Med I – Head, Face and Neck
Content
Medicine I – Head, Face and Neck HEAD AND FACE I. Inspection A. Hair • Note quantity, distribution, color, and pattern of loss, if any. • Normal: symmetrically distributed, no splitting or cracked ends • Loose flakes of dandruff • Nits – tiny white ovoid granules that adhere to hairs B. Scalp • Part hair in several places • Note scales, lumps, nevi or other lesions • Redness and scaling – may indicate seborrheic dermatitis, psoriasis, soft lumps of pillar cysts (wens), pigmented nevi C. Skull • Note size and contour • Note any deformity, depressions, lumps or tenderness D. Skin • Note color, pigmentation, texture, thickness, hair distribution and any lesions. E. Face • Note shape and symmetry of facial features (eyelids, eyebrows, palpebral fissures, mouth) • Observe at rest, movement, and expression. • May vary (race, gender, body build) • Slight asymmetry is common. Characteristic Facies: 1. Cushing’s Syndrome (Moon Facies)
Features: - Moon facies - Hirsuitism - Thick neck - Erythematous Skin 2. Hippocratic Facies
*Terminal Stage Throat Cancer or Malnutrition Features: - Marked cachexia - Sunken eyes and cheeks - Temporal muscle wasting - Sharp nose - Dry rough skin 3. Myxedema Facies
*Severe Hypothyroidism Features: - Round puffy face - Dry coarse, sparse hair - Periorbital edema - Slow speech, hoarseness - Cold, dry, thick, scaling skin
Causes of hypercortisolism: - Adenoma or adenocracinoma of adrenal cortex - Stimulation by excess ACTH from pituitary tumor - Corticosteroid therapy
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
4. Exophthalmia
-
Drooping of lower eyelid & corner of mouth Loss of nasolabial fold Inability to completely close eye
7. Acromegaly
*Hyperthyroidism Features: - Prominent eyes - Lid lag and retraction - Startled expression - Thin, fine hair - Moist, smooth skin 5. Butterfly Rash
Features: - Coarsening of facial features - Broadening of nasal alae and prominence of zygomatic arches 8. Down Syndrome *Trisomy 21 Features: - Depressed nasal bridge - Epicanthal folds - Mongoloid slant of eyes - Low set ears - Large tongue
*Systemic LupuscErythematosus Features: - Rash over malar surfaces and bridge of nose - blush with swelling - scaly, red, maculopapular lesions may be present 6. Bell’s Palsy 9. Pierre – Robin sequence Triad of: − Micrognathia − Glossoptosis − Palatal clefting Note: Small retruded mandible 10. Hurler Syndrome *Found in Mucopolysaccharidoses Features: - Enlarged skull - Low forehead - Corneal clouding - Short neck
*Facial Nerve Palsy Features: - Asymmetry of one side of face
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
11. Hydrocephalus
14. Apert and Crouzon Syndrome
Features: - Enlarged head - Thinning of the scalp - Dilated scalp veins - Bossing of the skull - Sclera visible above the iris - Paresis of upward gaze 12. Fetal Alcohol Syndrome *One of the most common cause of acquired mental retardation
Features: - Oxicephaly - top of the head assumes a conical or pointed shape because of premature closing of the lambdoid and coronal sutures - Antimongoloid slant - nasal corners of the palpebral fissure are higher than the temporal corners; occurs when the lateral palpebral ligament is inserted lower than the medial palpebral ligament - Hypertelorism - Proptosis - Low-set ears - Midface hypoplasia - Parrot-beak nose - Open bite II. Palpation A. Hair • Note texture • Coarse, dry brittle – hypothyroidism • Fine, silky hair – hyperthyroidism or familial B. Scalp and Skull • Palpate in a gentle rotatory movement progressing symmetrically from front to back • Indistinguishable bones • Scalp should move freely over the skull • No tenderness, swelling or depression • Indentation – skull fracture C. Salivary glands • Note asymmetry or enlargement • If present, palpate for possible discrete enlargement • Note whether fixed or movable, soft or hard, tender or nontender • Ask pt to express material through the salivary duct as you press on the gland • Enlarged, tender – viral or bacterial infection, ductal stone (prevents saliva from exiting gland) • Discrete nodule – cyst, tumor (benign or malignant
Features: - Poorly formed philtrum - Widespread eyes - inner epicanthal folds - Mild ptosis - Hirsute forehead - Short nose - Relatively thin upper lips 13. Treacher – Collins Syndrome
Features: - Maxillary hypoplasia - Micrognathia - Auricular Deformity
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
III. Percussion *Done only when evaluating for hypercalcemia *Percuss masseter muscle – hyperactive masseteric reflex (Chvostek sign) IV. Auscultation *In diplopia – bruit over orbit (rare) (suggests expanding cerebral aneurysm) *Vascular anomaly in brain - Use bell - Listen over temporal region, over eyes, below occiput - (+) Bruit – temporal arthritis TYPES OF HEADACHES 1. Classic Migraine • Childhood onset • Unilateral or generalized • Lasts hours to days; twice a week; morning or night • Pulsating or throbbing pain • Females • Other symptoms: N/V • Prodromal event: neuro and personality changes, fluid retention, appetite loss, scotoma, aphasia, hemianopsia, aura • Precipitating event: menstrual period, missed meal, BCP, letdown after stress 2. Cluster • Adulthood onset • Unilateral • Half to two hours mainly at night for several nights then none • Intense burning, boring, searing, knifelike • Other symptom: increase lacrimation, nasal discharge • Prodromal event: personality changes, sleep disturbances • Precipitating event: alcohol consumption 3. Hypertensive • Adulthood onset • Bilateral or occipital • Lasts for hours; morning/ daily • Throbbing • Male and females • Generally remits as day progresses 4. Medication Rebound: • Holocranial or diffuse • Last for hours • Begins within hours to days of last dose • Dull or throbbing pain
• • • • •
Gradual increase in headache frequency to daily Females Other symptoms: meds fail to control headache Prodromal event: daily analgesics use Precipitating event: abrupt discontinuation of analgesics
5. Muscular tension: • Adulthood onset • Unilateral or bilateral • Hours to days everyday • Anytime, common afternoon/evening • Band-like constricting pain • Male and female • Precipitating event: stress, anger, bruxism 6. Space occupying lesion: • Any age • Localized • Rapidly increasing frequency and progressive • Awaken from sleep • Male and females • Prodromal event: aggravated by cough or bending forward • Precipitating event: develops in temporal relation to the neoplasm • Symptoms: vomit, confusion, abnormal neuro findings, gait abnormalities, papilledema, nystagmus 7. Temporal Arteritis: • Older adulthood onset • Unilateral or bilateral • Hours to days everyday at anytime • Throbbing • Male and female
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
NECK I. Inspection • Anatomic position, slight hyperextension, deglutition • Note alignment of trachea, landmarks of the ant and post triangles, any subtle fullness at the base of the neck • Note symmetry, masses, webbing, xss skin folds, unusual shortness or scars. • Not JV distension or prominent carotid • Webbing, xssive post cervical skin, unusually short neck – congenital anomalies • Marked edema – local infection
5. 6. 7. 8. 9.
Submandibular Submental Superficial cervical Posterior cervical Deep cervical chain – often inaccessible; hook fingers around either side of SCM 10. Supraclavicular IV. Thyroid Gland • Pt’s neck flexed slightly forward and laterally toward side being examined • Ask pt to hold water in mouth, position your hand then let pt. swallow
II. Palpation • Place a thumb along each side of the trachea in the lower portion of the neck • Compare space b/w trachea and SCM on each side • Unequal – displacement of trachea – d/t mass or pathologic condition in the chest • Identify the hyoid bone, and thyroid and cricoid cartilages. • Smooth and nontender, moves with deglutition • Tracheal rings in the lower part of neck should be distinct and nontender. • Oliver’s /Cardarelli’s Sign − Extend pt’s neck, place thumb and index finger on each side of trachea below thyroid isthmus − (+) tugging sensation synchronous with pulse III. • • Lymph Nodes Use pads of 2nd and 3rd digits, move skin over underlying tissues Pt should be relaxed, neck flexed slightly forward and toward side examined Note size, shape, delimitation, mobility, consistency, tenderness Tender – inflammation Hard or fixed - malignancy Small, mobile, discrete nontender – “shotty” – normal
Frontal Approach: - Place hand over trachea, 3cm below prominence of thyroid cartilage – find isthmus - Right lobe – left thumb presses trachea toward the left, palpate w/ right hand - Place 1st 3 fingers on right thyroid bed then ask pt to swallow - Reverse hand positions for left lobe Results: • Should be small, smooth, free of nodules • Rise freely with swallowing • R is 25% larger than L • Firm yet pliable consistency • Coarse tissue or gritty sensation – inflammation • Nodules – note number, smooth/irregular, soft/hard • Enlarged, tender – thyroiditis • If enlarged – auscultate for vascular sounds with bell • Hypermetabolic state – inc. blood supply, (+) bruit
• • • •
Sequence: 1. Preauricular 2. Posterior auricular 3. Occipital 4. Tonsillar
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
Features: - Moon facies - Hirsuitism - Thick neck - Erythematous Skin 2. Hippocratic Facies
*Terminal Stage Throat Cancer or Malnutrition Features: - Marked cachexia - Sunken eyes and cheeks - Temporal muscle wasting - Sharp nose - Dry rough skin 3. Myxedema Facies
*Severe Hypothyroidism Features: - Round puffy face - Dry coarse, sparse hair - Periorbital edema - Slow speech, hoarseness - Cold, dry, thick, scaling skin
Causes of hypercortisolism: - Adenoma or adenocracinoma of adrenal cortex - Stimulation by excess ACTH from pituitary tumor - Corticosteroid therapy
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
4. Exophthalmia
-
Drooping of lower eyelid & corner of mouth Loss of nasolabial fold Inability to completely close eye
7. Acromegaly
*Hyperthyroidism Features: - Prominent eyes - Lid lag and retraction - Startled expression - Thin, fine hair - Moist, smooth skin 5. Butterfly Rash
Features: - Coarsening of facial features - Broadening of nasal alae and prominence of zygomatic arches 8. Down Syndrome *Trisomy 21 Features: - Depressed nasal bridge - Epicanthal folds - Mongoloid slant of eyes - Low set ears - Large tongue
*Systemic LupuscErythematosus Features: - Rash over malar surfaces and bridge of nose - blush with swelling - scaly, red, maculopapular lesions may be present 6. Bell’s Palsy 9. Pierre – Robin sequence Triad of: − Micrognathia − Glossoptosis − Palatal clefting Note: Small retruded mandible 10. Hurler Syndrome *Found in Mucopolysaccharidoses Features: - Enlarged skull - Low forehead - Corneal clouding - Short neck
*Facial Nerve Palsy Features: - Asymmetry of one side of face
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
11. Hydrocephalus
14. Apert and Crouzon Syndrome
Features: - Enlarged head - Thinning of the scalp - Dilated scalp veins - Bossing of the skull - Sclera visible above the iris - Paresis of upward gaze 12. Fetal Alcohol Syndrome *One of the most common cause of acquired mental retardation
Features: - Oxicephaly - top of the head assumes a conical or pointed shape because of premature closing of the lambdoid and coronal sutures - Antimongoloid slant - nasal corners of the palpebral fissure are higher than the temporal corners; occurs when the lateral palpebral ligament is inserted lower than the medial palpebral ligament - Hypertelorism - Proptosis - Low-set ears - Midface hypoplasia - Parrot-beak nose - Open bite II. Palpation A. Hair • Note texture • Coarse, dry brittle – hypothyroidism • Fine, silky hair – hyperthyroidism or familial B. Scalp and Skull • Palpate in a gentle rotatory movement progressing symmetrically from front to back • Indistinguishable bones • Scalp should move freely over the skull • No tenderness, swelling or depression • Indentation – skull fracture C. Salivary glands • Note asymmetry or enlargement • If present, palpate for possible discrete enlargement • Note whether fixed or movable, soft or hard, tender or nontender • Ask pt to express material through the salivary duct as you press on the gland • Enlarged, tender – viral or bacterial infection, ductal stone (prevents saliva from exiting gland) • Discrete nodule – cyst, tumor (benign or malignant
Features: - Poorly formed philtrum - Widespread eyes - inner epicanthal folds - Mild ptosis - Hirsute forehead - Short nose - Relatively thin upper lips 13. Treacher – Collins Syndrome
Features: - Maxillary hypoplasia - Micrognathia - Auricular Deformity
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
III. Percussion *Done only when evaluating for hypercalcemia *Percuss masseter muscle – hyperactive masseteric reflex (Chvostek sign) IV. Auscultation *In diplopia – bruit over orbit (rare) (suggests expanding cerebral aneurysm) *Vascular anomaly in brain - Use bell - Listen over temporal region, over eyes, below occiput - (+) Bruit – temporal arthritis TYPES OF HEADACHES 1. Classic Migraine • Childhood onset • Unilateral or generalized • Lasts hours to days; twice a week; morning or night • Pulsating or throbbing pain • Females • Other symptoms: N/V • Prodromal event: neuro and personality changes, fluid retention, appetite loss, scotoma, aphasia, hemianopsia, aura • Precipitating event: menstrual period, missed meal, BCP, letdown after stress 2. Cluster • Adulthood onset • Unilateral • Half to two hours mainly at night for several nights then none • Intense burning, boring, searing, knifelike • Other symptom: increase lacrimation, nasal discharge • Prodromal event: personality changes, sleep disturbances • Precipitating event: alcohol consumption 3. Hypertensive • Adulthood onset • Bilateral or occipital • Lasts for hours; morning/ daily • Throbbing • Male and females • Generally remits as day progresses 4. Medication Rebound: • Holocranial or diffuse • Last for hours • Begins within hours to days of last dose • Dull or throbbing pain
• • • • •
Gradual increase in headache frequency to daily Females Other symptoms: meds fail to control headache Prodromal event: daily analgesics use Precipitating event: abrupt discontinuation of analgesics
5. Muscular tension: • Adulthood onset • Unilateral or bilateral • Hours to days everyday • Anytime, common afternoon/evening • Band-like constricting pain • Male and female • Precipitating event: stress, anger, bruxism 6. Space occupying lesion: • Any age • Localized • Rapidly increasing frequency and progressive • Awaken from sleep • Male and females • Prodromal event: aggravated by cough or bending forward • Precipitating event: develops in temporal relation to the neoplasm • Symptoms: vomit, confusion, abnormal neuro findings, gait abnormalities, papilledema, nystagmus 7. Temporal Arteritis: • Older adulthood onset • Unilateral or bilateral • Hours to days everyday at anytime • Throbbing • Male and female
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
NECK I. Inspection • Anatomic position, slight hyperextension, deglutition • Note alignment of trachea, landmarks of the ant and post triangles, any subtle fullness at the base of the neck • Note symmetry, masses, webbing, xss skin folds, unusual shortness or scars. • Not JV distension or prominent carotid • Webbing, xssive post cervical skin, unusually short neck – congenital anomalies • Marked edema – local infection
5. 6. 7. 8. 9.
Submandibular Submental Superficial cervical Posterior cervical Deep cervical chain – often inaccessible; hook fingers around either side of SCM 10. Supraclavicular IV. Thyroid Gland • Pt’s neck flexed slightly forward and laterally toward side being examined • Ask pt to hold water in mouth, position your hand then let pt. swallow
II. Palpation • Place a thumb along each side of the trachea in the lower portion of the neck • Compare space b/w trachea and SCM on each side • Unequal – displacement of trachea – d/t mass or pathologic condition in the chest • Identify the hyoid bone, and thyroid and cricoid cartilages. • Smooth and nontender, moves with deglutition • Tracheal rings in the lower part of neck should be distinct and nontender. • Oliver’s /Cardarelli’s Sign − Extend pt’s neck, place thumb and index finger on each side of trachea below thyroid isthmus − (+) tugging sensation synchronous with pulse III. • • Lymph Nodes Use pads of 2nd and 3rd digits, move skin over underlying tissues Pt should be relaxed, neck flexed slightly forward and toward side examined Note size, shape, delimitation, mobility, consistency, tenderness Tender – inflammation Hard or fixed - malignancy Small, mobile, discrete nontender – “shotty” – normal
Frontal Approach: - Place hand over trachea, 3cm below prominence of thyroid cartilage – find isthmus - Right lobe – left thumb presses trachea toward the left, palpate w/ right hand - Place 1st 3 fingers on right thyroid bed then ask pt to swallow - Reverse hand positions for left lobe Results: • Should be small, smooth, free of nodules • Rise freely with swallowing • R is 25% larger than L • Firm yet pliable consistency • Coarse tissue or gritty sensation – inflammation • Nodules – note number, smooth/irregular, soft/hard • Enlarged, tender – thyroiditis • If enlarged – auscultate for vascular sounds with bell • Hypermetabolic state – inc. blood supply, (+) bruit
• • • •
Sequence: 1. Preauricular 2. Posterior auricular 3. Occipital 4. Tonsillar
Sources: Mosby’s Guide to Physical Examination 7th ed. Bates’ Guide to Physical Examination and History Taking, 10th ed.
