Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 6. Head and Neck

EQUIPMENT

image Tape measure

image Cup of water

image Stethoscope

image Transilluminator

EXAMINATION

Ask patient to sit.

TECHNIQUE

FINDINGS

HEAD AND FACE

Observe head position

 

EXPECTED:Upright, midline, still.

 

UNEXPECTED:Tilted, horizontal jerking or bobbing, tics, nodding,.

Inspect facial features

image Shape

Observe eyelids, eyebrows, palpebral fissures, nasolabial folds, mouth at rest, during movement, with expression.

EXPECTED:Variations according to race, sex, age, body build.

UNEXPECTED:Change in shape. Unusual features: Edema, puffiness, coarsened features, prominent eyes, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations.

image Symmetry

Note if asymmetry affects all features of one side or a portion of face.

EXPECTED:Slight asymmetry.

UNEXPECTED:Facial nerve weakness or paralysis, or problem with peripheral trigeminal nerve.

Inspect skull and scalp

image Size/shape/symmetry

image Scalp condition

image Systematically part hair from frontal to occipital region.

image Hair pattern

Pay special attention to areas behind ears, at hairline, at crown.

EXPECTED:Symmetric.

UNEXPECTED:Lesions, scabs, tenderness, parasites, nits, scaliness.

EXPECTED:Bitemporal recession or balding over crown in men.

UNEXPECTED:Random areas of alopecia or alopecia totalis.

Palpate head and scalp

image Symmetry

Palpate in gentle, rotary motion from front to back.

EXPECTED:Symmetric and smooth with bones indistinguishable. Ridge of sagittal fissure occasionally palpable.

UNEXPECTED:Indentations or depressions.

Palpate hair

imageTexture/color distribution

EXPECTED:Smooth, symmetrically distributed.

UNEXPECTED:Splitting or cracked ends. Coarse, dry, or brittle. Fine and silky.

Palpate temporal arteries

Note course of arteries.

UNEXPECTED:Thickening, hardness, or tenderness.

Auscultate temporal arteries and over skull and eyes

 

EXPECTED:No bruits.

image

Inspect salivary glands

image Symmetry/size

Palpate if asymmetry noted. Have patient open mouth and press on salivary duct to attempt to express material.

UNEXPECTED:Asymmetry or enlargement. Tenderness. Discrete nodule.

NECK

Inspect neck

image Symmetry

Inspect in usual position, in slight hyperextension, and during swallowing. Look for landmarks of anterior and posterior triangles.

EXPECTED:Bilateral symmetry of sternocleidomastoid and trapezius muscles.

UNEXPECTED:Asymmetry, torticollis webbing, excessive posterior skinfolds, unusually short neck, distention of jugular vein; prominence of carotid arteries, or edema

image Trachea

Inspect in usual position, in slight hyperextension, and while patient swallows.

EXPECTED:Midline placement.

UNEXPECTED:Masses.

Evaluate range of motion

Have patient flex, extend, rotate, laterally turn head and neck.

EXPECTED:Smooth.

UNEXPECTED:Pain, dizziness, or limitation of motion.

Palpate neck

image Trachea

Place thumb on each side of trachea in lower portion of neck, and compare space between trachea and sternocleidomastoid on each side.

EXPECTED:Midline position.

UNEXPECTED:Deviation to right or left.

image

image Hyoid bone/thyroid and cricoid cartilages

Have patient swallow.

EXPECTED:Smooth. Moves during swallowing.

UNEXPECTED:Tender.

image Cartilaginous rings of trachea

Have patient swallow.

EXPECTED:Distinct.

UNEXPECTED:Tender.

image Tracheal tug

With neck extended, palpate for movement with index finger and thumb on each side of trachea below thyroid isthmus.

UNEXPECTED:Tug synchronous with pulse.

Palpate lymph nodes

image Size/consistency, mobility/condition

UNEXPECTED:Enlarged, matted, tender, fixed, warm.

Palpate thyroid gland

image Symmetry

Observe from frontal and lateral positions while patient hyperextends neck. Then observe as patient sips water while neck is hyperextended.

UNEXPECTED:Asymmetry. Enlarged and visible thyroid gland.

image Size/shape/configuration/consistency

Stand either facing or behind patient. Have patient hold head slightly forward and tipped toward side being examined. Lightly palpate isthmus and lateral lobes. Give water to patient to facilitate swallowing.

From the front, examine the left lobe by sitting on the left side of the patient and pressing the trachea to the left with the left thumb. Place the first three fingers in the thyroid bed just medial to the sternocleidomastoid. Keep your fingers still while the patient again swallows, thereby moving the gland beneath your fingers.

Repeat on the right side.

If gland is enlarged, auscultate for vascular sounds with stethoscope bell.

EXPECTED:Lobes small and smooth. Gland rises freely with swallowing. Right lobe as much as 25% larger than left. Tissue firm and pliable.

UNEXPECTED:Enlarged, tender nodules (smooth or irregular, soft or hard); coarse tissue; gritty sensation.

UNEXPECTED:Bruit.

image

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Myxedema

Subjective Data:Cognitive impairment, slowed mentation, poor concentration, decreased short-term memory, social withdrawal, psychomotor retardation, depressed mood, and apathy.

Objective Data:Dull, puffy, yellow skin. Coarse, sparse hair. Temporal loss of eyebrows. Periorbital edema. Prominent tongue. Hypothyroidism (see table on p. 68).

Graves disease

Subjective Data:Symptoms of hyperthyroidism palpitations, heat intolerance, and weight loss, fatigue increased appetite, tachycardia.

Objective Data:Diffuse thyroid enlargement, hyperthyroidism. Various pathologic conditions—ophthalmologic (prominent eyes, lid retraction, staring or startled expression), dermatologic (fine and moist skin, fine hair), musculoskeletal (muscle weakness), cardiac (tachycardia) (see table on p. 68).

Headaches

image image image

Hyperthyroidism Versus Hypothyroidism

System or Structure Affected

Hyperthyroidism

Hypothyroidism

Constitutional

   

Temperature preference

Cool climate

Warm climate

Weight

Loss

Gain

Emotional state

Nervous, easily irritated, highly energetic

Lethargic, complacent, uninterested

Hair

Fine, with hair loss; failure to hold permanent wave

Coarse, with tendency to break

Skin

Warm, fine, hyperpigmentation at pressure points

Coarse, scaling, dry

Fingernails

Thin, with tendency to break; may show onycholysis

Thick

Eyes

Bilateral or unilateral proptosis, lid retraction, double vision

Puffiness in periorbital region

Neck

Goiter, change in shirt neck size, pain over thyroid

No goiter

Cardiac

Tachycardia, dysrhythmia, palpitations

No change noted

Gastrointestinal

Increased frequency of bowel movements; diarrhea rare

Constipation

Menstrual

Scant flow, amenorrhea

Menorrhagia

Neuromuscular

Increasing weakness, especially of proximal muscles

Lethargic, but good muscular strength

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

HEAD AND FACE

Palpate head and scalp

image Symmetry

In infants, transilluminate skull

EXPECTED:An infant’s head circumference is 2 cm greater than chest circumference up to the age of 2 years.

UNEXPECTED:Ring of light greater than 2 cm with transillumination.

imageSkull condition

EXPECTED:In infants, posterior fontanel closed at 2 months; anterior fontanel closed at 18 to 24 months.

UNEXPECTED:Tenderness or depressions; sunken areas; swelling, bulging, or depressed fontanels.

imageScalp

EXPECTED:Free movement.

UNEXPECTED:Fixation of scalp, bulging either on one side or crossing midline of scalp.

Percuss skull

 

EXPECTED:Macewen sign, percussion near junction of frontal, temporal and parietal bones producing a stronger resonant sound, is physiologic when fontanels are open.

 

UNEXPECTED:Macewen sign may indicate hydrocephalus, a brain abscess is present, or increased intracranial pressure after fontanel closure.

Auscultate temporal arteries and over skull and eyes

 

EXPECTED:Bruits are common in children up to age 5 years.

NECK

Palpate thyroid gland

imageSymmetry

EXPECTED:In children, thyroid gland may be palpable.

UNEXPECTED:Tenderness.

SAMPLE DOCUMENTATION

Head.Held erect and midline. Skull normocephalic, symmetric, smooth without deformities. Facial features symmetric. Salivary glands not inflamed or tender. Temporal artery pulsations visible bilaterally, soft and nontender to palpation. No bruits.

Neck.Trachea midline. No jugular venous distention (JVD) or carotid artery prominence. Thyroid palpable, firm, smooth, not enlarged. Thyroid and cartilages move with swallowing. No nodules or tenderness. No bruits. Full range of motion (ROM) of neck without discomfort.