Combined set clin skills

stenson's duct

parotid glands

-enters oral cavity through buccal mucosa opposite the upper second molar

submandibular salivary glands

deep to the mandible, beneath floor of mouth

wharton's ducts

wharton's ducts

enters the floor of the mouth near the lingual frenula

sublingual glands

below mucous membranes of the floor of the mouth

anterior cervical triangle

borders the mandible, anterior border of sternocleidomastoid, and neck midline

in front of SCM

posterior cervical triangle

borders posterior border of sternocleidomastoid, trap and clavicle

behind SCM

common carotid artery (great arteries of neck)

internal carotid a. = intracranial

external carotid a. = extracranial

great veins of neck

internal and external jugular veins

hyoid bone

mobile bone right below mandible

thyroid cartilage

adams apple - notch on superior edge

thyroid gland

just above suprasternal notch and isthmus

spans 2, 3, and 4 tracheal rings

order of midline neck cartilage

thyroid cartilage

cricoid ligament

cricoid cartilage

submental lymph node

directly behind mandible

submandibular lymph node

midway point between mandible tip and angle

tonsillar lymph node

angle of mandible

preauricular lymph node

in front of ear

posterior auricular lymph node

behind ear

occipital lymph node

base of posterior skull

superficial anterior cervical lymph node

superficial to SCM muscle

superficial posterior cervical lymph node

along anterior edge of trapezius

deep cervical chain lymph node

supraclavicular lymph node

deep in angle formed by clavicle and SCM

head ROS

hair loss/changes

h/o headaches

-frequency, location, associations

h/o head injury

neck ROS

masses

enlarged or tender glands

goiter

h/o thyroid disease

painful areas

neck stiffness

what to inspect for in hair

quantity

distribution

texture

patterns of hair loss

dandruff

what to inspect for on scalp

scaliness

masses

lesions

what to inspect for on skull

size

contour

deformities

depressions

masses

what to inspect for on face

facial expression

contours

symmetry

involuntary movements

masses

edema

examination for skin on face

color

texture

thickness

hair distribution

lesions

rashes

acne

how to palpate lymph nodes

-gently in circular motion w/ pads of index and middle fingers b/l

-pt should be relaxed w/ neck flexed forward

what to note about lymph node exam

size

shape

delimination (single or matted together)

mobility

consistency

tenderness

any overlaying skin changes

mobile vs. fixed lymph node

mobile = benign

fixed = malignant

virchow's node

enlargement of supraclavicular nodes

esp in L side - suggest metastasis from thoracic or abdominal cancer

tender lymph nodes

inflammation

hard/fixed lymph nodes

suspicious for malignancy

generalized lymphadenopathy

include infection, inflammation, or malignancy

HIV, IM, lymphoma, leukemia, sarcoidosis

inspect trachea for

deviation from midline

deviation = tension pneumothorax

palpate trachea for

tracheal deviation by placing one finger on side of trachea and note space between it and SCM

compare b/l spacing

auscultating trachea

stethescope diagram over trachea and note breath sounds

note stridor

stridor

high-pitched musical sound indicating respiratory emergency

how to inspect thyroid gland

tip head back and feel while they swallow

note contour, symmetry, and swelling of gland

how to palpate thyroid gland

-behind neck, position head forward

-place pads of both fingers below cricoid cartilage

-ask to swallow

-displace trachea and palpate lobes

note size, shape, and consistency

what to do if thyroid is enlarged

auscultate over lateral lobes for potential bruit (turbulent blood flow)

diffuse thyroid enlargement

indicated thyroid disease like graves, hashimotos, goiter

single nodule in thyroid

determine if benign or malignant

multinodular goiter

enlarged gland w/ multiple nodules

review of head and neck exam

-inspect hair

-inspect scalp

-inspect skull

-inspect face

-inspect skin of face

-palpate lymph nodes

-palpate trachea

-palpate and auscultate thyroid

battle sign

ecchymosis over the temporal bone, behind the ear

indicates head trauma and possible basilar skull fracture

parotid gland

near the ear

contains stenson's ducts

auricle

outer ear

-helix, antihelix, lobule, tragus

helix

prominent curved outer ridge

antihelix

parallel and anterior to helix

lobule

ear lobe

tragus

nodular protrusion covering entrance of ear canal

ear canal

begins at external auditory meatus and extends to TM

function of middle ear

connect nasopharynx to Eustachian tube

-drains ear to help with pressure regulation

-sinuses and nose drain into the eustachian tube to cause ear pain

ossicles

malleus, incus, stapes

-hands of malleus and short process of malleus seen on TM

cone of light

light reflection fans down and anterior from umbo

-in OM, you can't see it

pars flaccida

part of eardrum above short process of malleus

pars tensa

remainder of eardrum

labyrinth

inner ear

-cochlea

-semicircular canals

-vestibule

semicircular canals

rotational movement

vestibule

linear movement

vestibulocochlear nerve (CN VIII)

sends nerve impulses to brain to be interpreted

conductive phase

external to middle ear

-air conduction: normal hearing where sound travels through air to middle ear to cochlea

sensorineural phase

transmission from cochlea to CN VIII

-bone conduction: bypasses external and middle ear by sending vibration from skull to cochlea

conductive hearing loss

-conductive pathway impacted

-external or middle ear dysfunction

-impaction of ear due to cerumen or infection

sensorineural hearing loss

cochlear nerve damage

-little-to-no hearing in affected ear

turbinates

superior, middle, and inferior bony structures with highly vascularized mucous membranes

middle turbinate

drains paranasal sinuses

inferior turbinate

drains nasolacrimal duct

paranasal sinuses

maxillary, ethmoid, frontal, sphenoid

-only front and maxillary accessible on PE

-palpation can determine location of sinus infection

labial frenulum

connects lip to gingiva

ear ROS

hearing loss - sudden or gradual

hearing aid use?

ear pain

ear discharge

tinnitus

vertigo

presyncope

disequilibrium

meiniere's hx?

nose ROS

rhinorrhea

color

laterality and odor (bad smell in kids = obstruction)

pruritus

allergies/meds

nasal stiffness or congestion

associated symptoms: cough, fever, ear pain, dental pain, sore throat

epistaxis

sinus pain

h/o sinusitis

throat ROS

sore throat or tongue

bleeding of gums

last dental exam

dentures, endentulous, partials or implants

hoarsness/voice change (epiglottitis or peritonsilar abscess)

swelling of lips or throat

lesions of gums, lips, mucous membranes

dry mouth

key components of an ear exam

-inspect auricle and surrounding tissue

-palpate and move auricle, tragus, and mastoid

-inspect ear canals and TM w/ otoscope

-test auditory acuity and gross hearing (if hearing loss is present, test with tuning forks)

mastoid pain

mastoiditis

auricle pain

otitis externa (will also have ear discharge)

auricle exam

inspect for deformities, discharge, lumps, lesions

palpate tragus

move auricle up and down

palpate mastoid process

acute mastoiditis

painful mastoid process

redness, swelling, tenderness

"protrusion of the auricle"

otoscope technique

-straighten ear canal by pulling up, back, and away

-hold like pencil, brace fingers against face

-gently direct otoscope down and forward

-bilaterally

otitis externa

-swollen ear canal, moist and erythematous

-drainage known as otorrhea

ask if they've swam recently

ear exam of tympanic membrane

describe structures: handle of malleus, short process of malleus, pars flaccida, pars tensa

inspect for: color, contour, cone of light

tympanic mobility: assess w/ pneumatic otoscope

perforation of TM

tympanosclerosis

scarring of eardrum

cholesteatoma

accumulation of skin cells in the middle ear that can destroy surrounding tissue

is a growth

serous effusion

collection of amber serous fluid behind the TM

-associated with URI, can lead to acute OM

acute otitis media

AOM

bulging and erythematous TM

bullous myringitis

painful hemorrhagic vesicles on TM

whispered voice test

-inform pt you will state a sequence of numbers and letters

-stand 2 ft behind pt

-occlude and rub tragus of R ear

-whisper combination of 3 numbers/letters

-correct = normal hearing

-incorrect = repeat

-3/6 combinations correct = passed test

rinne test

-compared AC and BC

-vibrate tuning fork and put on mastoid bone

-when pt can't hear it anymore, take off and hold near external auditory canal

-AC should be > BC

Abnormal: AC=BC or AC

weber hearing test

-tests for lateralization

-vibrate fork, put on top of pt head

-ask where its heard best

normal = sound in both ears

abnormal = one or the other

weber test conductive hearing loss

sound goes to the bad ear

b/c it travels faster due to air block

weber test sensorineural hearing loss

sound goes to good ear b/c inside is messed up

nose exam

-inspect anterior surface

-test for obstruction

-inspect nasal mucosa, nasal septum, inferior and middle turbinates

-palpate frontal and maxillary sinuses

what can cause deviated nasal septum

hematoma

how to do nose exam

inspect for: asymmetry, deformity, obstruction

nasal obstruction test: occlude one ala nasi and have them breathe in, do b/l

inspection of nares

-place otoscope in nares, ask to tilt head back

-inspect mucosa for: color, edema, bleeding, exudate

-inspect septum for: deviation, inflammation, perforation, ulcers, polyps

mouth inspection

-inspect lips

-inspect and palpate oral mucosa

-inspect gingiva and gum margins

-inspect teeth

-inspect hard palate and floor of mouth

-inspect all surfaces of tongue

-inspect soft palate, anterior and posterior pillars, uvula, tonsils, pharynx

-note rise of soft palate