Ch 9 and Ch 10 (Lymphatic, Head, Neck) Flashcards
What are the 7 parts of the lymphatic system?
fluid, collecting ducts, lymph nodes, spleen, thymus, tonsils, adenoids, and peyer patches.
Can you find parts of the lymphatic system in the stomach, appendix, bone marrow and lungs?
yes
if (blank) is failing the patient may suffer from allergies, immune deficiency, or autoimmune diseases
lympathic system
The only tissues in the body that do not have lymphatic vessels are the (blank) and (blank)
brain and placenta
Fluid balance, production of lymphocytes, production of antibodies, phagocytosis of other cells/foreign bodies, backup of normal hematopoietic cells and (blank)
absorption of fat soluble substances from the GI tract
What color is lymph?
clear to yellow
What has cellular components mostly made of WBC’s “lymphocytes” with possible RBC’?.
lymph fluid
The microscopic ducts eventually coalesce and drain into the venous system at the (blank)
subclavian veins.
The lympathic system relies on the (blank) for flow
cardiovascular system
What are these:
Encapsulated structures that usually occur in groups. Superficial nodes are in the subcutaneous tissue. Deeper nodes exist in body cavities and under fascia and muscles. Most are smaller than 0.5 to 1cm.
lymph nodes
(blank) are a hint at the lymphatic system’s function via inspection/palpation for changes from baseline. Changes are mostly seen due to infection or malignancy.
superficial lymph nodes
(blank) cause an increase in lymphocyte counts.
Viral infections
Where is the spleen located?
left upper quadrant
The (blank) are activated by inhaled and intranasal antigens.
palatine tonsils
lymphatic system begins at (blank) gestation but is still immature at birth.
20 weeks
(blank) should always start a possible suspicion for malignancy.
Supraclavicular nodes
Palpable lymph nodes (inguinal, occipital, and postauricular nodes) after (blank) of age are more likely to be abnormal and indicate infection in children
2 years
Hep A, Hep B, Rubella, rubeola, and varicella, often present with obvious (blank)
Posterior cervical nodes
What makes for a suspicious node?
fast growing, immovable, painful, and large (2 cm) , should keep an eye out of bigger than .5cm
Is it a problem to have children with enlarged palantine tonsils?
no
Diphenylydantoin, aspirin, barbiturates, penicillin, tetracyclin, iodide, cephalosporin, sulfonamide, mesanoin can cause what>
nodal enlargement
What are the signs of mumps (epedmic parotiditis)?
painful swelling of parotid gland, and swelling of salivary glands on the mandible
How can you tell the difference between mumps and cervical adenitis?
cervical adenitis doesnt obscure the angle of the jaw and you can separate the node from the angle so you can feel the jaw.
(blank) is lymph tissue in the mucosa of the small intestine.
peyers patches
The umbilical cord should drop off by (blank) weeks after birth. If it hangs on longer->immune system defect
1-2
If cervical and submandibular nodes are present in the first year of life is this abnormal?
yes!
(blank) nodes should always start a possible susupicion for malignancy.
supraclavicular
Changes in pregnant women are due to (blank X 3)
progesterone, estrogen, and cortisol levels
In pregnant women what increases cells increase?
their leukocytes form 7200 to 8500 with largest increase in neutrophils and granulocytes
What type of immunity is increased in pregnant women?
humoral immunity (possibel decrease in autoimmune/inflammatory disease)
Who does this happen to?
Number and elements of lymph nodes are lost; the nodes may become fatty and fibrotic, leading to decreased ability to fight infection.
Older adults
What is pruritis?
itchy sensation
What is this for?
Character: onset, location, duration, number, tenderness
Associated local symptoms: pain, redness, warmth, red streaks
Associated systemic symptoms: malaise, fever, weight loss, night sweats, abdominal pain or fullness itching “pruritis”
Predisposing factors: infection, surgery, trauma
Medications: chemotherapy, antibiotics
Swelling of Extremity
Unilateral or bilateral, intermittent or constant
Predisposing factors: cardiac or renal disorder, surgery, infection, trauma, venous insufficiency
Associated symptoms: warmth, redness or discoloration, ulceration
Efforts at treatment and their effect: support stockings, elevation
HPI of enlarged lymph nods
What is this for?
Chest radiographs; reason and results
Tuberculosis and other skin testing
Blood transfusions, use of blood products
Chronic illness: cardiac, renal, malignancy, HIV infection
Surgery: trauma to regional lymph nodes; organ transplant
Recurrent infections
Autoimmune disorder
Allergies
PMH for enlarged lymph nodes
What is this important for?
Malignancy, anemia, recent infectious diseases tuberculosis, immune disorders, hemophilia
FH for enlarged lymph nodes
What is this important for?
Travel (Asia, Africa, Western Pacific, India, Philippines), Recreational drugs (Especially injected), ETOH use, Sexual History (HIV risk factors.)
Personal/social history
What are these important for?
Recurrent infections: tonsillitis, adenoiditis, bacterial infections, oral candidiasis, and chronic diarrhea. Recent infections or trauma distal to nodes, poor growth/Failure to thrive, Loss of interest in playing/eating, immunization history, maternal HIV infection, hemophilia
For infants
What are these important for?
weeks of gestation, exposure to rubella or other infections, Pets in household (cat feces etc.)
Pregnant women
What is this important for?
Autoimmune disease, recent infection/trauma distal to affected L nodes, delayed healing.
Diseases involving the lymphatic system: Toxoplasmosis, Roseaola infantum (HHV-6), HSV 1 or 2, cat scratch disease, HIV/AIDS, Serum sickness, Latex allergy type IV dermatitis, Latex allergy type I reaction
Older Adults
What is tenderness indicative of?
inflammation
Are cancerous nodes large and tender?
just large, not tender
How and what should you palpate and inspect for when looking at lymph nodes?
Use the pads of your fingers to lightly palpate note the consistency, mobility, tenderness, size and warmth.
What is lymphadenopathy (adenopathy)?
enlarged lymph nodes
What is lymphadenitis?
inflamed and enlarged lymph nodes
What is lymphangitis?
inflammation of the lymphatics that drain an area of infection; tender erythematous streaks extend proximally from the infected area; regional nodes may also be tender
What is lymphedema?
edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage
What is lymphangioma?
Congenital malformation of dilated lymphatics
What are small nodes that feel like BBs or buckshot under the skin called?
shotty
What are wavelike motion that is felt when the node is palpated?
fluctuant
What are a group of nodes that feel connected and seem to move as a unit?
matted
Where are these nodes located:
Occipital, Postauricualr, Preauricular, parotid, retropharyngeal, submandibular, Submental, Anterior/Posterior Cervical Nodes, Supraclavicular (Virchow’s Node)
Head and neck
Axilla, Inguinal and Popliteal Fossa, Spleen are found where?
not the head and neck
(blank) are common sites of metastatic disease.
Supraclavicular nodes
The harder the node and the more discrete, the more likely it is a (blank)
malignancy
The more tender the node the more likely it is an (blank)
inflammation
Do nodes pulsate?
NOOOO!!! arteries do
A palpable (blank) node on the left is a significant clue to thoracic or abdominal malignancy
supraclavicular node
Slow growth means benign while fast growth without inflammation suggests (blank)
malignancy
If an enlarged lymph node is found examine (blank)
PALS
P=primary site A=all associated nodes
L= liver S=spleen
How is the order of the 6 step node check in the head done?
alphabetical order
Occipital, postauricular, presauricular, partorid and retropharyngeal, submandibular, submental
immunizations can cause what?
lymph node enlargement
Grading of lymphedema Stage 0 Stage 1 Stage 2 Stage 3
0= latent or subclinical
1= pitting may occur, there is early accumulation of fluid relatively high in protein content and subsides with elevation
2=tissue fibrosis present. Limb elevation alone rarely reduces tissue swelling. Pitting may be present. Late stage 2, the limb may or may not pit as tissue fibrosis supervenes.
3= pitting is absent. Trophic skin changes are present (acanthosis, fat deposits, warty overgrowths)
Red pulp consists of (blank)
White pulp consists of (blank)
venous sinusoids
Lymphatic nodules
(blank) exist in body cavities and under fascia and muscles
Deeper nodes
The lymph nodes that are most accessible to inspection and palpation include
The necklace of nodes which are what?
axillary epitrochlear supperficial superior inguinal Superficial inferior inguinal popliteal
When does lymphadenopathy require further investigation?
older patients w/ localized and persistent lymphadenopathy, young adults and children w/ localized supraclavicular lymphadenopathy, posterior cervical lymphadenopathy adds a risk for malignancy, more than lymphadenopathy that occurs in the anterior cervical chain, any lump that grows rapidly and insistently at any age
Is lymphangioma or hemangioma transilluminate?
Lymphangioma is transilluminate
From the hyoid bone to the trachea name everything in between?
hyoid bone, cricothyroid ligament, thyroid cartilage, cricoid cartilage, thyroid gland, pyramidal lobe, right lobe, isthmus, left lobe, trachea
What is this important for?
A. OLDCARTS (as it relates to complaint) – onset, location, duration, character, alleviating/aggravating factors, radiation, timing, severity
B. Focus –Head injury, headache, stiff neck, thyroid disorders
HPI head and neck
What is this important for:
Immunizations…CHF/Cancers, Hypertension, Asthma, Diabetes, Stroke)
B. Focus: Trauma, subdural hematoma, recent lumbar puncture, radiation treatment of head/neck, Headaches (vascular/migraine), previous surgeries, seizure disorder, thyroid disorders
PMI for head and neck
What is this important for?
Headaches: type, character
Thyroid disorders
FH for head and neck
What is this important for?
Employment/exposures, stress, Potential risk of injury, Nutrition/skipping meals, EtOh use, Drug use
Infants-intrauterine exposures of etoh/drugs, birth history, unusual head shape, ability to control head, any acute symptoms of illness, congenital anomalies, neonatal screening
Pregnant women-Weeks Gestation, pre-existing disease, Thyroid function, Pregnancy induced HTN, Drug Use
Older adults- dizziness or vertigo, weakness, fall risk, drug use
Social history for head and neck
What do you inspect for with the head and face?
Position, facial features, facies, symmetry, tics, size, shape
Coarse, dry and brittle hair may be associated with what?
hypothyroidism
(blank) has moon facies with thin erythemetous skin;
cushing syndrome
(blank) has Dull, puffy, yellowed skin, coarse sparse hair, temporal loss of eyebrows periorbital edema, and prominent tongue;
myxedema
(blank) has fine moist skin with fine hair, prominent eyes and lid retraction and staring/startled expression,
hyperthyroid
(blank) has butterfly rash
SLE/Lupus
(blank) has (CN VII) Facial asymmetry not able to close one eye, drooping of lower eyelid and mouth, loss of naso labial fold;
Bell’s palsy
(blank) has (CN VII) Facial asymmetry not able to close one eye, drooping of lower eyelid and mouth, loss of naso labial fold;
Acromegaly
(blank) has depressed nasal bridge, epicanthal folds, low set ears, large tongue; Fetal alcohol syndrome-smooth philtrum, wide set eyes, mild ptosis, thin upper lip.
Down syndrome
Upon palpation of head and neck what should you feel for?
Feel for shape, fusion of sutures (after 6 months), note texture of hair, temporal artery, salivary glands
When do you percuss?
What is a sign for hypocalcaemia?
only for hypocalcaemia (percussion on the masseter muscle may produce a hyperactive masseteric reflex denoting a chvostek sign)
-Trousseau’s sign
Occasionally auscultation can be used when necessary, a bruit can be heard over the eyeball, temple, and occiput; by using the (blank) of the stethoscope
bell
What is this important for?
Symmetry, anterior/posterior triangles, Jugular venous distention, carotid artery prominence, webbing, edema, thyroid enlargement
Inspection of the neck
What is this important for?
(may be difficult due to body habitus): midline trachea, hyoid bone, thyroid and cricoid cartilage, tracheal rings, May also elicit Cardarelli’s sign and Oliver’s sign for aortic aneurysm.
palpation of neck
What signs are important for aortic aneurysm?
Cardarellis and Oliver’s
What is this?
may involve inspection, palpation and auscultation. Have the patient slightly extend their neck, from the lateral view evaluate gland size while swallowing. Palpation can be done from in front of or behind the patient. Using one hand to deviate the trachea and the pads of the first three fingers on the other hand to evaluate for enlargement, masses, and texture. If the thyroid appears enlarged, auscultation is indicated to evaluate for increased vascularity/bruit.
Thyroid Exam
What is this important for:
measure head circumference, check for symmetry of shape, skin lesions, bulging or dented areas of the scalp/skull (caput vs. cephalohematoma)
Inspection of infant head
What is this important for:
Face: symmetry, features, paralysis, color, texture
Neck: Symmetry, size, shape, edema, neck veins, masses (Thyroglossal duct cyst vs. brachial cleft cyst, webbing and excessive nuchal skin, or fractured clavicle vs. cystic hygroma
Inspection of infant face and neck
What is this important for?
Identify suture lines, fontanels (Check for mastoid fontanel) tender areas of the scalp, molding from vaginal delivery usually resolves by 1 week of age.
Fontanels close by 24 months of age and should not measure greater than 4-5cm.
A bulging fontanel may be an indicator of hydrocephalus, intracranial mass, meningitis etc.
While palpating the scalp palpate firmly above and behind the ears for craniotabes.
Transillumination is performed in a dark room and can indicated increased fluid vs. decreased brain mass.
Palpation of the infant head
What is this important for?
palpate the sternocleidomastoid muscle for masses, palpate the trachea, and attempt to palpate the thyroid.
Palpation of the infant neck
Fontanels close by (blank) of age and should not measure greater than 4-5cm.
24 months
A bulging (blank) may be an indicator of hydrocephalus, intracranial mass, meningitis etc.
fontanel
(blank) is a thinning and softening of the infantile skull
craniotabes
Hyperpigmentation of the face “mask of Pregnancy is (blank)
cholasma
Who does this happen in?
Hyperpigmentation of the face “Cholasma”. The thyroid gland hypertrophies and may have an associated bruit.
pregnant women
Whos is this important in?
may vary with nutritional intake. Use caution when evaluating range of motion. Note any pain, crepitus, dizziness, jerkiness, or limitations on movement. The thyroid will likely feel more fibrotic, nodular, and irregular.
old people
What are these?
Salivary gland tumor, thyroglossal duct cyst, brachial cleft cyst, torticollis (wry neck), Hypo/Hyperthyroid, Myxedema, Grave’s disease, Hashimoto disease
Infants; Encephalocele, Microcephaly, craniosynostosis.
Important disease states for the head and neck
If you have high serum TSH what will you get?
If you have low serum TSH what will you get?
hypothyrdoism
Hyperthyroidism
(blank) is caused by iodine deficiency
goiter
In the normal gland, the right lobe is often (blank) than the left
larger
What kind of headache only happens at night?
only at morning?
cluster
hypertensive
Are cranial bruits common in children up to 5 yrs of age or who have anemia?
yes
Is it normal for pregnant women to have hypertrophy of thyroid gland?
yes
Does the thyroid gland move with swallowing?
yes (subcutaneous fat doesnt)
(blank) often feels firm and well defined upon palpation while (blank) feels soft with poorly deefined margins
Cephalohematoma
caput
Caput succedaneum is bleeding between the (blank) and the periosteum, while cephalohematoma is bleeding between the periosteum and the (blank).
skin of the scalp
bone of the skull
Ossification of sutures begins after completion of brain growth at age (blank) and finished by adulthood
6
The skull is composed of how many bones?
7
What are the palpebral fissures and the nasolabial folds?
major landmarks of the face
