Head and Neck - PDF Document

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  1. Head and Neck Year 1 Year 2 Core Clinical/Year 3+ Do 1. Head • Do: • Do: • Know • If hearing is abnormal perform Weber and Rinne testing Weber: 512 Hz tuning fork is placed on midline of patient’s forehead and patient asked which side is heard best. Normally sound is heard equally on each side. Rinne: 512 Hz tuning fork is placed on mastoid process testing conduction hearing. Patient describes when vibration is not heard and tuning fork is placed over ear to test air conduction. Normally air conduction (AC) is better than bone conduction (BC). Know • Normocephalic: a normal size/shape calvarium • Stridor: high pitched, fine noise with breathing that originates at the subglottis • Hoarseness: arises from abnormalities of the true or false vocal cords • An acute facial fracture may result in point tenderness, step-offs, edema, crepitus and/or facial numbness. • Weber testing causes lateralizing of sound by either: -sensorineural loss toward good ear -conductive loss toward impaired ear • Rinne testing (on side with decreased hearing): -in sensorineural hearing loss AC>BC (just as normally occurs) - in conductive hearing loss BC>AC • Lymph nodes are enlarged if they are over 1cm and when encountered should be noted for: location, size, consistency, tenderness, and degree of fixation. Perform pneumatic otoscopy Exam seated unless hospitalized may be in semi- recumbent position Inspect size and shape of head and scalp looking for asymmetry, masses, signs of trauma. 2. Face • Inspect for symmetry and lesions • Palpate bony prominences, parotid glands, and temporomandibular joints (TMJ). • Palpate/percuss paranasal sinuses for tenderness: above eyes (frontal), over malar eminences (maxillary) 3. Ears • Inspect auricle and mastoid • Palpate pinna and tragus for tenderness and percuss mastoid • With otoscope examine external auditory canals, tympanic membrane and the middle ear structures visualized through TMs • Assess hearing one ear at a time using 512Hz tuning fork, watch or finger rubbing 4. Eyes • Measure visual acuity with Snellen card at appropriate distance (with corrective lenses) one eye at a time then with both eyes • Assess visual fields and extraocular movements • Perform external exam of: eyelids, lashes, bulbar/palpebral conjunctiva, cornea, anterior chamber, and iris • Assess pupillary size, shape and reaction • Perform direct ophthalmoscopy, assessing red reflex, optic cup/disc, vessels, background, and macula • Scleral icterus (jaundice) starts to become appare at serum bilirubin (>3.0 mg/dL) Conjunctival pallor occurs in the anemic patient with hematocrit approximately <22-24% Anisocoria (unequal pupil size) may be normal in up to 20% or more of population. Other causes include: pharmacologic, Horner’s syndrome, and third nerve palsy On fundus examination the normal cup to disc ration should be <1;2 (usually <1:3). An optic cu >50% of the total disc diameter is suspicious for glaucoma. Pressure in the EAC is increased or decreased wi pumping rubber bulb attached to otoscope. Decreased mobility of TM during pneumatic otoscopy along with blanching of the TM with positive pressure suggests a middle ear effusion. The maxillary, anterior ethmoid, and frontal sinu drain into the middle meatus (space between mid turbinate and lateral nasal wall) purulent discharg here is a sign of sinusitis. Pale boggy mucosa is typical of allergic rhinitis. Oral malignancies are easily missed in the retromolar trigone and base of tongue (inspect the area medial to the mandible and lateral to the ton with the tongue pushed medially using a tongue blade). Palpation of these structures will often de lesions earlier than visually identifying surface mucosal ulceration. • • • • • • • Educators-4-CARE Benchmarks 2009-10, v1 Stanford University School of Medicine

  2. • 5. Nose • • Cervical lymph nodes should be distinguished by location- anterior vs. posterior. Inspect external nose Examine nares, septum, nasal cavities, includes inferior turbinates gently lifting tip of nose to see better into nasal cavity 6. Oral Cavity and Oropharynx • Inspect lips, buccal mucosa, tongue, floor of mouth, uvula, palate, palatine tonsils, and polsterior pharyngeal wall • Inspect teeth and gums for caries and periodontal disease • Palpate parotid and submandibular glands, salivary ducts (Stenson’s from parotid and Warthin’s from submandibular). Should use a gloved hand intraorally palpating base of tongue, the sublingual and sub-mental region 7. Neck • Inspect for asymmetry • Palpate each region of the neck including the laryngeal framework (hyoid, thyroid, cricoid, and tracheal cartilages), • Identify and palpate anterior border of sternocleidomastoid muscle to delineate lymph nodes in anterior and posterior cervical triangles and palpate supraclavicular lymph node areas • Palpate thyroid behind patient Know • Main landmarks of the ear- helix, antihelix tragus, lobule, external auditory canal (EAC) tympanic membrane, malleus (short process, manubrium, umbo) Educators-4-CARE Benchmarks 2009-10, v1 Stanford University School of Medicine