Heent

HEENTHEENTE. Solis MD, E. Solis MD,

MPHMPH

Learning ObjectivesLearning Objectives

The student will be able to identify The student will be able to identify different components of the head, different components of the head, eyes, ears, nose, and throateyes, ears, nose, and throat

The student will be able to identify The student will be able to identify anatomic landmarks of the head, anatomic landmarks of the head, eyes, ears, nose and throateyes, ears, nose and throat

The student will be able to identify and The student will be able to identify and perform the proper techniques for a perform the proper techniques for a basic exam of the head, eyes, ear, basic exam of the head, eyes, ear, nose and throatnose and throat

The student will be able to describe The student will be able to describe and record findings of the head, eyes, and record findings of the head, eyes, ears, nose and throat examinationears, nose and throat examination

Learning ObjectivesLearning Objectives

The student will be able to identify The student will be able to identify different disorders of the head, eyes, different disorders of the head, eyes, ears, nose, and throatears, nose, and throat

The student will be able to identify The student will be able to identify the signs and symptoms of HEENT the signs and symptoms of HEENT disordersdisorders

Objective 1: Components of Objective 1: Components of the HEENT Examthe HEENT Exam

HEADHEAD inspection:inspection: skull- size ,shape, symmetry, deformityskull- size ,shape, symmetry, deformity scalp- redness, scalingscalp- redness, scaling hair- quantity, distribution ,nits, licehair- quantity, distribution ,nits, lice face – symmetry, involuntaryface – symmetry, involuntary movements, skin lesions, color,movements, skin lesions, color, shapeshape

Palpation:Palpation: skull ( including temporal artery)- sizeskull ( including temporal artery)- size contour, lumps, deformities, contour, lumps, deformities, tendernesstenderness scalp- mobility, lesionsscalp- mobility, lesions hair – texturehair – texture Temporomandibular joint – pain, Temporomandibular joint – pain, decreased ROMdecreased ROM

NeckNeck

Lymph nodes- enlargement,mobilityLymph nodes- enlargement,mobility

Trachea – deviationTrachea – deviation

Thyroid gland- size, tenderness, Thyroid gland- size, tenderness, mobilitymobility

EYESEYES

Inspection:Inspection:

eyebrows- hair loss, scalingeyebrows- hair loss, scaling

eyelids – redness, swelling, lesionseyelids – redness, swelling, lesions

Conjunctiva – paleness, inflammationConjunctiva – paleness, inflammation

Sclera – icterus, inflammationSclera – icterus, inflammation

Cornea (anterior chamber) – opacitiesCornea (anterior chamber) – opacities

Lens- opacitiesLens- opacities

Pupils – size ,shape, equality, reactionPupils – size ,shape, equality, reaction

Tests:Tests:

-pupillary reactions-pupillary reactions

direct and consensualdirect and consensual

-accommodation -accommodation

-Extraocular movement-Extraocular movement

Funduscopic ExaminationFunduscopic Examination

- red orange reflex- red orange reflex

- optic disc - optic disc - blood vessels blood vessels - Hemorrhages, exudatesHemorrhages, exudates

Visual acuityVisual acuity- Near VisionNear Vision- Far VisionFar Vision- Peripheral visionPeripheral vision

EARSEARS


Auricle (anterior & posterior)- Auricle (anterior & posterior)-

deformities, lumps, lesions, deformities, lumps, lesions, positionposition

Palpation:Palpation:

Pulls on pinna – tenderness Pulls on pinna – tenderness

Otoscope exam Otoscope exam

external canal- cerumen, discharge, foreign external canal- cerumen, discharge, foreign bodies, swellingbodies, swelling

Tympanic membrane- color, landmarks, Tympanic membrane- color, landmarks, bulging ,retraction, perforationbulging ,retraction, perforation light reflexlight reflex

Tests Tests

Auditory acuity – decreased hearingAuditory acuity – decreased hearing

Weber test- lateralizationWeber test- lateralization

Rinne test- AC vs BCRinne test- AC vs BC

Nose and sinusesNose and sinuses


External nares – asymmetry, deformityExternal nares – asymmetry, deformity

Internal nares with otoscope – swelling, Internal nares with otoscope – swelling,

turbinates, septal deviation, turbinates, septal deviation,

perforation, discharge, blood perforation, discharge, blood

crusting, ulcers, polypscrusting, ulcers, polyps

Sinuses Sinuses

Palpation:Palpation:

Frontal – tendernessFrontal – tenderness

Maxillary- tendernessMaxillary- tenderness

Mouth and pharynx (throat)Mouth and pharynx (throat) Inspection:Inspection: Lips- color, moisture, lumps, ulcers, Lips- color, moisture, lumps, ulcers, crackingcracking

Buccal mucosa- color, moisture, lesionsBuccal mucosa- color, moisture, lesions

Teeth – loose, missing, dental cariesTeeth – loose, missing, dental caries

Gums- inflammation, swelling, bleeding,Gums- inflammation, swelling, bleeding, discolorationdiscoloration

Tongue (dorsal, ventral, sides, floor)Tongue (dorsal, ventral, sides, floor) - asymmetry, lesions, salivary - asymmetry, lesions, salivary ductsductsPalate- lumps, lesionsPalate- lumps, lesionsTonsils – presence, size, color, pus Tonsils – presence, size, color, pus symmetrysymmetryPharynx – inflammation, exudatesPharynx – inflammation, exudatesUvula- inflammation, deviationUvula- inflammation, deviation

Objective 2: Anatomic Objective 2: Anatomic LandmarkLandmark

To be able to identify common To be able to identify common structures in this region which are structures in this region which are routinely assessed during physical routinely assessed during physical examexam

HEADHEAD

Describe anatomy and landmarks of Describe anatomy and landmarks of the headthe head

The SKULLThe SKULL

Temporomandibular JointTemporomandibular Joint

Objective 3: Physical ExamObjective 3: Physical Exam

To be able to identify and perform To be able to identify and perform proper techniques for the basic proper techniques for the basic examination of the head, neck, eyes, examination of the head, neck, eyes, ears, nose and throatears, nose and throat

ProcedureProcedure

HEADHEAD Stand beside or behind the seated patientStand beside or behind the seated patient

Observe head positionObserve head position midline, tilted to one side, rotatedmidline, tilted to one side, rotated

SkullSkull ScalpScalp HairHair

Inspect the skull for:Inspect the skull for: - size – normocephalic, micro/macrocephalic - size – normocephalic, micro/macrocephalic

- shape - shape - deformity- deformity

Palpate the skull for:Palpate the skull for: - symmetry- symmetry - mass-if present give the exact location, size - mass-if present give the exact location, size

, shape ,mobility and tenderness, shape ,mobility and tenderness -deformity-deformity -tenderness- if present localize-tenderness- if present localize

The SCALPThe SCALP

Inspect the scalp for:Inspect the scalp for: - scales- scales - scars- scars - parasites, nits- parasites, nits - mass- mass - pay special attention to the areas behind the - pay special attention to the areas behind the ears, at the hairline and at the crown of the ears, at the hairline and at the crown of the head. Note for any hair loss patternhead. Note for any hair loss pattern

Palpate the scalp for:Palpate the scalp for:

- tendernesstenderness

-mass ( sebaceous cyst, lipoma, -mass ( sebaceous cyst, lipoma, tumor)tumor)

- or fluctuant scalp masses like - or fluctuant scalp masses like hematoma, abscess, depressed hematoma, abscess, depressed fracturefracture

- scalp movement- scalp movement

Hair : inspect and palpateHair : inspect and palpate - color- color - length- length - distribution- well distributed- distribution- well distributed - pattern of hair loss- receding hair line- pattern of hair loss- receding hair line - quantity –thin, thick or fairly abundant- quantity –thin, thick or fairly abundant - texture- fine or coarse- texture- fine or coarse - moisture – dry or oily- moisture – dry or oily - look for lice and nits- look for lice and nits

Palpation of Temporomandibular jointPalpation of Temporomandibular joint

Locate the TMJ with your fingertips placed just anterior to the tragus of each ear.

Allow your fingertips to slip into the joint space as the patient’s mouth open and gently palpate the joint space

An audible or palpable snapping or clicking

in the TMJ is not unusual, but pain, crepitus, locking or popping may indicate TMJ syndrome

Objective 4: Record FindingsObjective 4: Record Findings

To be able the describe and record To be able the describe and record findings of the head, neck, eyes, ears findings of the head, neck, eyes, ears and throatand throat

Record the FindingsRecord the Findings

Normocephalic, head held erect and Normocephalic, head held erect and in the midline, thick hair, well-in the midline, thick hair, well-distributed, no focal areas of hair distributed, no focal areas of hair loss, coarse and dry,loss, coarse and dry,

scalp moves freely under examining scalp moves freely under examining fingers, no mass or tenderness, fingers, no mass or tenderness, temporal arteries palpable but not temporal arteries palpable but not thickenedthickened

Describe anatomy and landmark of Describe anatomy and landmark of the the

FACEFACE

ProcedureProcedure

FACEFACE Stand or sit in front of the patient at the same levelStand or sit in front of the patient at the same level

Inspect the face for:Inspect the face for: - skin : color, pigmentation and lesions- skin : color, pigmentation and lesions - shape – oval, round, prominent and protruding chin- shape – oval, round, prominent and protruding chin - facial expression and involuntary movements- facial expression and involuntary movements - edema- edema - symmetry – if asymmetric present describe - symmetry – if asymmetric present describe eg..shallow nasolabial fold.eg..shallow nasolabial fold.

Palpate the temporal arteries, noting Palpate the temporal arteries, noting the ff:the ff:

- thickening- thickening

- hardness- hardness

- tendernesstenderness Auscultate temporal arteries for Auscultate temporal arteries for

bruitsbruits

Record findingsRecord findings

Face is oval in shape, symmetrical, Face is oval in shape, symmetrical, fair skinned, with occasional fair skinned, with occasional pigmented papules scattered over pigmented papules scattered over the face, no masses, nor involuntary the face, no masses, nor involuntary movements, temporal artery not movements, temporal artery not visible but palpable with strong visible but palpable with strong pulsation, walls not thickenedpulsation, walls not thickened

NECKNECK

Describe the anatomy and landmarks Describe the anatomy and landmarks of of

the NECKthe NECK

Thyroid GlandThyroid Gland TracheaTrachea Lymph NodesLymph Nodes Carotid pulsationsCarotid pulsations

..

ProcedureProcedure

Inspect the neck for :Inspect the neck for :

- symmetry - symmetry

- size ( long or short) - size ( long or short)

- deformity - deformity

- masses, webbing- masses, webbing

- alignment of trachea- alignment of trachea

- jugular vein distention- jugular vein distention

- carotid artery prominence- carotid artery prominence

Evaluate range of motion of the neckEvaluate range of motion of the neck

- flex, extend ,rotate and lateral turn of - flex, extend ,rotate and lateral turn of the head and neckthe head and neck

- movement should be - movement should be smooth ,painless and should not cause smooth ,painless and should not cause dizzinessdizziness

Palpate the neck for:Palpate the neck for:

- tracheal position- tracheal position

- carotid pulsationscarotid pulsations

- lymph nodeslymph nodes

- thyroid glandthyroid gland

The LYMPH NODES groupThe LYMPH NODES group

ProcedureProcedure

LYMPH NODESLYMPH NODES The examiner should stand behind The examiner should stand behind

the seated patientthe seated patient Use the pads of both index and Use the pads of both index and

middle fingers as you move the skin middle fingers as you move the skin over the underlying tissues in each over the underlying tissues in each area rather than moving your fingers area rather than moving your fingers over the skin in a rotatory fashionover the skin in a rotatory fashion

Feel in sequence for the following nodes

1. Preauricular –in front of the ear2. Posterior auricular – superficial to the

mastoid process3. Occipital – at the base of the skull4. Tonsillar – at the angle of the mandible5. Submandibular – midway between the

angle and the tip of the mandible

6. Submental – in the midline7. Superficial cervical – superficial to the SCM8. Posterior cervical chain –along the anterior

edge of the trapezius9. Deep cervical chain –deep into the SCM but

often inaccessible to examination10. Supraclavicular –deep in the angle formed

by the clavicle and the SCM

Palpate the lymph nodes for:Palpate the lymph nodes for: - size- size - shapeshape - delimitation ( discrete or matted - delimitation ( discrete or matted

together)together) - mobilitymobility - consistency- consistency - tenderness- tendernessSmall, mobile, discrete, nontender nodes are Small, mobile, discrete, nontender nodes are

frequently found in normal personsfrequently found in normal persons

Carotid pulsationCarotid pulsation

Locate for the carotid pulse, in the neck just medial to and below the angle of the jaw ( do not palpate simultaneously)

Excessive carotid massage can cause slowing of the pulse or a drop in blood pressure

If you have difficulty feeling the pulse, rotate the patient’s head to the side being examined to relax the SCM muscle

Examine the arterial pulse with the distal part of the 2nd and 3rd fingers

The TRACHEAThe TRACHEA

ProcedureProcedure

Inspect the trachea for any deviation Inspect the trachea for any deviation from its usual midline positionfrom its usual midline position

Then feel for any deviation by Then feel for any deviation by placing your finger along one side of placing your finger along one side of the trachea and note the space the trachea and note the space between it and the SCM.between it and the SCM.

Compare it with the other side. The Compare it with the other side. The spaces should be symmetrical. If spaces should be symmetrical. If asymmetrical there is deviationasymmetrical there is deviation

Describe the anatomy and landmarks Describe the anatomy and landmarks of of

the THYROID GLANDthe THYROID GLAND

ProcedureProcedure

THYROID GLANDTHYROID GLAND Patient should be seatedPatient should be seated Inspect the lower half of the neck in Inspect the lower half of the neck in

the anterior trianglesthe anterior triangles Have him swallow or sip a glass of Have him swallow or sip a glass of

water to note any ascending mass in water to note any ascending mass in the midline or behind the SCMthe midline or behind the SCM

If the patient is obese or has a short If the patient is obese or has a short neck , tilt the head back to be supported neck , tilt the head back to be supported by his hands clasped at the occiput.by his hands clasped at the occiput.

Ask him to swallow while in this postureAsk him to swallow while in this posture

The thyroid gland, thyroid cartilage, and The thyroid gland, thyroid cartilage, and cricoid cartilage all normally rise as the cricoid cartilage all normally rise as the person swallowsperson swallows

Palpation Palpation

-best done from behind the patient-best done from behind the patient

- cricoid cartilage is the basic landmark- cricoid cartilage is the basic landmark

for examinationfor examination

2 methods of palpation:2 methods of palpation:

a)a) Palpation from behindPalpation from behind

b)b) Frontal palpation of the thyroid glandFrontal palpation of the thyroid gland

Palpate the thyroid gland for :Palpate the thyroid gland for :

- size- size

- shapeshape

- symmetry- symmetry

- consistency of the gland, tenderness- consistency of the gland, tenderness

- presence of nodules- presence of nodules

- movement- movement

Record findingsRecord findings

NECKNECK Neck is supple with full range of Neck is supple with full range of

motion,motion,

trachea midline, no trachea midline, no lymphadenopathy noted. A 1x2 cm lymphadenopathy noted. A 1x2 cm nodule is palpated in the right lobe of nodule is palpated in the right lobe of the thyroid; smooth, soft, nontender, the thyroid; smooth, soft, nontender, moves freely when patient swallowsmoves freely when patient swallows

Objective 5:Record abnormal Objective 5:Record abnormal FindingsFindings

To be able to identify and record To be able to identify and record different disorders of head ,neck, different disorders of head ,neck, eyes, ears, nose and throateyes, ears, nose and throat

FaciesFacies

Expression or appearance of the face Expression or appearance of the face and features of the head and neck and features of the head and neck that whenthat when

considered together, are considered together, are characteristics of a clinical condition characteristics of a clinical condition or syndromeor syndrome

AcromegalyAcromegaly -large head-large head - forward projection of - forward projection of

jawjaw - protrusion of frontal - protrusion of frontal

bonebone

Cushing Cushing SyndromeSyndrome

- thin erythematous - thin erythematous

skinskin - hirsutism- hirsutism - rounded or moon - rounded or moon shaped faceshaped face

Mxyedema Mxyedema

- dull, puffy, yellowed - dull, puffy, yellowed skinskin - coarse sparse hair- coarse sparse hair - temporal loss of - temporal loss of eyebrowseyebrows - periorbital edema- periorbital edema - prominent tongue- prominent tongue

Hyperthyroid FaciesHyperthyroid Facies - fine moist skin- fine moist skin - fine hair- fine hair - prominent eyes- prominent eyes - lid retraction- lid retraction - startled - startled

expressionexpression

(R) Facial Palsy(R) Facial Palsy - assymmetry of one side of - assymmetry of one side of the facethe face - eyelid not closing - eyelid not closing

completelycompletely - loss of nasolabial fold- loss of nasolabial fold - drooping lower eyelid and - drooping lower eyelid and corner of the mouthcorner of the mouth

SIGNSSIGNS

Hydrocephalus Scars Head tumorHydrocephalus Scars Head tumor

Alopecia areataAlopecia areata

SYMPTOMSSYMPTOMS

HEADACHE HEADACHE

HEADACHE

- refers to pain perceived more than momentarily in the cranial vault , orbits and the nape. Pain elsewhere in the face is not included

Mechanisms of Headache 1. infection – meningitis, encephalitis 2. arterial dilatation – Malignant

Hypertension 3. hemorrhage – intracebral , subdural

and SAH4.Expanding mass lesion – brain tumor

5. Trauma – head trauma , inc. ICP

6. Tissue Ischemia – hypoxia, hypoglycemia

Muscle contraction headacheMuscle contraction headache

Muscle Contraction Headache: TensionMuscle Contraction Headache: Tension HeadacheHeadache - Mild or moderate discomfort, a heavy - Mild or moderate discomfort, a heavy

feeling, a sense of pressure, tight band, feeling, a sense of pressure, tight band, steady rather than throbbingsteady rather than throbbing

- related to emotional tension - related to emotional tension - not intensified by coughing- not intensified by coughing - improved by shaking the head, massage, - improved by shaking the head, massage,

mild analgesics, application of hot packsmild analgesics, application of hot packs

Migraine HeadacheMigraine Headache

Classic MigraineClassic Migraine

4 phases4 phases

1. Prodrome- an attack is often triggered 1. Prodrome- an attack is often triggered

by period of anxiety, tension, by period of anxiety, tension,

bright light, loud noise, bright light, loud noise,

skipped meals, foods andskipped meals, foods and

beverages, strong odors andbeverages, strong odors and

change in sleep patternschange in sleep patterns

2. Aura – visual disturbances2. Aura – visual disturbances3. Headache3. Headache - frequently present on awakening- frequently present on awakening -severe throbbing, boring, aching -severe throbbing, boring, aching headache over 1 hr.headache over 1 hr. - does not disrupt sleep- does not disrupt sleep - increased in the reclining position, - increased in the reclining position,

shakingshaking the head, coughing or straining at stoolthe head, coughing or straining at stool

- Associated symptoms are N/V, Associated symptoms are N/V, photophobia, annoyance for odors, photophobia, annoyance for odors,

maybe normal or cold limbs and pale maybe normal or cold limbs and pale skinskin

4. Recovery4. Recovery

Cluster HeadacheCluster Headache

Cluster headache : Histamine headacheCluster headache : Histamine headache

or Histamine Cephalgiaor Histamine Cephalgia

- due to dilatation of branches of the - due to dilatation of branches of the

internal carotid arteryinternal carotid artery

- 5-6x more common in men- 5-6x more common in men

- onset is typically 3- onset is typically 3rdrd- 4- 4thth decade of life decade of life

- commonly episodic and begins w/o- commonly episodic and begins w/o

auraaura

- Unilateral , severe ,boring,, and Unilateral , severe ,boring,, and throbbing headache that recurs throbbing headache that recurs consistently on the same side lasting consistently on the same side lasting an average of 40 minan average of 40 min

- Associated symptoms are flushing, Associated symptoms are flushing, rhinorrhea, conjunctivitis, lacrimation, rhinorrhea, conjunctivitis, lacrimation,

temporal artery dilatation on the temporal artery dilatation on the affected side, sweating of the skinaffected side, sweating of the skin

Other causes of headache:Other causes of headache: Hypertensive headacheHypertensive headache Brain tumorBrain tumor Hemorrhage Hemorrhage -intracereberal hemorrhage-intracereberal hemorrhage -subarachnoid hemorrhage-subarachnoid hemorrhage Bacterial meningitisBacterial meningitis Lumbar puncture headacheLumbar puncture headache

Hypertensive headache - due to segmental dilatation of

branches of external carotid artery - headache occurs in half of patients

with accelerated HPN without encepalopathy

- Headache often occipital, no aura- Diastolic pressure must exceed 120

mm hg to cause headache

Brain tumor- Benign and malignant intracranial

neoplasms compress and place traction on surrounding structures

- Headache maybe the first symptom, the onset is recent, a recent change in the customary headache pattern has occured

- An apparent migraine aura persists after the headache subsides

- Headache starts by abrupt change in position, exertion and inc. in recumbent position

- May interfere with sleep

Subarachnoid hemorrhage- Results fr. rupture of a saccular

anuerysm of the circle of willis, preceeded often by a leakage

- Excruciating generalized headache, followed by nuchal rigidity, then coma, often death

Meningitis - Headache , fever and signs of

meningeal irritation ( nuchal rigidity)- Headache intensified by sudden

movement of the head

NECKNECK

Stiff neck:Stiff neck:

1) Torticollis ( wryneck) 1) Torticollis ( wryneck)

- the congenital type is due to - the congenital type is due to hematomahematoma

or partial rupture of the muscle at or partial rupture of the muscle at birthbirth

resulting in unilateral muscle resulting in unilateral muscle shorteningshortening

2) Idiopathic – fibromyalgia2) Idiopathic – fibromyalgia

3) inflammatory/immune – osteomyelitis3) inflammatory/immune – osteomyelitis

4) Infectious – pharyngitis, meningitis4) Infectious – pharyngitis, meningitis

5) Metabolic - Tetanus5) Metabolic - Tetanus

6) Mechanical /trauma- fracture, 6) Mechanical /trauma- fracture, dislocationdislocation

7) Neoplastic – thyroid cancer, lymphoma7) Neoplastic – thyroid cancer, lymphoma

8) Neurologic – parkinson’s disease8) Neurologic – parkinson’s disease

9) Psychosocial – malingering 9) Psychosocial – malingering

Nongoitrous cervical massesNongoitrous cervical masses

Midline cervical massMidline cervical mass- Thyroglossal cystsThyroglossal cysts- Suprahyoid cystsSuprahyoid cysts- Subhyoid cystsSubhyoid cysts- Pyramidal lobe of thyroidPyramidal lobe of thyroid- Thyroid cartilage cystsThyroid cartilage cysts- Cricoid cartilage cystsCricoid cartilage cysts

Lateral cervical cystLateral cervical cyst- Branchial cystBranchial cyst- HygromaHygroma- Carotid body tumorCarotid body tumor- Cavernous hemangiomaCavernous hemangioma- Branchial fistula Branchial fistula - Zenker’s diverticulum ( pharyngeal Zenker’s diverticulum ( pharyngeal

pouch)pouch)

ThyroidThyroid

Thyroid enlargement ( GOITER)Thyroid enlargement ( GOITER) - results from:- results from: a) hyperplasia of the thyroid tissue a) hyperplasia of the thyroid tissue b) infectionb) infection c) neoplastic growth ( primary thyroid cancer, c) neoplastic growth ( primary thyroid cancer,

metastatic growth, lymphoma)metastatic growth, lymphoma) d) infiltration with foreign substances d) infiltration with foreign substances

( amyloid)( amyloid)

--

- patient complains of fullness of mass - patient complains of fullness of mass in the neck , pressure symptomsin the neck , pressure symptoms

- Determine the size of the component - Determine the size of the component of the gland, extension the gland of the gland, extension the gland within the neck or into the within the neck or into the retrosternal space, fixation to retrosternal space, fixation to surrounding structuressurrounding structures

-characterize the enlarge thyroid as -characterize the enlarge thyroid as diffuse, focal, nodular, or smoothdiffuse, focal, nodular, or smooth

- tendernesstenderness

-make an assessment of the state of thyroid -make an assessment of the state of thyroid function: Hypothyroid, Hyperthyroid, function: Hypothyroid, Hyperthyroid, euthyroideuthyroid

- Clinical classification is based whether Clinical classification is based whether thyroid is diffuse or nodularthyroid is diffuse or nodular

- Level of functional thyroid state: Level of functional thyroid state:

a) toxic goitera) toxic goiter

b) nontoxic goiter ( euthyroid or hypothyroid)b) nontoxic goiter ( euthyroid or hypothyroid)

Retrosternal Goiter ( substernal, Retrosternal Goiter ( substernal, intrathoracic , or submerged goiter)intrathoracic , or submerged goiter)

- when the lower border of a goiter - when the lower border of a goiter can’t be palpatedcan’t be palpated

- Goiter may rise only with inc. - Goiter may rise only with inc. intrathoracic pressure like coughing. intrathoracic pressure like coughing. This is also called plunging goiter. This is also called plunging goiter.

2 physical signs of retrosternal goiter

1) Tracheal displacement2) Venous engorgement in the neck

Diffuse toxic goiter ( Grave’s Diffuse toxic goiter ( Grave’s Disease)Disease)

-autoimmune disease char. by goiter, -autoimmune disease char. by goiter, exophthalmos, pretibial edema, exophthalmos, pretibial edema, hyperthyroidismhyperthyroidism

Thyroid syndromesThyroid syndromes - excess or deficit of thyroid hormones - excess or deficit of thyroid hormones

alter the physical structure of the alter the physical structure of the body to produce physical signsbody to produce physical signs

- examine your patient to determine - examine your patient to determine the size of the TG, to assess thyroid the size of the TG, to assess thyroid function, to judge the likehood of function, to judge the likehood of cancercancer

Thyroid syndromesThyroid syndromes a) Hyperthyroidism a) Hyperthyroidism - overproduction of the thyroid - overproduction of the thyroid hormone or excessive thyroid hormone or excessive thyroid medicationmedication - often with generalized muscle weakness, - often with generalized muscle weakness, energetic, irritable, tachycardic, tremor energetic, irritable, tachycardic, tremor frequent defecation, wt. loss , inc frequent defecation, wt. loss , inc

appetiteappetite

b) Hypothyroidismb) Hypothyroidism

-due to iodine deficiency, deficit of TH,-due to iodine deficiency, deficit of TH,

excessive dose of thiouracil drugs, excessive dose of thiouracil drugs,

lithium, thiocyanates, lithium, thiocyanates, paraaminosalicylicparaaminosalicylic

acid, phenylbutazoneacid, phenylbutazone

- slow metabolism, fatigue, loss of - slow metabolism, fatigue, loss of energy, wt gain, constipation, coldnessenergy, wt gain, constipation, coldness

Lymph NodesLymph Nodes

Determine if the lymph node is Determine if the lymph node is localized to the neck or generalized localized to the neck or generalized in other parts of the bodyin other parts of the body

Acute cervical lymphadenopathyAcute cervical lymphadenopathy

1) Localized lymphadenitis1) Localized lymphadenitis

- common infections of the scalp, - common infections of the scalp, face, face,

mouth, teeth, pharynx or earmouth, teeth, pharynx or ear

Submental lymph nodes - primary lesions from the lower lip,

anterior tongue, floor of the mouth Posterior cervical lymph nodes and

occipital - primary lesions from the posterior

2/3 of the scalp and nasopharynx

Anterior cervical lymph nodes - primary lesions from anterior 2/3 of

the scalp, face including maxillary sinus, oral cavity ( tongue, tonsils, larynx)

2) Generalized lymphadenitis2) Generalized lymphadenitis

- syphilis- syphilis

- rubella- rubella

- IM- IM

- HIV- HIV

- Generalized Furunculosis- Generalized Furunculosis

Chronic localized cervical Chronic localized cervical lymphadenopathylymphadenopathy

a) TBa) TB

b) Hodgkin diseaseb) Hodgkin disease

c) actinomycosisc) actinomycosis

d) Virchow node ( sentinel node)d) Virchow node ( sentinel node)

-enlargement of a single lymph node-enlargement of a single lymph node

usually in the left supraclavicular usually in the left supraclavicular groupgroup

- it may be the result of either - it may be the result of either abdominal or thoracic malignancyabdominal or thoracic malignancy

Thank YouThank You

Definitions of Parts Shown AboveDefinitions of Parts Shown Above Helix - The in-curve rim of the external earHelix - The in-curve rim of the external ear Antihelix - A landmark of the outer earAntihelix - A landmark of the outer ear Lobule - A landmark of the outer ear. The very bottom part of the outer Lobule - A landmark of the outer ear. The very bottom part of the outer

earear Crest of Helix - A landmark of the outer earCrest of Helix - A landmark of the outer ear ExternalAuditory Meatus - or External Auditory Canal. The auditory canal ExternalAuditory Meatus - or External Auditory Canal. The auditory canal

is the channel through which the sounds are led from the ear outside to is the channel through which the sounds are led from the ear outside to the middle ear.the middle ear.

Eardrum - (tympanic membrane) A thin layer of skin at the end of the Eardrum - (tympanic membrane) A thin layer of skin at the end of the external ear canalexternal ear canal

Auditory Ossicles - The three small bones in the middle ear, know as the Auditory Ossicles - The three small bones in the middle ear, know as the hammer (malleus), anvil (incus) and stirrup (stapes) which are hammer (malleus), anvil (incus) and stirrup (stapes) which are connected to one another. Together these ossicles are called the connected to one another. Together these ossicles are called the ossicular chain. Their purpose is to lead the sound striking the eardrum ossicular chain. Their purpose is to lead the sound striking the eardrum further into the inner earfurther into the inner ear

Oval Window - An opening in the bone between the air filled middle ear Oval Window - An opening in the bone between the air filled middle ear cavity and the fluid filled inner ear, and is covered by a thin membranecavity and the fluid filled inner ear, and is covered by a thin membrane

Cochlea - Part of the inner ear that contains part of the hearing organs.Cochlea - Part of the inner ear that contains part of the hearing organs. Semicircular Canals - Part of the organ of balance that is part of the Semicircular Canals - Part of the organ of balance that is part of the

inner earinner ear Eighth Nerve - Nerve that transmits messages from the inner ear to the Eighth Nerve - Nerve that transmits messages from the inner ear to the

brain.brain. Eustachian Tube - A tube connecting the middle ear cavity and the Eustachian Tube - A tube connecting the middle ear cavity and the

pharynx (back of the throat). It can be opened by coughing or pharynx (back of the throat). It can be opened by coughing or swallowing, though it is normally closed. The occasional opening of the swallowing, though it is normally closed. The occasional opening of the Eustachian tube is necessary to equalize the are in the middle ear cavityEustachian tube is necessary to equalize the are in the middle ear cavity

Describe common changes with age Describe common changes with age that occur in the head and neckthat occur in the head and neck

Identify common abnormalities which Identify common abnormalities which may be found on examination of hair, may be found on examination of hair, scalp, skullscalp, skull

Identify the purpose of testing :Identify the purpose of testing :

visual acuityvisual acuity

visual fields by confrontationvisual fields by confrontation

Define exophthalmos and name 2 Define exophthalmos and name 2 possiblepossible

causescauses

Identify common abnormalities which may Identify common abnormalities which may be found in examination of:be found in examination of:

eyebrowseyebrows eyelidseyelids lacrimal apparatuslacrimal apparatus

Identify the potential significance of:Identify the potential significance of: yellow schlerayellow schlera pale palpebral conjuctivapale palpebral conjuctiva

Define or describe the ff: terms or tests Define or describe the ff: terms or tests related to eyesrelated to eyes

a) anisocoriaa) anisocoria b) miosisb) miosis c) mydriasisc) mydriasis d) direct and consensual reactionsd) direct and consensual reactions e) near reactione) near reaction f) tests for weakness or imbalance of the EOMf) tests for weakness or imbalance of the EOM g) nystagmusg) nystagmus h) lid lagh) lid lag

Be able to describe the ff: parts of the Be able to describe the ff: parts of the normal fundoscopic exam and identify normal fundoscopic exam and identify them if given a diagramthem if given a diagram

a) red reflexa) red reflex b) optic discb) optic disc c) physiologic cupc) physiologic cup d) arteriolesd) arterioles e) veinse) veins f)macula foveaf)macula fovea

Describe or identify each of the ff: Describe or identify each of the ff: and give its significanceand give its significance

a) normal blurring of the disc outline a) normal blurring of the disc outline on the nasal sideon the nasal side

b) differentiate arterioles from veinsb) differentiate arterioles from veins

c) absent red reflexc) absent red reflex

d) AV nickingd) AV nicking

Describe or identify the common Describe or identify the common abnormalities which may be found abnormalities which may be found in the PE of patients within the PE of patients with

a)a) Otitis mediaOtitis media

b)b) Otitis externaOtitis externa

c)c) Serous effusionsSerous effusions

d)d) Retracted drumRetracted drum

Describe the Weber and Rinne test. How they Describe the Weber and Rinne test. How they are used to distinguished between conductive are used to distinguished between conductive hearing loss and sensorineural hearing losshearing loss and sensorineural hearing loss

Describe or identify the common abnormalities Describe or identify the common abnormalities which may be seen in the nasal exam ofwhich may be seen in the nasal exam of

a) nasal mucosaa) nasal mucosa b) nasal septumb) nasal septum c) frontal and maxillary sinus (palpation, c) frontal and maxillary sinus (palpation, transillumination)transillumination)

Describe or identify common Describe or identify common abnormalities which may be found on abnormalities which may be found on examination of the mouth and pharynxexamination of the mouth and pharynx

List 6 characteristics which can be noted List 6 characteristics which can be noted in describing lymph nodesin describing lymph nodes

Identify potential significance of tender Identify potential significance of tender nodes, hard or fixed nodesnodes, hard or fixed nodes

Identify the significance of tracheal Identify the significance of tracheal deviationdeviation

Define GOITERDefine GOITER

Describe physical characteristics of Describe physical characteristics of the thyroid in the normal and the thyroid in the normal and abnormal statesabnormal states

Define the ff: termsDefine the ff: terms PtosisPtosis EctropionEctropion EntropionEntropion

Define the ff: termsDefine the ff: terms a) Pingueculaa) Pinguecula b) Sty( hordeolum)b) Sty( hordeolum) c) Chalazionc) Chalazion d) Xanthelasmad) Xanthelasma e) Episcleritise) Episcleritis f) Dacryocystitisf) Dacryocystitis

Describe the ff: common causes Describe the ff: common causes and presentation of red eyeand presentation of red eye

Define or identify the ff:Define or identify the ff:a)a) Corneal arcusCorneal arcusb)b) Corneal scarsCorneal scarsc)c) Pterygium Pterygium d)d) cataractcataract

Define the ff:Define the ff: a) anisocoria a) anisocoria b) Argyll Robertson pupilb) Argyll Robertson pupil c) oculomotor nerve paralysisc) oculomotor nerve paralysis d) strabismusd) strabismus

Describe the normal appearance and Describe the normal appearance and variation of the optic disc. Be able to variation of the optic disc. Be able to describe papilledema and glaucomatous describe papilledema and glaucomatous cuppingcupping

Describe the normal retinal arteries Describe the normal retinal arteries and AV crossings. Describe the and AV crossings. Describe the change that occur with HPN change that occur with HPN including:including:

a) narrowed light reflexa) narrowed light reflex

b) copper wire arteriesb) copper wire arteries

c) silver wire arteriesc) silver wire arteries

For each of the ff: identify physical For each of the ff: identify physical finding finding

and cause:and cause:

a) superficial retinal hemorrhagea) superficial retinal hemorrhage

b) deep retinal hemorrhageb) deep retinal hemorrhage

c) pre retinal hemorrhagec) pre retinal hemorrhage

d) microaneurysmd) microaneurysm

e) neovascularizatione) neovascularization

For each of the ff: identify physical For each of the ff: identify physical finding and cause:finding and cause:

a) cotton wool patcha) cotton wool patch

b) hard exudatesb) hard exudates

If a patient has a chief complaint of If a patient has a chief complaint of any one of the head, eyes, ears, nose any one of the head, eyes, ears, nose and throat (HEENT) symptoms, you and throat (HEENT) symptoms, you must generally ask all of the HEENT must generally ask all of the HEENT ROS questions.ROS questions.

The ears, nose, and throat are The ears, nose, and throat are anatomically connected, hence anatomically connected, hence infection or obstruction in one infection or obstruction in one structure can lead to illness or structure can lead to illness or symptoms in the otherssymptoms in the others

Facial painFacial pain

Trigeminal neuralgia (Tic Doulourex)Trigeminal neuralgia (Tic Doulourex)- Compression of the 5Compression of the 5thth nerve root by a nerve root by a

vessel or a neoplasmvessel or a neoplasm- 22ndnd maxillary division ,commonly maxillary division ,commonly

involvedinvolved- Light touch, chewing, sneezing Light touch, chewing, sneezing

provokes a paroxysmprovokes a paroxysm- Hot lancinating ,periodic, unilateral painHot lancinating ,periodic, unilateral pain

Herpes zosterHerpes zoster

- sharp , burning, unilateral pain - sharp , burning, unilateral pain along the distribution of a branch of along the distribution of a branch of the trigeminal nervethe trigeminal nerve

Other causes:Other causes: acute suppurative sinusitisacute suppurative sinusitis Orbital cellulitisOrbital cellulitis

Swelling of the faceSwelling of the face

ParotitisParotitis

Preauricular abscess and ulcerPreauricular abscess and ulcer

Masseter muscle hypertrophyMasseter muscle hypertrophy

AcromegalyAcromegaly

myxedema facemyxedema face

PtosisPtosis

Health & Medicine

Heent