii. Look at Fovea/surrounding macula; Macular degeneration poor central vision in elderly 3. Ears a. Tug Test- move auricle up and down, press targus, and press firmly behind the ear. Pain during test= acute otitis externa; only tenderness behind the ear is present in otitis media. b. Otoscope- pull up, back, and slightly away from head. Brace the hand holding the otoscope against the patients face. Insert and direct downward i. Exostoses- nontender nodular swellings covered by normal skin deep in the ear; nonmalignant overgrowths which can obscure the drum. ii. Canal- swollen, narrow, moist, red, pale and tender = otitis externa iii. Eardrum/tympanic membrane- red bulging = otitis media c. Auditory Acuity- (I have no idea how to do this, bates did not make sense to me.) d. Air/Bone Conduction: 300 Hz-3000 Hz; human speech range; use 512/1024Hz Tuning Fork i. Weber Test- lateralization; place on top of patient s head. Normally, midline and equal in both ears. 1. Unilateral conductive hearing loss, sound is lateralized to the impaired ear. Otitis media, obstruction, perforation of tympanic membrane. 2. Unilateral sensorineural hearing loss, sound is lateralized to good ear. ii. Rinne Test- air conduction (AC) vs bone conduction(BC); place the fork on mastoid process, as soon as the patient can no longer hear the sound place fork close to ear canal. Normally, air conduction > bone conduction 1. Conductive hearing loss, BC = AC or BC > AC. 2. Sensorineural hearing loss, AC>BC. 4. Nose/Sinuses a. Tenderness w/ discharge, pain, fever suggest acute sinusitis b. Nasal Mucosa- red and swollen = viral rhinitis; pale, bluish, or red = allergic rhinitis 5. Mouth The sides, undersurface of tongue, and floor of mouth is the most common area for cancer. a. Tongue- deviation shows problem w/ CN 12 i. Aphthous ulcer = canker sore b. Gums- redness = gingivitis; black line = lead poisoning c. Soft Palate- say Ah, and see it raise, test of CN 10; also Uvula may deviate to opposite side of lesion 6. Neck a. Lymph Nodes- tender = inflammation; hard or fixed = malignancy. b. Trachea- deviation suggest mass in neck, mediastinal mass, atelectasis, or pneunothorax.

c. Thyroid- tilt patient head up, use tangential lighting. Below cricoid cartilage. Have the patient swallow and observe the thyroid move up. Palpate

Cardiac Anatomy
1. Borders: Lt Ventricle- left lateral margin; produces Apical impulse (Pt Max Impulse); 5th IC, 7-9cm lateral; Rt Atrium- right heart border; Lt Atrium- mostly posterior; Rt Ventricle- most of anterior surface 2. Cardiac Cycle a. Systole- Ventricular Contract; blood pass into Aorta; Diastole- Ventricular relax; blood atrium ventricle b. Diastole-at very end, atrial kick (slight pressure rise); Systole- closing of mitral and tricuspid valve (S1), pressure builds and exceeds that in Aorta, so valve opens; Aortic and Pulmonic valve closing (S2) c. S3- after mitral valve open, rapid vent filling produce sound in kids/young adults; pathologic in adults d. S4- atrial contraction; pathologic change in compliance 3. Splitting- during S2, sometimes get normal splitting of sound, especially w/ inspiration, slower P closure a. Tricuspid- best lower left sterna border; Pulmonic- 2nd/3rd Left IC spaces; Aortic- Rt 2nd IC to apex; Mitral4th/5th IC space, laterally 4. Auscultation of valves- mitral valvle- apex; tricuspid; lower left sternal border; pulmonic valve- 2nd and 3rd left interspaces close to the sternum; aortic valve- rt of apex, 2nd interspace. 5. ECG- signal initiate in SA node, then to AV node, then down bundle of HIs a. P wave-Atrial Depolarization; PR Interval ~ 120 ms; QRS complex- ventricular depolarization ~100 ms; Dn/Up/Dn; T wave- Ventricular repolarization b. Electrical impulse always proceeds contraction. 6. Factors affecting Arterial pressure- Stroke vol; distensibility of aorta; peripheral vascular resistance; volume of blood 7. Jugular Venous pressure- affected by CO and blood vol, it reflects rt atrial pressure; height of venous column of blood in int. jugular v, best on the rt side; vertical distance above sterna angle. 4cm above sternal angle or more than 9cm above rt. Atrium is elevated or abnormal. 8. Abnormalities a. Murmurs occur with age b. Pain location, intensity, and radiation are important c. Palpitations- unpleasant awareness of heart beat(skipping, racing, flutter, pounding/stop) 9. Hypertension- 35% of all MI s; 49% of heart failure; 24% premature deaths a. (Normal: <120-80 mmHg; Prehypertension: (120-139)/(80-89); Stage 1 hypertension- (140-159)/(90-99), indicates drug therapy b. Normotensive- @ age 55, 90% lifetime risk of developing; rel btwn Htn/CVD c. Screening- BP/BMI/Waist/Pulse (routine visits; 2years); lipid profile/glucose @ 5yrs, 2 years if @ risk 10. Cholesterol a. High Risk-CHD/all risk equivalents 10 yr risk >20%; Mod high risk- 2+ risk factors, 10 yr risk 10-20% i. Goal: LDL <100 for high risk, <130 for moderate, <160 for lower risk Health History 1. Chest pain and discomfort is the most important symptom you will assess. a. Angina pectoris- extertional chest pain with radiation to the left side on the neck and down left arm b. Aortic dissection- sharp pain radiating into the back or into the neck

2. 3. 4. 5.

c. Artial fibrillation- irregularly irregular Orthopnea- dyspnea while laying down and improves when the patient sits up; indicates left ventricular heart failure or mitral stenosis, may accompany obstructive lung disease Paroxysmal nocturnal dypsnea (PND)- sudden dyspnea or orthopnea that awakens the patient during sleep; indicates left ventricular heart failure or mitral stenosis and may be mimicked by nocturnal asthma attacks Dependent edema- appears on the lowest parts of the body, causes: CHF/hypoalbuminemia/positional. General edema- periorbital puffiness, tight rings on the fingers; causes renal and liver disease/nephritic syndrome. a. Enlarged waistline can indicate ascites and liver failure

Physical Exam 1. JVP/Pulsations: elevation at which highest oscillation point, or meniscus, of JVP evident; High if Hypervolemic; In hypovolemic patients they may have to lay down for you to see the vein a. Right- b/c gives best assessment of Rt atrium/CVP; b. Int Jugular vs Carotid:IJ, rarely palpable; rapid, irregular w/ 2 elevations and 2 troughs(a, x, v, y on ECG of venous pulsation); pulsations are eliminate by light pressure; pulsation change w/ position/inspiration 2. Carotid Pulsei. assess amplitude(pulse pressure); small thready pulse or weak pulse = cardiogenic shock, bounding pulse = aortic insufficiency. ii. contour(speed/duration); delayed carotid upstroke in aortic stenosis. iii. listen for thrills or bruits murmur like sound of vascular origin. Cardiac bruit in middle age+ person suggest arterial narrowing. b. Don t press both @ same time, b/c trigger Carotid Sinuses cause syncope c. Use Brachial if cannot assess carotid 3. Heart a. Palpate: Aortic Area (Rt 2nd Interspace); Pulmonic Area (Lt 2nd IS); Rt vent border (Lt sterna border); Lt Vent area/5th IS midclavicular (Apex)- look for Apical Impulse/PMI (diameter/amplitude/duration norm goes btwn S1/S2) b. Auscultate: Aortic (Rt 2nd IS); Pulmonic (Lt 2nd/3rd IS); Tricuspid (Lt 4th/5th IS); Mitral (Lt 5th IS, midclav) i. Diaphragm- high pitched sounds, S1 & S2; press firmly ii. Bell- S3 & S4 low pitched sounds; mitral stenosis, press lightly; have roll onto left side to help iii. Decreased S1 = 1st degree heart block; decreased S2 = aortic stenosis. iv. Apical impulse on the rt side = dextracardia c. Murmurs: Locate max intensity; radiation; Intensity; Pitch; Quality; Shape (Crescendo/Descrescendo/ Plateau murmur) and Timing: (Mid/Pan/Late Systolic; Early/Mid/Late Diastolic) i. Grade 1(must be tuned in); G2 (quiet, but heard); G3 (Mod loud); G4 (loud/palpable thrill); G5 (hear w/steth partly off chest); G6 (heard w/steth off of chest) ii. Soft decrescendo diastolic murmur= aortic insufficiency d. Rate: Normal (60-100); Slow (<60; Bradycardia or block); Fast (>100 A Tach/Flutter/V Tach fast); Completely irregular = Atrial Fibrillation

Skill Set #5 - Head & Neck (HEENT) y Demonstrate and document the examination of the following

Head o Shape o Hair Eye o Inspection o Visual acuity o Pupillary reaction to light o Extraocular movements o Fundoscopic exam Ear o External canal o Tympanic membranes Nose o Nasal septum o Nasal mucosa Mouth o Teeth o Tongue o Oral mucosa Pharynx o Tonsils o Posterior pharynx Neck o Lymph nodes o Thyroid gland

Skill Set #6 Cardiac y Review the normal cardiac cycle y Demonstrate and document the complete cardiac exam y Assess jugular venous pulsation (JVP) y Assess carotid pulses y Inspection of precordium y Palpation of the chest for apical impulse y Auscultation of 4 cardiac areas