Chapter 8: Head and Neck Flashcards
Physical Exam Components: Head
Observe head position:
Tilted
Tremor
Inspect skull and scalp for the following:
Size
Shape (molding)
Symmetry
Lesions
Trauma
Inspect facial features, including the following:
Shape
Symmetry
Characteristic facies
Pallor or pigmentation variations
Unusual features
Tics
Palpate head and scalp, note the following:
Symmetry
Sutures/fontanels
Hair texture, color, and distribution
Scalp movement
Tenderness (particularly over areas of frontal and maxillary sinuses)
When appropriate palpate and auscultate the temporal arteries, note the following:
Thickening
Hardness
Tenderness
Bruits
Inspect and palpate the salivary glands.
Transilluminate the skull of infants with rapidly increasing head circumference (if appropriate)
Physical Exam Components: Neck
Inspect the neck for the following:
Symmetry
Alignment of trachea
Fullness
Masses, webbing, and skinfolds
Palpate the neck, noting the following:
Tracheal position
Tracheal tug
Movement of hyoid bone and cartilages with swallowing
Lymph nodes
Joints, musculature, and spinous processes
Palpate the thyroid gland for the following:
Size
Shape
Configuration
Consistency
Tenderness
Nodules
If gland is enlarged, auscultate for bruits
Evaluate range of motion of the neck.
head and neck Anatomy & Physiology: Infants
Cranial bones are soft and separated by sutures
Skull molding from birthing process
Skull bones shift and overlap
Normal shape and size resumed within weeks
Sutures and fontanels permit skull expansion to accommodate brain growth.
Sutures ossify (age 6 to18 years)
Fontanels close -Posterior fontanel closes by 2 months of age, Anterior fontanel closes by 12 to 15 months of age
head and neck Anatomy & Physiology: Children and Adolescents
Subtle changes in facial appearance throughout childhood
Male adolescent facial changes
Nose and thyroid cartilage enlarge
Facial hair appears
head and neck Anatomy & Physiology: Pregnant Patients and Older Adults
Pregnant patients
Fetal thyroid gland becomes functional in second trimester
Pregnant patient requires increased iodine intake to maintain source of thyroid hormone for the fetus
Slight enlargement can be detected on ultrasound
Older adults
The rate of T4 production and degradation gradually decreases with aging
Thyroid gland becomes more fibrotic
History of Present Illness: head injury
Independent observer’s description of event
Level of consciousness
Any loss of consciousness after injury
Predisposing factors
Associated symptoms
Vomiting
Headache
Amnesia
HPI: HA
Onset
Duration
Location
Character
Severity
Visual prodrome
Pattern
Change in LOC
Episode pattern
Precipitating factors
Associated symptoms
Medications
Treatment efforts
HPI: stiff neck
Neck injury or strain, head injury, swelling
Fever, headache, meningitis
Character
Predisposing factors
Efforts to treat
Medications
HPI: Thyroid problem (adolescent/adult)
Changed temperature preference
Neck swelling, difficulty swallowing, redness, pain
Change in texture of hair, skin, or nails
Increased pigmentation of skin at pressure points
Change in mood/energy
Increased prominence of eyes (exophthalmos), periorbital swelling, blurred/double vision
Tachycardia, palpitations
Change in menses
Change in bowel habits
Medications: thyroid preparations
past medical history
Traumatic brain injury
Subdural hematoma
Radiation treatment around head and neck
Recent lumbar puncture
Headaches
Surgery for tumor, goiter
Seizure disorder
Thyroid dysfunction
Personal, Social, Family Histories
Personal and social
Employment
School/work
Sports participation: weight training, use of protective padding and helmet, if necessary
Nutrition
Stressors: demands at home, work, school
Injury risks
Use of recreational substances
Family
Headaches: type, character, similarity of that to patient
Thyroid dysfunction
History for Infants
Prenatal/birth/neonatal history
Head
Unusual shape
Head control
Congenital anomalies
Abnormal facies
Low set ears
Acute illness
History for Pregnant Patients and Older Adults
Pregnant patients
Gestation or postpartum duration
Presence of preexisting disease
History of pregnancy-induced hypertension
Use of alcohol/street drugs
Older adults
Dizziness or vertigo with head or neck movement
Weakness or impaired balance (increases risk of falling and head injury)
Physical Examination: Head and Face
Inspection
Facial features
Facial symmetry (rest and movement), expression
Facies
Head position and shape
Skull size and shape
Scalp
Hair pattern
Tics
Spasms
Palpation
Skull symmetric and smooth
Scalp movement
Hair texture
Temporal arteries
Temporomandibular joint (TMJ) space
Salivary glands
Percussion
Not routinely performed on head and face
One exception is when evaluating for hypocalcemia -Percussion on the masseter muscle may produce a hyperactive masseteric reflex, Chvostek’s sign.
Auscultation
Not routinely performed on skull
Bruit -Cerebral aneurysm, Temporal arteritis
Physical Examination: Neck
Inspection
Muscle symmetry
Alignment of trachea
Landmarks of triangles
Fullness at base of neck
Masses
Webbing
Unusual shortness
Asymmetry
Carotid artery prominence
Jugular vein distention
Range of motion (ROM)
Palpation
Tracheal alignment
Smoothness and tenderness -Hyoid bone, Thyroid cartilage, Cricoid cartilage
Tracheal tugging -Suggests the presence of an aortic aneurysm
Lymph nodes
Physical Examination: Thyroid Gland
Inspection
Symmetry
Size
Contour
Palpation
Size and shape
Configuration and consistency
Tenderness
Nodules
Auscultation
If enlarged, auscultate for vascular sounds
In a hypermetabolic state, the blood supply is dramatically increased and a vascular bruit, a soft rushing sound, may be heard
Physical Examination: Infants
Inspection
Head symmetry and circumference
Head control, position, movement
Fontanels
Hair and hairline
Scalp scaling/crusting, birthmarks, lesions, dilated scalp veins
Caput succedaneum or cephalohematoma
Face for features, symmetry, paralysis, skin color/texture
Neck symmetry, size, shape, range of motion
Palpation
Suture lines and fontanels
Craniotabes: softening of the outer table of the skull
Neck muscle tone and masses
Trachea
Clavicles
Transillumination
Transilluminate for suspected intracranial lesions or a rapidly increasing head circumference
Performed less often today because of availability of computed tomography (CT) scan
Physical Examination: Children
Percussion of skull with one finger to detect Macewen sign -Stronger resonant or “cracked pot” sound when either hydrocephalus or a
brain abscess is present
Bruits common in children up to 5 years of age
Thyroid may or may not be palpable
Physical Examination: Pregnant Patients and Older Adults
Pregnant patients
Inspect for chloasma (mask of pregnancy)
Palpate for hypertrophy of thyroid
Auscultate for thyroid bruit
Older adults
Facies vary with nutritional status
Sunken eyes
Eyelids loose and wrinkled
Evaluate range of motion (ROM) of neck slowly and cautiously -Pain, crepitus, dizziness, jerkiness, limited ROM
Palpate thyroid for nodules or irregularities
Head and Neck Abnormalities: Adult
Headaches
Salivary gland tumor
Mostly in parotid
Hypo-/hyperthyroidism
Under-/overactive thyroid
Myxedema
Prolonged hypothyroid disorder
Graves disease
Overactive thyroid caused by antibodies
Hashimoto disease
Underactive thyroid caused by antibodies
Head and Neck Abnormalities: Infants
Thyroglossal duct cyst
Palpable cystic mass in the neck
Branchial cleft cyst
Congenital lesion formed by incomplete involution of branchial cleft
Torticollis (wry neck)
Shortening/excessive contraction of sternocleidomastoid muscle
Encephalocele
Neural tube defect; protrusion of brain/membranes through skull openings
Hydrocephalus
Formation, flow, absorption CSF problem that causes increased CSF
Microcephaly
Circumference of head is smaller than normal because brain has not developed properly or has stopped growing
Craniosynostosis
Premature closure of cranial suture(s) before complete brain growth
Facial muscles are innervated by which of the following cranial nerves?
CN IV and V
CN V and VI
CN V and VII
CN VI and VII
ANS: C
Rationale: The facial muscles are innervated by cranial nerves V and VII.
Which is a chronic autoimmune disorder?
Microcephaly
Hashimoto disease
Salivary gland tumor
Down syndrome
ANS: B
Rationale: Hashimoto disease is a chronic autoimmune thyroid disease that occurs later in childhood and commonly affects women 30 to 50 years of age. The other choices are not autoimmune disorders.
Mrs. Wagner is a 45-year-old patient. You are examining her thyroid and note a course and gritty sensation. This is indicative of:
Cancer
Nodules
Goiter
Inflammatory process
ANS: D
Rationale: Course tissue or a gritty sensation suggests an inflammatory process.
