Head, face, neck, lymph Flashcards
Skull
- protects brain and sensory organs
- cranial and facial bones
- supported by cervical vertebrae
Neck
Conduit for vessels, muscles, nerves, lymph vessels, respiratory, endocrine and digestive systems
Lymph system
- separate vessel system from CV system
- immune function: get rid of dead WBCs after they fight infection
- detect and eliminate foreign substances from the body
Lymph nodes
- small, oval clusters of lymph tissue located along the lymph vessels
- filter lymph preventing harmful substances from entering the circulation
- accessible to examination in 4 areas: head and neck, arms, axillae and inguinal region
- when nodes are enlarged, check the area they drain for the sources of the problem
- check area upstream/proximal to the location of the enlarged node
Headache- symptoms analysis
- onset
- location
- duration
- severity
- quality
- timing
- associated symptoms/signs
- aggravating/alleviating factors
- personal perception
Inspect skull- expected findings
Normocephalic- normal size skull
Inspect skull- unexpected findings
- microcephaly
- macrocephaly
- hydrocephaly: accumulation of CSF causing enlargement
Palpate skull- expected findings
- non tender
- protrusions at mastoid process, occipital bone, forehead, lateral edge of parietal bone
Palpate skull- unexpected findings
- lumps
- depressions: signs of dehydration in infants
- abnormal protrusions: accumulation of CSF that with time can lead to hydrocephaly
Temporal artery assessment: palpate- expected findings
smooth, elastic pulsation
Temporal artery assessment: palpate- unexpected findings
tortuous/distended, hard, tender
Inspect/palpate TMJ: expected findings
- non tender
- no ROM limitations
Inspect/palpate: Facial expression- expected findings
consistent with behavior and mood
Inspect/palpate: Facial expression- unexpected findings
tight, rigid muscles- anxiety, pain
Inspect/palpate: Face symmetry- expected findings
eyebrows, palpebral fissures, nasolabial folds, sides of mouth
Inspect/palpate: Face symmetry- unexpected findings
asymmetry- CVA/stroke, peripheral damage to CNVII (Bell’s palsy)- drooping from temporary facial weakness
Inspect/palpate: Facial structure and movement-expected findings
even skin, no swelling or involuntary movements
Inspect/palpate: Facial structure and movement-unexpected findings
periorbital edema, excessive blinking, TMJ grinding, tics
Inspect/palpate neck: symmetry- expected findings
head midline, accessory neck muscles symmetrical, head held erect and still
Inspect/palpate neck: symmetry- unexpected findings
head tilt (muscle spasm), rigid (arthritis), swellling (parotid swelling or thyroid enlargement)
Inspect/palpate neck: ROM- expected findings
motion smooth and controlled; no pain; no enlargement of salivary, lymph or thyroid glands; no other pulsations besides the carotid artery
Inspect/palpate neck: ROM- unexpected findings
pain, limited ROM (arthritic neck= rigid), thyroid enlargement- unilateral lump or doughnut shape across lower neck
Lymph nodes expected findings
movable, discrete, soft and non-tender
Lymph nodes unexpected findings
- Enlargement (> 1cm) from infection, allergy or neoplasm= lymphadenopathy
- Nodes are bilateral, enlarged, warm, tender and firm but freely movable= acute infection
- Nodes are clumped= chronic inflammation e.g. tuberculosis
- Nodes are hard, unilateral, nontender and fixed= cancerous
- Nodes are enlarged, firm, nontender and mobile= HIV
- Single left node enlarged, nontender and hard= neoplasm in the thorax or abdomen
- Discrete nodes that are painless and rubbery gradually appear= Hodgkin’s lymphoma
Inspect/palpate trachea: expected findings
midline
Inspect/palpate trachea: unexpected findings
- tracheal shift to unaffected side (healthy side)= aortic aneurysm, tumor, unilateral thyroid lobe enlargement, pneumothorax
- trachea shift to affected side (diseased side)= large atelectasis, pleural adhesions, fibrosis
- tracheal tug: rhythmic downward pull that is synchronous with systole= aortic arch aneurysm, pediatric patients in acute respiratory distress
Palpate thyroid: expected findings
non palpable
Palpate thyroid: unexpected findings
- unilateral bulge (thryoid goiter, cyst, tumor)
- tenderness (subacute infections, trauma, radiation thyroiditis)
Ausculate thyroid: expected findings
no audible sound
Ausculate thyroid: unexpected findings
bruits (toxic goiter, hyperthyroidism)- sound of turbulent blood flow
Palpate carotid artery: expected findings
palpable
Palpate carotid artery: unexpected findings
non palpable
Ausculate carotid artery: expected findings
no bruits
Ausculate carotid artery: unexpected findings
bruit- accelerated or turbulent blood flow (hyperplasia)
Lymph node locations
- pre auricular: in front of the ear
- posterior auricular (mastoid): superficial to the mastoid process
- occipital: at the base of the skull
- submental: midline, behind the tip of the mandible
- submandibular: halfway between the angle and the tip of the mandible
- tonsillar: under the angle of the mandible
- superficial cervical: overlying the sternomastoid muscle
- deep cervical: deep under the sternomastoid muscle
- posterior cervical: in the posterior triangle along the edge of the trapezius muscle
- supraclavicular: just above and behind the clavicle, at the sternomastoid muscle
Developmental consideration head/face/neck/lymph: Infants and children
- bones of the neonatal skull are separated by sutures and by fontanelles, spaces where the sutures intersect
- at birth, head size is greater than chest circumference
- during infancy, trunk growth predominates, proportion of head size to body height changes
- in toddler, mandible and maxilla are small and the nasal bridge is low, and so the whole face seems small in comparison with the skull
- in adolescent males, the thyroid gland enlarges noticeably
Developmental consideration head/face/neck/lymph: Pregnant women
Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of the tissue and increased vascularity
Developmental consideration head/face/neck/lymph: Older adults
- facial bones and orbits appear more prominent and the facial skin sags as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin
- lower face may look smaller if teeth have been lost
Collecting health history on headache and rationale
- Question 1: Ask about location
- Rationale 1: Tension headaches- occipital or frontal, sensation of bandlike tightness; Migraines- supraorbital, retro-orbital or frontotemporal; Cluster headaches- pain around eye, temple, forehead, cheek
- Question 2: Is it localized on one side or all over?
- Rationale 2: Cluster headaches- pain always unilateral and always on the same side of the head
- Question 3: Is the pain mild, moderate or severe?
- Rationale 3: Pain is often severe with migrane and excruciating with cluster headache
- Question 4: Precipitating factors- what brings it on?
- Rationale 4: alcohol ingestion and daytime napping= cluster headaches; alcohol, letdown after stress, menstruation, eating chocolate or cheese= migraines
- Question 5: Associated factors- any relation to other symptoms
- Rationale 5: Nausea, vomiting and visual disturbances= migraines; eye reddening and tearing, eyelid drooping, rhinorrhea (runny nose), nasal congestion= cluster headaches; anxiety and stress= tension headaches; nuchal rigidity (neck stiffness) and fever= meningitis or encephalitis
- Question 6: Do you have any other illnesses?
- Rationale 6: hypertension, fever, hypothyroidism and vascuilitis can produce headaches
- Question 7: Do you take any medications?
- Rationale 7: Oral contraceptives, bronchodilators, alcohol, nitrates and CO inhalation can produce headaches
- Question 8: family history?
- Rationale 8: yes= migraines
- Question 9: Effort to treat
- Rationale 9: Migraines= people lie down to feel better; Cluster headaches= people need to move to feel better
Collecting health history on head injury and rationale
Question: did you lose consciousness and then fall?
Rationale: loss of consciousness before a fall may have a CV cause e.g. heart block
Collecting health history on dizziness and rationale
- Question: Describe your dizziness
- Rationale: Dizziness= includes presyncope (feeling like going to pass out), a lightheaded, swimming sensation or a feeling of falling caused by decreased blood flow to the brain or heart irregularity causing decreased CO; Vertigo= sense of true rotational spinning often from a labyrinthine-vestibular disorder in the inner ear, Objective vertigo= person feels like the room is spinnig, Subjective vertigo= person feels as if they are spinning; Disequilibrium= shakiness or instability when walking related to musculo-skeletal disorder or multi sensory deficits
Collecting health history on lumps or swelling and rationale
- Question 1: Difficulty swallowing
- Rationale 1: Yes= dysphagia
- Question 2: Do you smoke? How much alcohol do you drink a day?
- Rationale 2: Smoking and chewing tobacco increase the risk for oral and respiratory cancers, smoking and large alcohol consumption together increase the risk for cancer
How to assess: Skull
- To assess shape, place your fingers in the person’s hair and palpate the scalp
- Skull normally feels symmetrical and smooth
- No tenderness on palpation
- Note lumps, depressions or abnormal protrusions
How to assess: Temporal area
- Palpate the temporal artery above the zygomatic (cheek) bone between the eye and top of the ear
- Temporomandibular joint is just below the temporal artery and anterior to the tragus- palpate the joint as the patient opens the mouth
How to assess: Face
- Inspect face, noting the facial expressions and its appropriateness for behavior or reported mood
- Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth
How to assess: Neck
- Ask patient to touch the chin to the chest, turn the head to the right and left, try to touch each ear to the shoulder (without elevating shoulders), and to extend the neck backward
- Test muscle strength and status of cranial nerve XI by trying to resist the patient’s movements with your hands as the patient shrugs the shoulders and turns the head to each side
How to assess: Lymph nodes
- Using a gentle circular motion of your fingertips, palpate the lymph nodes
- Beginning with the preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph nodes in a routine order
- Palpate gently because strong pressure could push the nodes into the neck muscles
- Palpate with both hands- to compare both sides symmetrically
- When you palpate with one hand, use your other hand to position the person’s head
- For the deep cervical chain, tip the person’s head toward the side being examined to relax the ipsilateral muscle. Then press your fingers under the muscle
- Search for the supraclavicular node by having the person hunch the shoulders and elbows forward, this relaxes the skin
How to assess: Trachea
Place your index finger on the trachea in the sternal notch and slip it off to each side
How to assess: Thyroid gland
- Position a standing lamp to shine tangentially across the neck to highlight any possible swelling
- Supply patient with a glass of water, and first inspect the neck as the patient takes a sip and swallows
- Thyroid tissue normally moves up with a swallow
Assessing thyroid: Posterior approach
- Move behind the person
- Ask the person to sit up very straight and then to bend to the head slightly forward and to the right- relax muscles
- Use the fingers of your left hand to push the trachea slightly to the right
- Curve your right fingers between the trachea and the sternomastoid muscle, retracting it slightly, and ask the patient to take a sip of water
- The thyroid moves up under your fingers with the trachea and larynx as the patient swallows
- Reverse for left side
How to ausculate: Thyroid gland
If the thyroid is enlarged, auscultate it for the presence of a bruit- soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope
