Physical Examination and History Taking PDF

Physical Examination and History Taking: Comprehensive Assessment of the Adult DR. ROMEO T. CRUZ, JR.  Objectives At the end of this unit students will be able to: Organize patient’s health history Determine the sequence of physical examination Identify techniques o...

Physical Examination and History Taking: Comprehensive Assessment of the Adult DR. ROMEO T. CRUZ, JR.  Objectives At the end of this unit students will be able to: Organize patient’s health history Determine the sequence of physical examination Identify techniques of examination for each component of the physical examination Patient Assessment:  Subjective Data What the patient tells you The history, from Chief Complaint through Review of Systems  Objective Data What you detect through observation and obtaining medical history All physical examination findings  Health History Contains 7 components: 1. Identifying Data and Source of the History 2. Chief Complaint 3. History of Present Illness 4. Past Medical History 5. Family History 6. Personal and Social History 7. Review of Systems  1. Identifying Data Identifying Data – demographics, ie. age, gender, occupation, etc. Source of History – usually the patient, but can be a family member or friend, letter of referral, or the medical record Note: Reliability of information varies according to patient’s memory, trust, reason for visit, and mood  Date and Time Everything!!! Be sure to document the date and time that you evaluate the patient, especially in urgent and emergent settings.  2. Chief Complaint The patient’s reason for coming to the clinical setting today. One or more symptoms or concerns that caused the patient to seek medical care  Chief Complaint: Quote the Source of Information! When possible quote the patient in their own word. This means this should be written in quotation marks. If the patient is not the one you are obtaining information from quote them.  3. History of Present Illness; Amplifies the Chief Complaint; describes how each symptom developed Includes patient’s thoughts and feelings about the illness Answers the question: What led up to the patient’s current state of health? Chronologic account of progress of patients symptoms  History of Present Illness Narrative should include: The onset of the problem The setting in which it has developed Manifestations Treatments attempted Answers question: Did anything make it better or worse?  4. Past Medical History List childhood illnesses List adult illnesses and surgeries with dates Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety Hospitalizations Psychiatric illnesses and time frame, diagnoses, hospitalizations, and treatment Immunizations - Find out whether the patient has received vaccines for: Tetanus Hepatitis A Pertussis Hepatitis B Diphtheria Pneumococci Polio Meningitis Measles Human Papilloma Rubella, Virus Mumps Varicella Influenza  Screening Tests Tuberculin skin tests Pap smears Mammograms Stool tests for occult blood Cholesterol tests Sickle cell tests HIV tests Hepatitis A, B, C  5. Family History Outlines or diagrams age and health, or age and cause of death of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family Diseases/Conditions to evaluate include the following: Coronary artery disease Suicide Hypertension Alcoholism Cerebrovascular Accident Kidney Disease (Stroke) Lung Disease Diabetes Hyperlipidemia Cancer Arthritis Tuberculosis Headaches Asthma Seizure disorder Mental Illness Substance abuse Allergies Liver disease  6. Personal and Social History Describes educational level, family of origin, current household, personal interests, and lifestyle Captures the patient’s personality and interests, sources of support, coping style, strengths, and fears Includes occupation and the last year of schooling; home situation, and significant others; sources of stress, both recent and long term; important life experiences,  Personal and Social History Conveys lifestyle habits that promote health or create risk Use of safety measures Alternative health practices  7. Review of Systems Documents presence or absence of common symptoms related to each major body system Think about asking a series of questions going from head-to-toe Start with fairly general questions about systems that may be of concern based on Chief Complaint and History of Present Illness. Sequence of Clinical Examination 1. General appraisal (including temperature, pulse rate, and blood pressure 2. Head 3. Body 4. Skin 5. Neck 6. Jaws 7. Soft tissues 7.1. lips 7.2. Labial or buccal mucosa 7.3. Palate 7.4. Oropharynx 7.5. Floor of the mouth 7.6. Tongue 7.7. Periodontium 8. Teeth 9. Occlusion  General Weight Weakness Fatigue Fever  A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first, then the basic biometrics of height, weight and pain are done.  Temperature recording It gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions. It does though vary with time of day and body conditions but prolonged significant temperature elevation (hyperthermia) or depression (hypothermia) are incompatible with life.  Blood pressure recording The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolicor resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm.  pulse The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute.  height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs.  weight It is the anthropometric mass of an individual. A scale is used to measure weight. Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.  pain Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from '0' (no pain at all showing a normal happy face) to ‘10' (the worst pain ever experienced by the patient).  Skin Rashes Lumps Sores Itching Dryness Changes in color Changes in hair or nails Changes in color or size of moles  Head Headache Head injury Dizziness Syncope Vertigo Lumps Sores  Eyes Vision Glasses or contacts lenses; last examination Pain Glaucoma Redness Cataracts Excessive tearing Itching Double or blurred vision Decreased tearing Spots Specks Flashing lights  Ears Hearing Tinnitus Vertigo Earaches Infection Discharge Use of hearing assistive devices  Nose and Sinuses Frequent colds Nasal stuffiness Discharge Itching Hay fever Nosebleeds Sinus Infections  Throat (Mouth and Pharynx) Condition of teeth and gums Bleeding gums Dentures Last dental examination Sore tongue Dry mouth Frequent sore throats Hoarseness  Neck Swollen glands Goiter Lumps Pain Stiffness  Breast Lumps Pain Nipple discharge Self-Examination practices  Respiratory Cough Sputum (color, quantity) Hemoptysis Dyspnea Wheezing Pleurisy Chest X-Ray Cardiovascular Chest pain Heart murmurs Heart conditions Palpitations Hypertension Paroxysmal nocturnal dyspnea Rheumatic fever Edema Dyspnea Electrocardiograms Orthopnea Echocardiograms Past other cardiovascular tests  Gastrointestinal Trouble swallowing Pain with defecation Heartburn Rectal bleeding or black tarry Decreased/Increased stools appetite Hemorrhoids Nausea/vomiting Constipation Jaundice Diarrhea Hepatitis Abdominal pain Bowel movements Food intolerance Stool color, size, and Excessive belching or consistency flatulence Change in bowel habits Liver or gallbladder problems  Peripheral Vascular Intermittent claudication Leg cramps Varicose veins Deep vein thrombosis Swelling in calves, legs, or feet Color change in fingertips or toes during cold weather Swelling with redness or tenderness  Urinary Frequency of urination Kidney or flank pain Polyuria Kidney stones Nocturia Ureteral colic Urgency Suprapubic pain Burning or pain during Incontinence urination Reduced urinary Hematuria stream Hesitancy Urinary infections Dribbling  Genital: Male Hernias Discharge from or sores on the penis Testicular pain or masses Scrotal pain or swelling History of sexually transmitted diseases and their treatments Sexual habit, interest, function, satisfaction, birth control methods, condom use and problems Concern about HIV infection or exposure  Genital: Female Age of onset of menarche, regularity, frequency, and duration of menstrual cycle; amount of bleeding; bleeding between cycles or after intercourse; last menstrual period; dysmenorrhea; premenstrual syndrome Age at menopause, menopausal symptoms, post menopausal bleeding  Genital: Female Vaginal discharge, itching, sores, lumps, sexually transmitted diseases and treatments Number of pregnancies, number and type of deliveries, number of abortions, complications of pregnancy, birth control methods Sexual preference, interests, function, satisfaction, any problems, including dyspareunia Concerns about HIV infection or exposure  Musculoskeletal Muscle or joint pain Stiffness Arthritis Gout Backache Neck or low back pain Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness  Psychiatric Nervousness Tension Mood Including depression Memory change Suicide attempts  Neurologic Changes in mood, Seizures attention, or speech Weakness Changes in Paralysis orientation, memory, Numbness or loss of insight, or judgment sensation Headache Tingling or “pins and Dizziness needles” Vertigo Tremors or involuntary Syncope seizures Blackouts  Hematologic Anemia Easy bruising or bleeding Past transfusions Transfusion reactions  Endocrine Thyroid conditions Heat or cold intolerance Excessive sweating Excessive thirst or hunger Polyuria Change in glove or shoe size Beginning the Evaluation: Setting the Stage  Preparing for the Physical Examination Reflect on your approach to the patient Adjust the lightning and the environment Make the patient comfortable Check your equipment Choose the sequence of examination  Equipment for the Physical Examination Ophthalmoscope Otoscope Flashlight or penlight Tongue depressors Flexible tape measure, preferably marked in centimeters Thermometer Watch with a second hand Sphygmomanometer Stethoscope  Methods of Clinical Examination 1. Inspection-Visual Inspection 2. Palpation 3. Percussion 4. Auscultation  Inspection Inspection is the thorough and unhurried visualization of the client. This requires the use of the naked eye. During inspection, the examiner observes:  External signs: Body features and symmetry appearance Nutritional state or weight Skin color Frequency and volume of breaths during respiration Movement of the abdomen and each side of the chest during respiration Hair distribution Gait and manner of speaking  Gross Deviation: Abnormal contour Scars and striae Visible masses Discoloration Swelling Tremor  In medical practice, inspection is however not limited to visual information alone. Inspection also involves: Listening to any sounds emanating from the patient Odors that may be present  Palpation Palpation is a method of examination in which the examiner feels the size or shape or firmness or location of something. Palpation is used by doctors particularly for thoracic and abdominal examinations, but also for examination of edema and palpation of pulses.  Percussion Percussion is a method used by a doctor to find out about the changes in the thorax or abdomen. It is done by tapping on a surface to determine the underlying structure.  Auscultation Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity  Protective Barriers Gloves Gowns Aprons Masks Protective eyewear Hats/ Head cap Shoe covers Personal Protective Equipment (PPE) THE END ORAL PHYSIOLOGY Dr. Romeo T. Cruz Jr. DMD, MACT, EdD ORAL PHYSIOLOGY Branch of dentistry concerned with the study of functions and activities of the different structures found in the oral cavity  Stomatognathic System The stomatognathic system It encompasses various refers to the collective structures components, including the and functions involved in the teeth, jaws, temporomandibular process of chewing, joint (TMJ), muscles of swallowing, breathing and mastication, salivary glands, voice production. taste buds, and other oral structures  STOMATOGNATHIC SYSTEM Composed of structures of the mouth and jaws considered collectively as they subserve the functions of mastication, deglutition, respiration and speech. STOMA: Mouth. GNATHIA: Upper and lower jaws.  FUNCTIONS OF THE STOMATOGNATHIC SYSTEM  1. Mastication  2. Deglutition  3. Speech  4. Respiration  1. MASTICATION  > is a physiologic activity formed when there is normal occlusion in a cyclic movement.  > simply the chewing process. MASTICATION  > Purposes:  1. Physiological transformation of food.  2.Enhances growth & development of dento-alveolar structures through stimulation.  3. Stimulates salivary flow.  4.There is volatilization of food to increase appetite.  5. Protection of the individual from undesirable food components.  6. Help further develop or allow jaw bone to grow.  2. DEGLUTITION  > once the food is chewed, the next step is to swallow it.  > swallowing is a complex group of reactions to move food onwards in the digestive tract while preserving the airway DEGLUTITION  > transport of material from mouth to esophagus:  Adult swallow deglutition/swallowing  Infant swallow - suckling – earliest means of food transport - sucking/drinking – fluid transport  3. SPEECH  > an expression of thought either written or spoken. SPEECH Speech is produced by bringing air from the lungs to the larynx where the vocal folds may be held open to allow the air to pass through or may vibrate to make a sound (phonation). Purposes: - Communication: Speech enables the exchange of thoughts, ideas, and emotions between individuals. - Articulation and pronunciation: Speech involves the precise movements of the mouth and vocal organs to produce clear and correct sounds. - Oral motor control: Speech requires coordination and control of the muscles involved in breathing, phonation, and articulation  4. RESPIRATION  > a continuous process closely associated with deglutition.  > also referred to as ventilation wherein there is the entrance of oxygen & release of carbon dioxide.  RESPIRATION Purposes: - Homeostasis: Respiration contributes to the maintenance of physiological balance, including the regulation of body temperature. *person gasping air through mouth - Energy production: The process of respiration generates energy in the form of ATP (adenosine triphosphate) through cellular respiration. - Gas exchange: Respiration facilitates the exchange of oxygen and carbon dioxide between the body and the environment. NINE STRUCTURAL COMPONENTS OF THE STOMATOGNATHIC SYSTEM: I. Basal bones superiorly- maxillary and palatine bones inferiorly- mandibular bone JAWS The jaws, also known as the mandible (lower jaw) and maxilla (upper jaw), provide the framework for the teeth and play a crucial role in the process of mastication. The mandible is the only movable bone in the skull and is connected to the skull through the temporomandibular joint (TMJ). The jaws work together to facilitate biting, chewing, and other oral functions. II. Muscles of Mastication 1. Temporalis muscle- elevates and positions the mandible 2. Masseter- elevates the mandible 3. External/Lateral Pterygoid- positions the mandible and moves the jaw laterally. It depresses the mandible 4. Internal/Medial Pterygoid- elevates the mandible.. MUSCLES OF MASTICATION The muscles of mastication are responsible for the movement of the jaw during chewing. These muscles work together to coordinate the complex motions required for effective chewing and grinding of food. Functions of Muscles of Mastication The muscles of mastication perform several functions, including: - Initiating and controlling the movement of the mandible during chewing. - Maintaining the stability and alignment of the temporomandibular joint (TMJ). - Providing the necessary force for effective mastication and grinding of food. - Assisting in the proper positioning and alignment of the teeth for optimal occlusion (bite). - Contributing to the production of speech sounds and facial expressions. Functional Movement III. TEMPORO-MANDIBULAR JOINT Main Components of TMJ 1. Mandibular Condyles 2. Articular surface of the mandibular bone 3. Capsule 4. Articular disc 5. Ligaments 6. Lateral Pterygoid. TEMPOROMANDIBULAR JOINT (TMJ) The temporomandibular joint (TMJ) is the joint that connects the mandible to the skull. It allows for the movement of the jaw, including opening and closing of the mouth, as well as side-to-side and forward-backward movements. Features of TMJ □ Left and right joints work in harmony. □ Articular disc separates upper and lower compartments. □ The upper compartment is for the transitory, gliding movement. □ The lower compartment is for rotary or opening movement. □ Covered with avascular fibrocartilage. IV. Dentition TEETH Teeth are hard structures located in the mouth and serve various functions in the digestive process. They are classified into different types based on their shape and function, including: INC IS O R Incisors: Sharp-edged teeth at the front of the C A NINE mouth used for cutting and biting. Canines: Pointed teeth next to the incisors, used for tearing and gripping food. Premolars: Broad teeth with cusps, involved in chewing and grinding. PR E MO L A R Molars: Large, flat teeth at the back of the mouth, responsible for crushing and grinding MO L A R food. V. Supporting Structures Periodontium 1. GINGIVA 2. PERIODONTAL LIGAMENT 3. CEMENTUM 4. ALVEOLAR BONE VI. Limiting structures Outer limiting structures- cheeks, lips Inner limiting structure- tongue  Tongue The tongue is a muscular organ located in the oral cavity and is essential for various functions, including taste perception, swallowing, and speech production. It is composed of muscles and covered with taste buds that allow for the perception of different tastes, such as sweet, sour, salty, bitter, and umami. The movements of the tongue aid in chewing and forming food into a bolus for swallowing, as well as shaping sounds for speech. Tonsils The tonsils are part of the lymphatic system and are located at the back of the throat. They play a role in the body's immune response by trapping and filtering harmful bacteria and viruses that enter the body through the mouth and nose. The tonsils are part of the body's defense mechanism against infections. VII. Saliva/ Salivary Gland Saliva: An aqueous solution which moistens the oral cavity. The major salivary glands are the ff: Parotid gland - Stensen’s duct Submandibular gland - Wharton’s duct Sublingual gland - Bartholin’s duct and the duct of Rivinus VIII Neural □ A communication network that transmits information by electrical signal in and out of the CNS. □ Trigeminal nerve is the main nerve supply of the oral cavity. Neural System of the Oral Cavity The oral cavity is innervated by a complex neural system that includes sensory and motor components. The sensory nerves provide feedback regarding touch, temperature, and taste sensations, while the motor nerves control the movements of the muscles involved in chewing, swallowing, and speech. The main nerve involved in oral sensation and motor control is the trigeminal nerve (cranial nerve V). Other cranial nerves, such as the facial nerve (cranial nerve VII) and glossopharyngeal nerve (cranial nerve IX), also contribute to the neural innervation of the oral cavity. IX. Blood and Lymph Nodes  Blood and Lymph Nodes The oral cavity is supplied with blood vessels and contains lymph nodes that play important roles in maintaining oral health and immune function. The blood vessels deliver oxygen and nutrients to the oral tissues, while the lymph nodes filter and help eliminate toxins, bacteria, and other harmful substances. Proper blood circulation and lymphatic drainage are essential for the overall health and function of the oral cavity. ROMEO T. CRUZ, JR. DMD, MACT, EdD  Is a term applied to the accumulated excretory and secretory products which is a viscous fluid discharged by the salivary glands into the oral and vestibular cavities, by the major and minor ducts. ( mixed fluid in the mouth)  Hypotonic fluid relative to plasma  Saliva contains 99.5% water and.5% organic and inorganic constituents.  PH of saliva varies from an acidity of 5.6 to an alkalinity of 7.6. The average is slightly acid 6.8 or neutral. Normal daily production of saliva = 0.5-1.5 liters  Accdg. To Bhaskar:  750 ml- is the quantity of saliva that secreted per day.  60% to 70%- produced by submandibular glands.  25% to 35%- by parotid  5% or less- by sublingual glands Composition of Saliva: I. Organic constituents: 1. Proteins amylase or ptyalin lysozymes Glycoproteins IgA Blood protein traces 2. Nitrogenous Compound Amino acids. Peptides Urea Creatinine Uric Acid Ammonia- formed by bacteria from urea and amino acids. 3. Glucose  II. Inorganic Constituents Sodium (Na+) Chloride (Cl-) Bicarbonate (HCO3-) Potassium (K+) Phosphate * the composition of saliva depends strongly on the flow rate Pure saliva Mixed saliva Active saliva  May be obtained directly from the gland.  It is a clear, colorless fluid.  Is frothy and opalescent fluid containing water, protein, mineral salts, ptyalin, mucin, food particles, desquamated epithelial cells, and salivary corpuscles.  Results from sight or smell of food or from stimulating material of the oral cavity.  Resting Saliva- occurs in absence of excitation. Properties of Saliva: 1. Spinnbarkeit: Ability to be drawn out into long elastic threads. 2. Viscosity: sticky. 3. Buffering power: power to resist change in the pH when acid or alkali are added to a solution. - bicarbonate, phosphate and protein 4. Reducing power: Chemical reaction in w/c compounds with a high molecular weight are reduce to a compound of lower molecular weight. I. Includes all those functions made possible by virtue of its liquid state: 1. Excretion 2. Solvent action 3. Lubricant (glycoproteins) 4. Cleansing action 5. Aid in deglutition II. Includes all those functions effected by virtue of its chemical component. 1. Bacteriolysis 2. Digestion (Amylase) 3. Decrease of blood clotting time  Glands- are important for metabolism because they play an important part in modification, absorption, utilization and excretion of food substances. Human submaxillary gland. At the right is a group of mucous alveoli, at the left a group of serous alveoli.  Salivary glands of man are classified according to the nature of secretion as exocrine( secretion passes the duct), and according to the behavior of glands as merocrine (no change in cytoplasm of the gland. 1. Primary function- is to transform and secrete materials coming from the circulatory fluid of the body. 2. Secondary function- to excrete certain substances. I. Accdg. To size 1) Major Glands (extrinsic glands) a) Parotid gland b) Submandibular (submaxillary) c) Sublingual gland 2) Minor Glands (intrinsic glands) a) Labial glands b) Buccal glands c) Lingual glands d) Palatine glands I. Major Duct Type of Secretion (compound) Parotid Stensen’s Serous Submandibular Wharton’s Mixed (mainly Serous) Sublingual Bartholin’s (major)/ Mixed (mainly mucous) Ravinian (minor) II. Minor Type of Secretion (simple non Branching) Labial Mixed (mainly mucous) Lingual anterior lingual Mixed (mainly mucous) posterior lingual Mucous buccal Mixed (predominantly mucous) Von Ebner ‘s gland Serous Palatine Mucous Glossopalatine Mucous  Terminal secretory end pieces – acinar cells  Intercalated ducts  Striated cells  Main excretory duct  Oral cavity  Type of salivary gland  Nature of the stimulation  Duration of the stimulation Is the removal of food that enters the mouth Oral Clearance Rate is the time taken either to clear the substances from the mouth or to reduce to a very low concentration  Reaches the stimulation Substance Increased Inc vol. of Stimulate (high conc.) salivary prod salivary flow saliva in Is introduced to rate the the mouth mouth Repeat process Swallow Reaches threshold will occur or swallowing Low subst. Reduce conc. stimulation Unstimulated level  Is the ability of the saliva to maintain the pH when exposed to acid 3 important buffer system in human being 1. Bicarbonate buffer system 2. phosphate buffer system 3. protein buffer system  Main buffer system in human saliva  Most effective as a buffer at pH 6  Contribution to the overall buffer capacity a) 50%- unstimulated saliva b ) 90% - stimulated saliva  Most effective as buffer at pH 6.8  Contribution to the overall buffer capacity -50% in unstimulated saliva -minor contribution for the stimulated saliva  Most effective as a buffer at pH value of less than 5  Some salivary pH increase the viscosity of the saliva when the pH becomes acidic to cover and physically protect the teeth against acid load  Salivary levels of “Recreational drugs” (cocaine, marijuana, alcohol) is a good reflection of the plasma level Pollutants (lead, cadmium and copper) Determine the profile of the infection of the oral cavity Any change in the quantitative and/or qualitative change in output of SALIVA Hypofunction- decrease in salivary function Hyperfunction- increase in salivary function Sialorrhoea – Genuine salivary hyperfunction Caused by mucosal irritation or Idiopathic Drooling is a result of neurological disorders like: Cerebral palsy Parkinson’s disease Mentally handicapped patient Neuroleptic medications in adults  Iscommon condition in people with underlying disease or those who take certain medication  Hyposalivation- a term based on objective measures of the saliva production  Often associated with xerostomia – decrease salivary flow rate change in composition cause iatrogenic Medications (antidepressants diuretics , antihistamine Antihypertensives, antipsychotic, opiates, Chemotherapy, radiotherapy to the head and neck region Autoimmune disease Rheumatoid arthritis, Sjogren’s Syndrome, sarcoidosis Neurological disorders Mental depression, cerebral palsy, Hormonal disorders Diabetes mellitus, hyper/hypothryoidism infections HIV / AIDS, epidemic parotitis Local salivary disease Sialolithiasis, sialadenitis infections HIV / AIDS, epidemic parotitis Hereditary disorders Cystic fibrosis, ectodermal dysplasia Metabolic disturbances Malnutrition, eating disturbance, bulimia, anorexia nervosa, dehydration Other conditions Menopause, impaired masticatory performance  Oral mucosal dryness and soreness  Burning sensation  Difficulty in speech  Difficulty in chewing food  Difficulty wearing removable denture  Bad breath  Sensation of thirst  Dry glazed and red oral mucosa  Bacterialsialadenitis relatively rare condition usually in elderly who have reduced salivary flow due to systemic disease Characterized by acute tender swelling of the salivary gland Mumps is the most common form of viral sialadenitis  Calcified masses within the salivary duct (saliva stones )  Asymptomatic and unilateral  parotid gland  Minor gland  Submandibular gland  Sublingual gland