Head and Neck Assessment Study Notes

• Study notes on head and neck topics

Children: Skull

• Transilluminate the skull in infants
• Infant head circumference should be 2 cm greater than chest circumference up to age 2.
• The posterior fontanel closes around 2 months.
• The anterior fontanel closes between 12-15 months.
• There should be no tenderness, depressions, sunken areas, swelling, bulging, or depressed fontanels.

Macewen Sign

• Percussion near the junction of the frontal, temporal, and parietal bones produces a stronger resonant sound.
• This sound is considered physiologic when fontanels are open
• A higher resonant sound heard after fontanels are closed could indicate hydrocephalus, brain abscess, or increased intracranial pressure (ICP), which would be considered pathologic.
• It sounds like a cracked pot.
• Bruit over temples and eyes is physiologic in children up to age 5.

Neck

• The thyroid gland may be palpable, but not tender.

Normal Findings in the Older Adult

• Rate of T4 production and degradation decreases with aging
• The thyroid gland becomes more fibrotic.
• Faces of older adults vary with their nutritional status, eyes may appear sunken with soft bulges and eyelids may appear wrinkled and hang loose
• Alopecia is hair loss.
• Tinea capitis is a fungal infection of the scalp that can cause hair loss.

Symmetry

• The face is slightly asymmetrical, but observe for significant asymmetry

Abnormal Symmetry: CN V - Trigeminal

• Palpate the jaw for tone and strength; ask the patient to clench teeth and assess for fasciculations
• Assess for pain, touch, and temperature
• Trigeminal Neuralgia, also known as Tic Delaroux, causes pain coming from the trigeminal nerve

Problems with CN VII - Facial

• Ask the patient to smile, frown, and puff out the cheek
• This is associated with Bell's Palsy

Facial Spasm

• Percuss the masseter muscle and observe for spasms.
• These spasms are known as Chvostek's Sign.
• This sign is for hypocalcemia.
• Also check for hypoparathyroidism

Auscultate Temporal Artery

• Should be negative for bruit
• A bruit could indicate expanding aneurysm, vascular anomaly, or temporal arteritis. _ Bruits should not be heard in neonates or older adults but can be common in childhood

Thyroid

• If FIRM on palpation it could indicate Hashimoto's Thyroiditis, malignancy, or benign or malignant nodules.

• Hashimoto's is where the body attacks the thyroid, resulting in hypothyroidism

• Hypothyroidism is an underactive thyroid

• In primary cases the thyroid gland produces insufficient amounts of thyroid hormone

• In secondary cases there's insufficient thyroid secretion due to inadequate secretion of TSH or TRH

• Subjective issues include weakness, weight gain, constipation, fatigue, and cold intolerance

• Dementia, ataxia, and carpal tunnel are subjective issues in older adults

• Objective issues include a normal size thyroid, goiter, or nodules, elevated TSH, and decreased T3/T4

• Myxedema coma occurs in severe untreated cases.

• This is severe hypothyroidism.

• Subjective: cognitive impairment and slowed mentation

• Also poor concentration, short term memory loss, social withdrawal, apathy, depression, and increased infections (pneumonia)

• Objective: dull, puffy, yellow skin, coarse, sparse hair, temporal loss of eyebrows, and periorbital edema

• A prominent tongue and hypothyroiditis are objective signs

• SOFT on palpation or BRUIT is heard over the thyroid could indicate Graves or Hyperthyroidism

• Graves' Disease is an autoimmune disease where the body attacks the thyroid and directly affects TSH, results in over active thyroid

• Subjective: Symptoms of hyperthyroid, Palpitations, Tachycardia, Heat intolerance, Weight loss, Fatigue, and Increased appetite

• Objective: A diffuse thyroid enlargement - GOITER, Exophthalmos, Startled or staring expression, Fine, moist skin, Fine hair, Weak muscles, and Tachycardia

• Hyperthyroidism is an overactive thyroid

• There are multiple causes including malignancy, medications, or inflammation of the thyroid

• Subjective: Weight loss, Tachycardia, Diarrhea, Heat intolerance and Decline in functional capacity, loss of appetite, and CHF for older adults

• Objective: Normal size thyroid, goiter, or nodules, fine hair, brittle nails, exophthalmos, Tachycardia, and Lid lag/lid retraction

Lymphatics in Children

• Occipital and Postauricular
• Small, Firm, Discrete, Nontender, and NONmovable
• Inguinal and Popliteal
  • Small, firm, and discrete

Normal Findings in Older Adults

• Number of lymph nodes diminishes and size may decrease
• Nodes more likely to be fibrotic and fatty contributing to an impaired ability to resist infection

Physical Assessment Findings

• Disorders of the lymph system present with 3 signs:
• Lymphadenopathy: enlarged lymph nodes
• If this is widespread = systemic disease
• Lymphangitis: red streaks on the overlying skin inflamed and enlarged lymph nodes
• Lymphedema: edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage
• Lymphangioma: congenital malformation of dilated lymphatics
• A node fixed to surrounding tissues is cause for concern
• When enlarged lymph nodes are encountered, explore the area adjacent and regions drained by those nodes for signs of possible infection or malignancy
• Shorty nodes: small nontender nodes that feel like BB's or buckshot under the skin
• Generally, no clinical consequence and usually represent enlargement after a viral infection
• The more tender a node, the more likely there is an inflammatory process
• Virchow node: palpable supraclavicular node on the left is a significant clue to thoracic or abdominal malignancy
• Bacterial infections: Nodes may become warm or tender, and matted

Respiratory for Older Adults

• Barrel chest occurs from loss of muscle strength in the thorax and diaphragm
• Loss of lung resiliency
• Stiffing and decreased expansion of the chest wall
• Alveoli less elastic and more fibrous
• Decreased alveolar surface for gas exchange
• Loss in strength of the muscles for respiration = underventilation of the alveoli in the lower lung fields (decrease vital capacity, increase in residual volume)
• Drier mucous membranes, less able to clear mucus

Shortness of Breath

• Orthopnea: SOB that begins or increases when the pt lies down
• Ask whether the patient needs to sleep on more than one pillow and if that helps
• Paroxysmal Nocturnal Dyspnea: A sudden onset SOB after a periods of sleep
  • Sitting upright is helpful
• Platypnea: Dyspnea increases in the upright position

Physical Assessment Findings

• Barrel chest results from compromised respiration, and Ribs being more horizontal
• Also the Spine is kyphotic and the sternal angle is more prominent
• Trachea may be displaced posteriorly
• Crepitus: Crackly or crinkling sensation
  • Can be both palpated and heard
  • Indicates air in the SUBQ tissue from a rupture somewhere in the respiratory system or by infection
• Pleural friction rub: Coarse, grating vibration usually on inspiration and c/b inflammation or the pleural spaces
• Hyperresonance: Associated with hyperinflation
  • May indicate emphysema, pneumothorax, and asthma
• Dullness/flatness with percussion
  • May indicate pneumonia, atelectasis, pleural effusion, and asthma Descent of diaphragm may be limited by pulmonary/abdominal processes, or superficial pain
• Breath sounds
  • Vesicular: low pitch/intensity-heard over healthy lung tissue
  • Bronchovesicular: moderate pitch/intensity- heard over major bronchi (abnormal if heard over peripheral lung tissue)
  • Bronchial: high pitch/intensity- heard over the trachea (abnormal if heard over peripheral lung tissue)
  • Fine crackles: high pitched, discrete, discontinuous crackling sounds heard during the end of inspiration- not cleared by a cough This is c/b disruptive passage of air through the small airways
  • Medium crackles: lower, more moist sound heard during the mid-stage of inspiration - not cleared by a cough
  • Coarse crackles: loud, bubbly noise, heard during inspiration- not cleared by a cough
  • Rhonchi: loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration- coughing may clear which usually means mucus accumulation -c/b passage of air through an airway obstructed by thick secretions, muscular spasm, tumor, or external pressure
  • Wheeze: musical noise most often heard continuously during inspiration or expiration, usually louder on expiration -c/b high velocity airflow through a narrowed or obstructed airway - the longer the wheeze and the higher the pitch the worse the obstruction
    • Pleural friction rub: dry, rubbing, or grating sound, c/b inflammation, heard during inspiration or expiration, loudest over lateral anterior surface

Vocal resonance

• Bronchophony: greater clarity and increased loudness of spoken sounds
• Whispered pectoriloquy: where the whispered voice can be heard clearly and intelligibly
• Egophony: intensity of spoke voice if increase and there is a nasal quality
• these changes may be present in any condition that consolidates lung tissue*

Respiratory Abnormalities

• Asthma -Small airway obstruction due to inflammation of the airways and acute episodes are triggered by allergens
  • Results in mucosal edema, increased secretions, and bronchoconstriction with increased airway resistance and impeded respiratory flow
• Subjective data: Episodes of paroxysmal dyspnea with CP. Episodes can last for mins, hrs, days but
• Subjective data: may be asymptomatic between episodes
• Tachypnea and paroxysmal coughing with wheezing on inspiration/expiration
• Objective data: Prolonged expiration with labored breathing/fatigue/anxious expression, Hypoxemia, and Decreased peak expiratory flow rate Also has Nasal flaring/retractions, diminished fremitus and Hyperresonance with percussion occasionally
• Bronchitis
  • Inflammation of the large airways; Acute: fever/CP Subjective data: Chronic: productive cough
  • Hacking nonproductive cough with minimal auscultation findings or no respiratory distress
  • Objective data: Greater involvement may lead to wheezing or dampened auscultation of involved areas
• Pleurisy
  • Inflammatory process involving the visceral and parietal pleura
  • Result of PE or infection, connective tissue disease, and tumor

Cardiac Cycle

• Systole: ventricles contract and eject blood
• As systole begins ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valve closed and which produces the 1st heart sound: S1(lub)
• Intraventricular pressure rises until it exceeds that in the aorta and pulmonary artery. Then the aortic and pulmonic valves are forced open
• When the ventricles are almost empty the pressure in the ventricles falls below that of the aorta and pulmonary artery, allowing the aortic and pulmonic valves to close which causes the second heart sounds: S2(dub)
• As ventricular pressure falls below atrial pressure, the mitral and tricuspid valves open
• Diastole: ventricles dilate drawing blood into the ventricles as the atria contract
  • Then atria contract to ensure This can sometimes be heard as a 4th sound: S4

Older Adults - Cardiac

• Heart size may decrease unless HTN or heart disease causes enlargement
• Left ventricular wall thickens and valves tend to fibrose and calcify
• Decrease in atrial elasticity, increase in atrial stiffness
• Stroke volume decreases and cardiac output during exercise decreases with Myocardium less elastic and more rigid;
• Frailty syndrome is d/d of weakness, slowing, decreased energy, lower activity, unintended weight loss with
• Frailty syndrome- Apical pulse is harder to find

Cardiac - Comparing Origins of CP

• Cardiac: Vague Onset and r/t food consumption or psychosocial stress
• GI: May go on for several hours regardless of effort with
• GI- Pt's can often continue activity, It's relieved at other times with antacids and No particular relationship to time of day, it's related with food/tension

CP - Physical Assessment Findings

• Apical impulse may be visible but is easily obscured by large breasts or obesity
• Splitting: occurs when the mitral/tricuspid or pulmonic/aortic valves do not close simultaneously

Cardiac - Cardiac Examination

• 5 Areas for Listening to the Heart
  • Aortic Right 2nd Intercostal Space
  • Pulmonic Left 2nd Intercostal Space
  • ERB'S POINT Left 3rd Intercostal Space
  • TRICUSPID Lower Left Sternal Border 4th Intercostal
  • MITRAL Left 5th

Systolic Murmurs

-Aortic stenosis

• Calcification of valve cusps restricts forward flow and Forceful ejection from ventricle into systemic circulation with
• Calcification of valve cusps is heard best @right 2nd intercostal/aortic area with pt leaning forward. Murmur is harsh, loud and associated with thrill It may radiate to carotid, left sternal border and apex and there is a Early ejection click

Cardiac - Pulmonic Stenosis

-Valve restricts forward flow, forceful ejection from ventricle into pulmonary circulation, C/B: Also has Dyspnea, cyanosis, syncope on exertion, palpitations, RHF. S2 often diminished with click,

Mitral Regurgitation

• Valve incompetence allows backflow from ventricle to atrium, and if Often occurs with Mitral

Mitral Characteristics

• Heard best @ apex,
• SD: Dyspnea, Palpitations, A-fib with

Diastolic Murmurs

• Mitral Stenosis; Arterial pulse amplitude is increased + with Loud S1

Cardiac - Cardiac Abnormalities

• Angina; SD: Substernal pain or intense pressure radiating to neck/jaw/arms; is to find pain or intense pressure radiating to neck/jaw/arms accompanied by with
• Ischemia may lead to crackles due to of S4; and Other and (COPD, and (COPD, HTN,, murmurs)
• Pericarditis: may get is worse may get; SOB with lying down, to the is with Scratchy

Cardiac - Heart Sounds

• Fixed Splitting of S2: RV failure
• Wide splitting of S2: aortic valve s/t LBBB

Cardiac - Heart Rhythms

• The Sinoatrial Node (SA Node), the Normal Sinus Rhythms - but originates Sinus Tachycardia: HR greater than atrium from the 100; or Movement Asystole
• There and that is but; and that is with Asystole

Blood Vessels- JVP and Pressure

• Pressure :

• Signs (Jugular Veins); distension of jugular. jugular.

• Artery's are Arterial walls lose elasticity and vasomotor tone and is found with

• PAD Stenosis of the blood supply to the

• Many of the cases of is predictable; with Extremities by is

Blood Vessels - SD

• Pain in muscle with Atheriosclerosis
• OD: Limb appears healthy A: (S/S/S) Venous and is (S/S/S) Venous and is and Minimal ankle edema

Cardiac - Venous Insufficiency

• Symptoms may improve that with of to of

Cardiac - Venous Insufficiency

• Edema is usually for a with A) Varicose veins
• Dry skin, hyperkeratotic is found on,
• SD are due or and Skin and (S/S/S) Venous and is is and Minimal ankle edema
• SD (Signs, and SD (Signs, and SD(Signs, and

SD (SD) Signs and

• Skin, hair, and nails, 1Normal Changes and 24Physical

Skin and Nails - Examination

• Skin, hair, and nails, 1Normal Changes and 24PhysicalExamination
• Nails usually become long, and
• Always asses skin

Nail Examination (Onychodystrophy) in elderly

• May Loose ability to
• MayLoose ability to
• Skin and nails,

Abnormal Nails

• Inflammatory
• Acute
• Skin and
• Examination are red, is with with skin

Additional points

-Nodules usually have and more to the and on of examination,

• Vesicles are and, Skin

Skin Cancer Risk Factors

• Age > 50

• Repeated trauma

• Sun burn to skin -Exposure to arsenic Skin Examination should examine and assess ALL

  Abnormalities of skin - a) Examination (with infection Examination always include that skin of any type to to

Concise study notes on head and neck assessments, covering skull transillumination in infants, fontanel closure, and the Macewen sign. Includes normal and pathological findings, as well as neck examinations and considerations for older adults.