诊断学头颈部检查.ppt

Head,Wang xinjun 王新军,PE of the Head is by inspection and palpation,The inspection is esp, important and useful for PE of head This is because many traits or findings from the head, esp, the face, is so attractively draw our attention when we firstly look at the patient. For Ex, the emotional reactions:,Thyrotoxic faces The patient is often thin and wasting, accompanied by an alert, startled, flushed and anxious appearance.,Cushingoid face Features: moon face, plethora, acne, hirsutism (over-growth of body hair, esp. mustache of a woman),Inspect for asymmetry of the skull, ears, eyes, nose, mouth, jaw, and cheeks. Note any masses or deformities.,Paralysis of facial,Head examination,In the general head examination, the examiner should: Identify signs of generalized disease Recognize local lessions within the purview of the generalist Recognize local lesions requiring specialist care,HAIR, SCALP AND SKULL,changes in the hair Alopecia 脱发 Clinical occurrence: hypothyroidism et al Hirsutism and hypertrichosis多毛症和毛发过多 polycystic ovary, glucocorticoid excess 多囊卵巢、糖皮质激素过多,SKULL MALFORMATION 头颅畸形,Craniosynostosis颅缝早闭: premature union of special sutures leads to skull malformations. Hydrocephalus脑积水 Meningocele脑脊膜膨出,Eyes,Eyelids 眼睑 Conjunctiva 结膜 Eye ball 眼球 Cornea 角膜 Sclera 巩膜 Iris and lens and pupils 虹膜、晶状体、瞳孔,eyelids,Lid inversion (entropion) 睑内翻 Lid eversion (ectropion)睑外翻 Failure of lid closure (paralysis of orbicularis muscle) 眼睑闭合障碍 Failure of lid opening (ptosis of the lid)上睑下垂 Lid swelling (palpebral edema)眼睑水肿,Failure of lid closure,The facial nerve(CN VII) supplies the orbicularis oculi muscle眼轮匝肌. Disorder of this nerve, as in Bell palsy（贝尔麻痹，面神经麻痹）, causes partial or complete paralysis of the orbicularis.,Failure of lid opening,The congenital form is usually bilateral from paralysis or failure to develop the levator palpebrae superioris提上睑肌. Clinical occurrence: encephalitis, Horner syndrome, paralysis of the levator muscle.,ptosis of the lid (Horner syndrome),Interruption of the cervical sympathetic chain interupts sympathetic innervation of the eye and face. The complete syndrome has ptosis上睑下垂, miosis瞳孔缩小,and anhydrosis on the affected side患侧面部无汗.,Lid swelling,Local infection cause inflammatory edema of the eyelids. nephritis. It occurs early in the course of both myxedema and the exophthalmos of Graves disease.,Eye ball,Lid lag(Von Graefe Sign)(hyperthyroidism) A lag is indicated by white sclera appearing between lid and limbus.,Sclera巩膜,In obstructive jaundice（黄疸）, conjugated bilirubin胆红素 infiltrates all body tissues and fluids, it colors the sclera evenly.,Iris and lens and pupils 虹膜、晶状体和瞳孔,Note the size, shape, and equality of the pupils.,pupillary reaction to light,Test pupillary reaction to light by having the patient fix on a distant object so that the patient does not fixate on the light and use accommodation.,pupillary reaction to light,Shine a penlight into the pupil from the side while obseving the direct pupillary reaction直接对光反射.,pupillary reaction to light,Remove the light and repeat the process, this time looking at the opposite(unlighted) pupil for consensual reaction间接对光反射. Repeat this sequence exposing the opposite eye to the light.,ears,Pinna耳廓 External acoustic meatus外耳道 Rough quantitative test for hearing loss,nose,External nasal deformities Epistaxis(nosebleed)鼻出血 Suppurative paranasal sinusitis化脓性鼻窦炎,Epistaxis(nosebleed),Nosebleed can be a spontaneous and trivial occurrence or a sign of serious local or generalized disease. Inquire about trauma, predisposing local or systemic disease, and the amount of blood lost. Blood-tinged fluid suggests a cerebrospinal fluid脑脊液 leak.,Mouse and parotid gland腮腺,Examination is by inspection and palpation. Facing the patient, hold a tongue blade压舌板 in the left hand and a penlight in the right. If a head lamp or mirror is used, your right hand is free to hold a nasal or laryngeal mirror喉镜.,Mouse and parotid gland,Lips口唇 Buccal mucosa口腔黏膜 Teeth牙齿 Gums牙龈 Tongue舌 Oropharynx口咽 Tonsils扁桃体 Larynx喉 Parotid gland腮腺,lips,Have the patient attempt to whistle, to reveal paralysis from facial nerve(CN VII) lesions.,Labial enlargement,The lips may appear large in cretinism克汀病/呆小病, myxedema粘液性水肿, acromegaly肢端肥大症.,Buccal pigmentation(Addison disease),Dappled brown pigment in the lining of the cheek strongly suggests Addison disease.,Oral white patches(口腔白斑，鹅口疮),Infection of the oral mucosa with Candida spp.白色念珠菌 occurs in patients who are immunosuppressed or have received broad spectrum antibiotics.,teeth,Pigmented teeth(fluoride氟 pits) Opaque chalkwhite spots, 12 mm in diameter, are seen scattered on the surface of multiple teeth. This is a harmless condition found in persons who have ingested large amounts of fluoride in the water during childhood.,Tongue舌,Have the patient protrude his tongue. Assess its size; look for deviation from the midline.,Lingual enlargement舌体增大,The tongue is enlarged in Down syndrome, cretinism, and adult myxedema. It increases in size during the development of acromegaly.,Lingual tremor,Increased sympathetic activity is associated with fine tremor. A fine tremor of the tongue is often present in hyperthyroidism.,Lingual deviation(paralysis of the hypoglossal nerve(CN XII),The tongue protrudes by tensing the two lateral muscle bundles, paralysis of one bundle causes the tongue to deviate to the paralyzed side.,tonsils,The normal adult tonsils seldom protrude beyond the faucial pillars咽腭弓. Hyperplasia is usually attributed to chronic infection, but it may be associated with obesity, hyperthyroidism, or lymphoma.,Larynx喉 laryngeal paralysis喉麻痹,The vocal cords声带 are innervated by the recurrent laryngeal nerves喉返神经, which are susceptible to injury in the neck and chest inferior to the larynx. Following thyroidectomy(either or both sides), aneurysm of the aortic arch主动脉弓(left side), and mediastinal tumor纵膈肿瘤,neck,If cervical fracture is suspected, and in trauma cases, immobilize the patient and obtain X-rays before trying to elicit physical signs.,Inspection视诊 The neck is inspected for Asymmetry Limitation of motion Abnormal pulsations Goiter Masses Neck scar (thyroidectomy,tracheotomy),Neck,Anatomy,Followed by checking of the front cervical triangle searching for enlarged lymph nodes and tumors, then the parotid, salivary glands, and the pre-auricular lymph nodes.Then, the tracheal position is determined for deviation.,Elevated central venous pressure,Overfilling of the vascular space kidney failure, rapid infusion of fluids and bood products, chronic congestive heart failure with edema.,Thyroid gland and trachea,The normal adult thyroid is often not palpable. A goiter is any enlarged thyroid gland.,inspection,Have the patient seated in a good cross-light. Inspect the lower half of the neck in the anterior triangles. Have the patient swallow to note any ascending mass in the midline.,Palpation from behind,Have the patient seated in a chair and stand behind her. Instruct the patient to lower her chin and relax her neck muscles. Place your thumbs in back of the patients neck, curling your fingers anteriorly so their tips just touch while resting over the upper tracheal rings.,Palpation from behind,Run the fingers up and down the tracheal rings, feeling for any tissue on their anterior surface. If found, it is likely to be a hyperplastic thyroid isthmus. During the examination, shift the inclination of the patients head to relax the neck muscles, and have the patient swallow to test the adherence of palpated masses to the trachea.,Should be done with the pt seated in a chair while the physician examines the neck for both behind and in front,of the pt,Palpation of the thyroid,Frontal palpation,Face your patient placing the fingers of one hand at the back of the neck with your extended thumb forward at the base of the thyroid cartilage.