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1、Physical Exam of the Head&NeckA Lect.of Clin Skills for Med Students(Nepalese Class),Part I PE of the Head,All through the approach of PE in general involves 4Steps Sequentially:Inspection Palpation Percussion Auscultation,the 1st one(inspection)is esp,important and useful for PE of headThis is beca
2、use many traits or findings from the head,esp,the face,is so attractively draw our attention when we firstly look at the ptFor Ex,the emotional reactions:,expressive/unexpressive,keen/dull;nutritional status palor,puffiness of the faces,Plethora,Xanthoma,over growth of facial hair of a woman,and fac
3、ial asymmetries,all highly pathogenomonic for a peculiar illness,A certain feature of observation or the integration of a set findings will lead to an“armchair diagnosis”of a disease for an experienced physician,General appearance(faces),Thyrotoxic faces The pt is often thin and wasting,accompanied
4、by an alert,startled,flushed and anxious appearance.,Eye signs of Graves disease,This is characterized by protrusion of one or both eyes(exophthalmos)associated with retraction of the upper eyelids,(“lid lag”)which results in exposure of the white conjunctiva above the cornea(Von-Gravefs Sign)Other
5、eye signs including,Cushingoid f.Features moon f.plethora,acne,hirsutism(over-growth of body hair,esp.mustache of a woman),The appearance of the f.of some pts with mitral stenosis of long duration,marked by rosy,flushed cheeks and dilated capillaries.,Mitral f./mitrotricuspid f.,Other facesCretins f
6、.dull,yellow appearance with thick lips,enlarged tongue,puffy eyelids,wrinkled forehead.Nephritic f.Edematous eyelid and pale appearance.,Acromegalic face A typical appearance characterized by a prominent forehead and large nose,Other signs of the face,Paralysis of facial nAsymmetry of the f.esp.the
7、 loss of the normalnasolabial fold,indicating the paralysis of facialn.This changes become most obvious if you letthe pt try to smile or show his/or her teeth.,Paralysis of facial n.,The ability to wrinkle pts forchead onthe affected side helps to identify thetype of the lesion.A:How to distinguish?
8、,Color and pigmentationVitiligoAbsence of pigm of the f.skin.occurring in patches.Mask of pregnancyyellowish brown pigm symmetrically on the forehead,cheeks,and neck of some woman during pregnancy.or taking contraceptive pills.(due to hormonal changes),Systemic lupus erythematosis(SLE)the skin lesio
9、n with pigm(facial rash)is distributed in a butterfly shape over the cheeks and the surfaces and bridge of the nose)Jaundice yellowish pigm mild degree of jaundice can be found by carefully check the sclerae in daynight.(may not be visible in artificial light).,Jaundice should not be confused with c
10、arotenemia,resulting from excessive ingestion of carrots or be secondary to increased serum levels of carotene in the setting of hypothyroidism and nephrosis.,Sudden obstruction of the airwayCOPDPneumonia(critical SARS)HF(esp CHF)Congenital heart disease(with the shunt of RL）Note cyanosis may not oc
11、cur in case that Hb is less than 5g/dl even through all Hb became HHb,Xanthoma This is circumscribed collections of lipid material in the eyelids,a flat/elevated yellowish patch vary in size from 1mm to 2cm.(associated with TC and DM),Facial hairExcessive growth of hormone-dependent hair(hair on che
12、eks or upper lip,chin)in women,suggesting hirsutism,and verified by associated androgenism,such as the levels of male hormones,muscularity,and an enlarging clitoris.,This is seeing in androgen-secreting tumors,such as Polycystic ovaries Adenoma/carcinoma of adrenal glands Drugs(androgen,contraceptiv
13、e pills),Loss of facial hair growthon the other hand,in a man may imply some disorders related to hypogonadism(Klinefelters syndrome,Kallmanns syn)and hypopituitarism(Sheehans syn),Nasal ale flag/short of breath seeing in acute obstruction of airway in children,asthma,pneumonia and acute heart failu
14、re Nasal discharge(thick,yellow)neso/sinus inflammation The study of Oro-eye-ENT Exam in detail is available in related Div/Dept of Medicine,Deformities of skull(cranium)Microcephaly a congenitally small skull resulting fr failure of the brain Macrocephalus is an abnormally large head due to hydroce
15、phalus,Pagets disease(osteitis deformans),and acromegaly Oxycephaly(steeple skull)characterized by a long anteroposterior axis,narrow in width,and pointed at the vertex.The is caused by premature union of the cranial sutures,NeckInspectionThe neck is inspected for Asymmetry Limitation of motion Abno
16、rmal pulsations Goiter Masses Neck scar(thyroidectomy,tracheotomy),Anatomy,PalpationPalpation of the neckShould be done with the pt seated in a chair while the physician examines the neck for both behind and in front of the pt,A systematic approach to examination is followedFirst to have the pts nk
17、relaxed by asking that pt chin down.Then the posterior lateral nk are palpated for lymph nodes and masses,Followed by checking of the front cervical triangle searching for enlarged lymph nodes and tumors,then the parotid,salivary glands,and the pre-auricular lymph nodes.Then,the tracheal position is
18、 determined for deviation.,Palpation of the thyroidShould be done with the pt seated in a chair while the physician examines the neck for both behind and in front,of the pt,Auscultation,Bruit Put the stethoscope over the thyroid gland,and listen carefully.If a systolic bruit heard over the thyroid i
19、s almost diagnostic of diffuse toxic goiter(blood flow to the thyroid).,A&Q Questions,What are the facial feature of esetinism?How to distinguish central Vs peripheral paralysis of the facial nerve?What are the common causes of cyanosis?What is the cliniacal implication of virchows lymph node?Briefl
20、y depict the skill for the palpation of thyroid gland.,References,History and Examination.Edited by James Marsh Pages 77,97-98,112,137 and 158-160.Mosby,2002 Physical Diagnosis.Edited by prior JA and Silberstein J.S.5th ed.Ch7,8,9,10 C.v.Mosby,1977.Swarz M H:Textbook of Physical Diagnosis 4th de,Ch8,P179-193,2002,W.B.Saunder W.,
