Exam 1 | Head and Neck

Question 1

Questions to Ask

Answer 1

• Ask if they have family or personal Hx of headaches bc family Hx may be positive in pts w/ migraines
• OLD CART
• Associated Manifestations: did you experience any vision changes? Nausea or vomiting?
  
  • Prodrome: early sign or Sx of unusual feelings like euphoria
    
    • Euphoria: feeling of elation inappropriate to situation
    • 60%-70% of pts w/ migraines have prodrome prior to onset
    • 20% experience aura, including photophobia, scintillating scotoma (blind spot), or reversible visual and sensory Sxs
• Relieving Factors: Ask if coughing, sneezing, changing position of head has any effect on headaches bc they may increase pain from brain tumor or acute sinusitis

Question 2

Head - hair abnormal findings

Answer 2

• fine hair (hyperthyroidism)
• coarse hair (hypothyroidism)
• Nits (eggs of lice): tiny white ovoid granules that adhere to hairs

Question 3

Head - scalp abnormal findings

Answer 3

• indentations, scaling, lumps, nevi, lesions
• Redness and scaling ⇒ might be seborrheic dermatitis or psoriasis

Question 4

Head - skull abnormal findings

Answer 4

• deformities, lumps, depressions, tenderness
• Macrocephaly: large head in proportion to body and underdeveloped brain
• Microcephaly: small head in proportion to body and underdeveloped brain
• Palpate for percussion: tap on head for pain → if pain ⇒ sinus pain and issue

Question 5

Head - palpate for TMJ joint movement

Answer 5

• Clicking/Clunking sound = lack of joint movement

Question 6

Head - face abnormal findings

Answer 6

• asymmetry, involuntary movements, edema, masses
• Facial Droop: can be Bell’s Palsy, Stroke, etc.
• Parkinsonian: lack of facial expressions and stare (matter of muscles)
• Exophthalmos: hyperthyroid disease
• Trisomy 21/Down Syndrome: low set eyes and ears

Question 7

Neck - thyroid abnormal findings

Answer 7

• Goiter: Enlarged thyroid gland
• Scar of past thyroid surgery often clue to under-reported thyroid disease
• With goiter, thyroid function may be increased, decreased, or normal
• Hashimoto’s Thyroiditis: firm thyroid nodules
  
  • can cause hypothyroidism
  • autoimmune disease

Question 8

Neck - lymph nodes abnormal findings

Answer 8

• any visible lymph nodes
• BIG RED FLAG: supraclavicular lymph node on left side ⇒ sign of malignancy

Question 9

Neck - abnormal auscultation of carotid arteries

Answer 9

• Swishing noise ⇒ bruit (partial occlusion of artery)
• Localized systolic or continuous bruit may be heard in hyperthyroidism

Question 10

Primary Headaches

Answer 10

• migraines
• tension
• cluster

Question 11

Migraines

Answer 11

• unilateral, happens on one side of head, neurovascular dilation of area
• Men > women
• Pain: moderate - severe, throbbing/aching pain
• W/ or w/o auras
• Lasts: 4 - 72 hrs
• Caused by neurovascular dilation of area
• S&S: photophobia, phonophobia, nausea w/ or w/o vomiting
• Triggers: not having enough sleep, dehydrated, skipping meals, menstrual cycles, too much caffeine, caffeine withdrawal
• Advil doesn’t work
• 4 phases: prodrome, aura (change in visual fields like microsomia where everything looks small), migraine headache itself, postdrome (fatigue and difficulty w/ concentration is common)

Question 12

Tension

Answer 12

• bilateral, most common, least debilitating
• Feels like a pressure band tightening on head
• Pain: mild - moderate
• Lasts: days
• Causes: stress
• Triggers: sustained muscle tension, stress, sleep disturbances

Question 13

Cluster

Answer 13

• unilateral, usually behind or around eye
• Men > women
• Onset: fast, episodic, peaks within mins
• Lasts: not long
• Pain: severe - severe
• Doesn’t kill you but is dangerous
• S&S: pain on one side of head (usually around eye area), watery eyes, eye redness, runny/stuffy nose, droopy lids, flushing/sweating
• Triggers/factors: during attack, sensitivity to alcohol increases

Question 14

Secondary Headaches

Answer 14

• analgesic rebound
• meningitis
• subarachnoid hemorrhage
• temporal arteritis
• brain tumor

Question 15

analgesic rebound

Answer 15

• related to withdrawal of headache medication
• Pts taking headache meds >2x/week ⇒ increased risk of analgesic rebound headache

Question 16

Meningitis

Answer 16

• viral, bacterial, fungal infection of meninges (surrounding brain and spinal cord), generalized headaches
• Pain: severe, steady or throbbing pain
• Onset: sudden
• S&S: fever, nuchal rigidity, photophobia

Question 17

subarachnoid hemorrhage

Answer 17

• bleeding in subarachnoid space (brain bleeds) → no place for blood to go → pressure builds → life threatening, generalized headache
• Onset: thunderclap
• Pain: “worst headache of my life (red flag),”
• S&S: NVD, LOC, neck pain

Question 18

Temporal Arteritis

Answer 18

• vasculitis involving giant cells near involved area, generalized
• Pain: severe, throbbing, persistent
• Onset: gradual or rapid
• S&S: tenderness of involved area

Question 19

Brain Tumor

Answer 19

• related tumor, location varies, and may progress as mass grows
• Pain: aching, dull, worse after waking up
• S&S: changes in vision, nausea, vomiting, change in personality, seizures

Question 20

Red flags

Answer 20

• SNOOP
• Systemic signs, Sxs, or illness: “worst headache of [pt’s] life (red flag),” elevated bp, stiff neck, signs of infection, presence of cancer, HIV, pregnancy, vomiting
• Neurologic deficits: altered mental status, seizures, papilledema
• Onset (new or sudden): after age of 50, acute onset like “thunderclap” ⇒ subarachnoid hemorrhage
• Other associated conditions: after head trauma, increases w/ valsalva maneuver or position changes, triggered by exercise or awakening from sleep
• Prior Hx: headaches are different than previous ones in progression, pattern, frequency, and/or severity

Question 21

TBI (definition, causes, prevention)

Answer 21

• what: acquired brain injury that can range from brief change in mental status or consciousness to extended period of unconsciousness or memory loss
• causes: Motor Vehicle Accidents (MVA), Blunt impact / Being struck by foreign object, Penetrating injury, Blast wave, Accelerating – Decelerating force, Sound waves, Falls
• prevention: Seatbelts, helmets, Throw rugs, Athletes need to be checked for any head injuries frequently

Question 22

TBI S&S

Answer 22

• PEBACPR
• Physical and Environmental: sensory overload and changes in routines (Fx, fever, dysphagia, fatigue, loss of vision, loss of hearing/sense of touch)
• Behavioral/Affective: self-control and time management & moods and feelings (anxiety, agitation, frustration, impulsiveness, repetitiveness, depression, regression)
• Cognitive/Perceptual: negative thoughts abt self and others (lack of attention, memory loss, lack of judgment)
• Relationships: interpersonal communication (communication problems)

Question 23

Causes of Enlarged Lymph Nodes

Answer 23

• Enlarged tender lymph nodes ⇒ commonly accompany pharyngitis
• Inflamed lymphadenopathy ⇒ raises suspicion of HIV or AIDS

Question 24

HYPERthyroidism

Answer 24

• Intolerance to heat
• Enlarged thyroid
• Exophthalmos
• Finger clubbing
• Diarrhea
• Localized edema
• Moist skin / Sweating
• Muscle wasting
• Tachycardia
• Weight loss
• Autoimmune disease: Grave’s Disease

Question 25

HYPOthyroidism

Answer 25

• Intolerance to cold
• Hair loss
• Apathy
• Lethargy
• Facial and eyelid edema
• Brittle hair and nails
• Dry skin
• Anorexia
• Bradycardia
• Weight gain
• Autoimmune disease: Hashimoto’s Disease

Question 26

Age related considerations

Answer 26

• Infants: fontanelles or soft spots in developing cranium
• Geriatrics: new onset of headaches = concerning if they’re over 50 yo
• Pregnant women:
  
  • Increased blood flow to neck/head
  • Hormonal changes