Head and Neck Anatomy

Head Anatomical Structures

• The cranium includes the frontal, parietal, occipital, and temporal bones
• The face consists of 14 bones
• C7 vertebrae provide cervical support

Neck Anatomy and Function

• The neck serves as a conduit for blood vessels, muscles, nerves, lymphatics, and viscera
• Key muscles include the sternomastoid (for head and neck movement) and trapezius (for neck rotation)
• The thyroid gland is an endocrine gland with a rich blood supply, located in the middle of the neck, straddling the trachea
• The thyroid gland synthesizes and secretes thyroxine (T4) and triiodothyronine (T3) to stimulate cellular metabolism
• Thyroid dysfunction can lead to hypothyroidism or hyperthyroidism
• The thyroid cartilage forms the Adam's apple in men
• The hyoid bone is the first bone broken during strangulation

Lymphatic System of Head and Neck

• The lymphatic system drains excess interstitial fluid from the head and neck
• Lymph nodes filter lymph, engulfing pathogens
• Swollen lymph nodes can indicate infection
• Accessible examination areas for lymph nodes include the head/neck, arms, axillae, and inguinal area

Key Lymph Node Locations

• Pre-auricular lymph nodes are located in front of the ear
• Post-auricular lymph nodes are located behind the ear, near the mastoid process
• Occipital lymph nodes are located at the base of the skull
• Submental lymph nodes are located under the chin
• Submandibular lymph nodes are located halfway between the angle and tip of the mandible
• Jugulodigastric/Tonsillar lymph nodes are located at the angle where the jaw meets the neck
• Deep cervical lymph nodes are located under the sternomastoid muscle
• Posterior cervical lymph nodes are located along the edge of the trapezius muscle
• Supraclavicular lymph nodes are located above the clavicle in the groove

Lymph Node Palpation Technique

• Gentle circular motion should be used to palpate lymph nodes
• Begin palpation with the pre-auricular nodes
• Palpate with both hands (except for the submental nodes) to compare sides
• Ask the patient to tip their head toward the side when palpating the deep cervical chain
• When palpating the supraclavicular nodes, ask the patient to hunch their shoulders
• Enlarged lymph nodes may indicate acute infection, chronic inflammation, cancer, or autoimmune disease

Trachea Assessment

• A normal trachea should be midline
• Palpate the trachea by placing an index finger in the tracheal notch
• Tracheal shift (an abnormal finding) happens when the trachea is pushed to one side
• Causes of tracheal shift include aortic aneurysm, tumors, thyroid enlargement, and pneumothorax

Thyroid Assessment Approaches - Posterior Approach

• The examiner stands behind the patient
• The patient slightly bends their head forward
• Use fingers to gently push the trachea
• Ask the patient to swallow water to observe thyroid movement

Thyroid Assessment Approaches - Anterior Approach

• The examiner stands facing the patient
• The patient tips their head forward and to the right
• Use the examiner's right thumb to displace the trachea
• Palpate using the examiner's left hand

Thyroid Palpation

• The thyroid is normally not palpable
• For enlarged thyroids, listen for bruits (soft, pulsatile whooshing sound) using the bell of a stethoscope

Developmental Considerations for Infants and Children

• Measuring head size is important up to 2 years of age for infants
• The anterior fontanel closes between 9 months and 2 years
• The posterior fontanel closes by 1-2 months
• The neck is normally short and lengthens during the first 3-4 years
• Lymph nodes are not usually palpable in infants, but may be palpable in children
• The thyroid may or may not be palpable.

Developmental Considerations for Aging Adults

• Facial bones become more prominent due to loss of subcutaneous fat
• Facial skin sags because of decreased elasticity
• The lower face may appear smaller if teeth are lost
• The neck can lengthen due to muscle atrophy and fat loss
• Senile tremors (head nodding and tongue protrusion) may develop

Subjective Data Collection

• Inquire about headaches, assessing severity, character, duration, onset, and associated factors
• For head injuries, determine if there has been a loss of consciousness (LOC)
• Inquire about dizziness/vertigo and its impact on daily activities, along with any fall risk
• Assess neck pain by assessing limitation of motion
• Inquire about any dysphagia (difficulty in swallowing) and prioritize assessment in stroke patients
• Obtain the patient's surgical history and note any neck surgeries or disfigurements

Objective Assessment

• Inspect the skull for size, shape (normocephalic), contour, deformities, and hair distribution
• Assess facial expression (happy, sad, crying)
• Assess symmetry of eyebrows and nasolabial folds
• Check for involuntary movements

Objective Neck Assessment

• Note the neck's position, range of motion, and any enlargement
• Palpate the neck for any lumps or masses
• Assess the presence of lymphadenopathy
• Assess tracheal position
• Palpate the thyroid gland
• Auscultate the thyroid for bruits

Abnormal Findings - Size/Contour Abnormalities

• Hydrocephalus involves excessive CSF accumulation
• Paget's disease involves disrupted bone tissue replacement
• Acromegaly involves excessive growth hormone from the pituitary, causing enlarged skull and facial bones

Abnormal Findings - Swelling

• Goiter indicates multiple nodules indicating inflammation, often from iodine deficiency
• Thyroid nodules present as abnormal growths on the thyroid
• Parotid gland enlargement is commonly associated with mumps (viral infection of salivary glands)

Neurological/Chronic Conditions

• Bell's Palsy causes facial asymmetry and a painful smile
• Stroke presents facial asymmetry, weakness, and dysphagia (risk for aspiration)
• Parkinson's Syndrome causes tremors
• Cushing Syndrome causes characteristic facial features
• Cachectic Appearance includes sunken eyes and hollow cheeks (seen in cancer, HIV)
• Scleroderma is a chronic hardening of skin and connective tissue

Patient Education

• Teach patients to buy salt with iodine to prevent thyroid issues
• Implement fall precautions for patients with dizziness
• Never offer food or drink when there is a possibility of stroke due to aspiration risk

Structure and Function - Nose

• The nose is the first segment of the respiratory system
• The nose warms, moistens, and filters inhaled air
• The nose is a sensory organ of smell, innervated by cranial nerve I
• The external nose and nasal cavity are divided by the septum
• Turbinates (superior, middle, inferior) are bony projections, 3 per side
• Paranasal sinuses include the frontal, maxillary, ethmoid, and sphenoid sinuses

Structure and Function - Mouth

• The mouth is the first part of the digestive system and is used for respiratory functions
• The mouth contains taste buds and aids in speech production
• The hard palate is made of bone and appears whitish
• The soft palate is made of muscle, is pinker, more mobile
• The uvula is a free projection hanging from the middle of the soft palate
• The tongue is a mass of striated muscle with a crosswise pattern for side-to-side movement
• Salivary glands include the parotid (within the cheeks), submandibular (floor of mouth, beneath the mandible), and sublingual (floor of mouth, under the tongue) glands
• Adults have 32 permanent teeth

Structure and Function - Throat

• The pharynx is located behind the mouth and nose
• The nasopharynx is continuous with the oropharynx and is located behind the nasal cavity
• The oropharynx is located below the nasopharynx and is separated from the mouth by folds of tissue
• Tonsils are lymphoid tissue that enlarge during childhood and puberty, then involute
• The pharyngeal tonsils (adenoids) and eustachian tube openings are located in the nasopharynx

Developmental Care - Aging Adults (after age 60)

• Diminished smell and taste occur due to lose of nerve fibers
• Decreased appetite can cause malnutrition
• Atrophic tissues and dental changes occur
• Tooth loss can cause temporomandibular joint (TMJ) pain and osteoarthritis
• Dental issues may cause eating softer, high-carbohydrate foods
• Decreased intake of protein increases risk of nutritional deficiencies
• Loss of subcutaneous tissue can affect denture fit

Subjective Data (Health History Questions) - Nose

• Color and consistency of discharge (watery, purulent, mucoid, bloody) should be assessed
• The frequency and severity of colds should be noted
• Determine the presence of sinusitis and if applicable, the treatment methods
• Ask about any history of nasal trauma and whether the patient can breathe through the nose
• Determine epistaxis (nosebleeds) frequency, amount, color, and triggers
• Ask about allergies, triggers, and management methods
• Assess for any altered sense of smell

Subjective Data (Health History Questions) - Mouth and Throat

• Duration, recurrence, triggers (e.g., stress, seasonal changes, food) of sores or lesions in the mouth and throat should be assessed
• Frequency, associated symptoms, and treatment of any sore throat should be noted
• It is important to determine any bleeding gums and duration
• Assess toothaches: sensitivity to temperature and any tooth loss
• The duration and any associated symptoms of hoarseness should be assessed
• Inquire about dysphagia: difficulty swallowing, location of obstruction, and pain
• Find out if there is any altered taste
• Smoking/alcohol consumption: type, frequency, and duration should be assessed
• Determine self-care behaviours: brushing, flossing, dental exams, and denture care

Objective Data (Physical Examination) - Preparation

• Position the patient sitting upright with their head at the same level as the examiner's eyes
• You will need an otoscope with nasal speculum, penlight, tongue blades, gauze, gloves
• Ask your patients with dentures to remove them (place in towel to prevent damage)

Nose Examination

• Inspect the external nose for symmetry, deformities, and inflammation
• Assess patency using the sniff test (occlude one nostril at a time)
• Examine the nasal cavity using an otoscope or penlight
• Observe the color of the mucous membrane (it should be dry, redness may indicate infection)
• Check for any septum deviation
• Palpate the frontal sinuses (under the eyebrows) and the maxillary sinuses (below the cheekbones)

Mouth Examination

• Inspect the lips for color, moisture, cracking, and lesions
• Lips should be pink in white individuals, but may be bluish/darker in African-American or Mediterranean individuals
• Examine teeth and gums for condition, looseness, and positioning
• Gums should be pink
• Observe the tongue for color (should be pink and even), surface characteristics, and moisture
• Check the buccal mucosa (inside of cheeks) - should be pink and free of nodules or lesions
• Examine the hard and soft palate (roof of mouth)
• Observe uvula movement when the patient says "ah" - it should rise and fall

Throat Examination

• Use a tongue blade to visualize tonsils and the posterior pharyngeal wall
• Tonsil grading:
  • 1+: visible
  • 2+: halfway
  • 3+: touching uvula
  • 4+: touching each other
• Assess the gag reflex (cranial nerve X) by touching the posterior pharynx

Developmental Considerations - Infants and Children

• Infants are obligate nose breathers
• Nasal flaring indicates respiratory distress
• Sucking tubercle (callus on upper lip) is normal, caused by friction from feeding

Developmental Considerations - Aging Adults

• Nasal prominence increases due to loss of subcutaneous tissue
• The teeth may exhibit yellowing
• Gums might be receded

Abnormal Findings - Nose Abnormalities

• Perforated septum is a hole in the septum, often from cocaine use, chronic infections, trauma, or nasal surgery
• Epistaxis is nosebleeds
• Can also occur with foreign bodies

Nose Abnormalities

• Acute rhinitis
• Allergic rhinitis
• Sinusitis
• Nasal polyps
• Carcinoma

Lip Abnormalities

• Cleft lip is a congenital deformity that could be related to maternal use of phenytoin, alcoholism, or diabetes
• Herpes simplex I presents common cold sores, vesicles with red base
• Angular cheilitis (stomatitis) involves fissures at corners of the mouth that may be a result of vitamin B12 deficiency
• Carcinoma
• Mucocele

Teeth and Gum Abnormalities

• Malocclusion
• Dental caries
• Gingival hyperplasia occurs as painless enlargement of gums, can also occur during puberty, pregnancy, leukemia, or phenytoin use
• Gingivitis results in red, swollen gums that bleed easily

Oropharynx Abnormalities

• Cleft plate is a congenital defect
• Bifid uvula, making the uvula appear sliced open, affect the speech development
• Oral Kaposi's sarcoma may be a lesion that can be a sign of progression of AIDS
• Acute tonsillitis and pharyngitis give the throat a red shine, and can give way to swollen glands as well as either a white or yellow exudate

Clinical Implications

• Proper assessment helps identify nutritional deficiencies in older adults
• Early detection of oral lesions can be critical for diagnosing systemic conditions
• Understanding normal variations across different age groups and ethnicities is essential
• Thorough history taking is crucial for identifying potential causes of symptoms

Anatomical Overview - Abdomen

• The abdomen is a large oval cavity extending from the diaphragm down to the pelvic brim, bordered by the vertebral column and paravertebral muscles at the back, and by the lower rib cage and abdominal muscles at the sides and front.

Structure and Function - Abdomen

• Viscera: All internal organs
  • Solid viscera: *Liver, pancreas, spleen, adrenal glands, ovaries, and uterus
  • Hollow viscera: Stomach, gallbladder, small intestine, colon, and bladder (shape depends on contents)

Abdominal Quadrants and Contents

• Right Upper Quadrant (RUQ): Liver, gallbladder, duodenum, head of pancreas, right kidney, hepatic flexure of colon, parts of ascending and transverse colon
• Right Lower Quadrant (RLQ): Cecum, appendix, right ovary and tube, right ureter, right spermatic cord
• Left Upper Quadrant (LUQ): Stomach, spleen, left lobe of liver, body of pancreas, left kidney, splenic flexure of colon, parts of transverse and descending colon
• Left Lower Quadrant (LLQ): Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord

Abdominal Regions

• Epigastric: Upper middle region
• Umbilical: Middle region around the navel
• Hypogastric/Suprapubic: Lower middle region

Assessment Techniques - Abdomen

Subjective Data Collection

Health History Questions

• Inquire about changes in appetite and in the patient's weight (gain or loss)
• Ask about difficulty swallowing (dysphagia)
• Inquire about specific food intolerances and allergies
• Ask about abdominal pain: location, character, timing, relation to meals
• Ask about nausea or vomiting: frequency, content, color
• Inquire about normal bowel habits for the patient (frequency, color, consistency, diarrhea, constipation)
• Ask about use of laxatives or aids for digestion
• Observe any signs in the stool of GI bleeding such as black or tarry stools
• Observe bright red blood in stool (potential hemorrhoids or lower GI bleeding)

Past Medical History

• Inquire about any gastrointestinal disorders
• Discuss any history of hepatitis or cirrhosis
• Ask about any abdominal or urinary tract surgeries
• Discuss any history of urinary tract infections
• Discuss any other major illnesses

Personal and Social History

• Ascertain menstrual history for females
• Ask about alcohol intake
• Ask about smoking habits
• Clarify if there are any stressful events
• Inquire about possible exposure to infectious diseases
• Determine if there is any trauma history
• Ask about use of street drugs
• Conduct a nutritional assessment through obtaining a 24-hour recall of food consumption

Cultural Considerations

• Lactose intolerance can be as high as 70-90% in Blacks, Native Americans, Asians, and Mediterranean groups
• Chronic liver disease has a higher prevalence in Hispanic and African-American populations

Objective Data Collection

Preparation for Assessment

• Expose only the abdomen
• Encourage the patient to completely empty their bladder
• Have the patient lie supine with their knees elevated using a pillow in order to relax the abdominal muscles
• Be sure to advise that the patient does not to put arms over their head during the inspection (tenses abdominal muscles)
• Make sure to examine any painful areas last
• Make utilization of distraction techniques for relaxation to reduce anxiety
• Advise the patient of the reasoning for doing the specific procedures to help reduce anxiety as well

Inspection

• The skin should be free of scarring, excessive veins, or any hyper/hypo-pigmentation as well as striae (stretch marks)
• The contour's should be flat, scaphoid (curved inward), rounded, or protuberant (distended)
• Note symmetry's for any protrusions (hernias)
• Usually, the umbilicus should be in the midline and inverted (may be everted in pregnancy)
  • Abnormal findings: Bulging (umbilical hernia), discoloration (Cullen's sign - bluish discoloration indicating intraperitoneal bleeding)
• Pulsations or movement can be seen, but mainly in thin patients

Auscultation (should be performed before doing percussion and palpation)

• Observe and asses bowel sounds:
  • Normal: Irregular clicks and gurgles occurring 5-30 times per minute
  • Hypoactive: Decreased motility (inflammation, post-surgery, late bowel obstruction)
  • Hyperactive: Increased motility (diarrhea, early mechanical bowel obstruction)
  • Listen for at least 5 minutes before declaring sounds absent
  • Listen in all four quadrants
• Observe and asses vascular sounds:
  • Use the bell of the stethoscope
  • Listen over the aorta (2cm above umbilicus), renal arteries, iliac arteries, and femoral arteries
    • Bruits: Swishing sounds indicating stenosis, partial occlusion, or aneurysm
    • Friction rubs: Rough, grating sounds indicating peritoneal inflammation
    • Venous hum: Medium-pitched continuous sound with palpable thrill

Percussion

• General Tympany should be percussed lightly in all four quadrants
• Tympany: Normal sound over hollow organs
• Dullness: Should be percuted over solid organs (liver, spleen) or fluid-filled structures
• Hyperresonance: Comes over gaseous distention
• Liver Span should be measured from the patient's 6th to 8th intercostal space
  • Normal: 4-8 cm in midclavicular line and between 6-7 cm on right midclavicular line
• Spleinic Dullness is not usually palpable unless enlarged
  • A normal spleen to only be palpable must typically be 3 times the normal size
• Checking Costovertebral Angle Tenderness: Percuss over the kidney area (12th rib)
  • Pain indicates there is possible Kidney inflammation or otherwise infection

Special Procedures

• Ascites Assessment (free fluid in peritoneal cavity):
  • Fluid Wave: Place hand on one side of abdomen, tap other side
  • Testing for wave of Shifting Dullness: Percuss for dullness, have patient turn to side, and percuss again

Palpation

• Begin from the light palpation:
  • Use your first 4 fingers, depress skin no more then 1 cm
  • Asses skin for any signs of tenderness or muscle resistance
• Proceed to deep palpation:
  • Depress skin typically as far as 5-8 cm (2-3 inches)
  • After depressing the skin, asses for masses of any kind as well as any organ abnormal enlargement
• Proceed with specific Organ specific Palpation:
  • For the Liver: Use hooking technique at right costal margin
  • Spleen assessment: Should typically never be generally palpable and should never asses if there has been considerable suspected trauma (risk of rupture)
  • Kidneys: Check utilizing the Bimanual technique to ensure proper kidney function
  • Lastly, check for normal aorta sounds: Normally 2.5-4 cm wide, as well as make certain it may not be widened with aneurysm

Abnormal Findings

• Enlarged liver may indicate Smooth and non-tender (fatty infiltration)
• Enlarged gallbladder may suggest: acute cholecystitis or obstruction
• Enlarged spleens can be indicators of infection (mononucleosis), trauma, or neoplasm
• Aortic aneurysm which can located around he renal arteries. extending into iliac arteries
  • Do not palpate if aneurysm suspected

Special Tests

• *Rebound tenderness (Blumberg's sign): Press opposite side, pain on release indicates peritoneal inflammation also appendicitis
• Assess Murphy's sign for indication of assessment of gallbladder inflammation
• Iliopsoas muscle test for assessment of whether there is appendicitis
• Using palpitation assess theObturator test to asses if there may be indication of appendicitis

Summary of Assessment Sequence

1. Inspect contour, symmetry, umbilicus, skin, pulsations
2. Auscultate bowel sounds and vascular sounds
3. Percuss all four quadrants, liver, and spleen
4. Palpate all four quadrants, liver, spleen, and kidneys

Anatomical Landmarks and Structure

• Suprasternal notch
• Sternum
• Sternal angle (key landmark for numbering ribs)
• Xiphoid process
• Costal angle (normally 90 degrees, can increase with chronic over-inflation)

Posterior Landmarks

• Vertebra prominens (C7 spinous process)
• Spinous processes
• Inferior border of scapula
• 12th rib

Reference Lines

• Anterior: midclavicular, midsternal
• Posterior: vertebral, scapular
• Lateral: anterior axillary, mid-axillary, posterior axillary

Lung Lobes

• The right lung contains a: upper, middle, and lower lobes
• The left lung contains a: upper and lower lobes

Respiratory System Structure and Function

• Visceral pleura: lines the outside of the lung
• Parietal pleura: lines the inside of the chest wall and diaphragm

Tracheal and Bronchial Tree

• Trachea divides into right and left main bronchi below the sternal angle
• The right bronchus is shorter, wider, and more vertical then the left
• Serves the function to: transports gases and protects airways from particles via mucus and cilia

Respiratory Functions

• Provides oxygen and removes CO2
• Maintains acid-base balance
• Assists with heat exchange
• Normal AP to transverse diameter ratio is 1:2

Control of Respiration

• Is Mediated by the respiratory center in the brainstem
• The normal stimulus to breathe is increased CO2 in the blood

Developmental Considerations

Infants and Children

• You need Surfactant (complex lipid substance) for proper alveolar inflation
• It is presented at 32 weeks gestation
• The respiratory system develops in utero but doesn't function until the baby is born
• A child is more vulnerable to respiratory issues due to small size and immature pulmonary system
• Exposure to smoke increases health risks