1. If certain Lymph nodes are enlarged, where else would you assess? Think about the drainage pattern.
Lymph Nodes in Head & Neck
• Preauricular, in front of the ear
• Posterior auricular (mastoid), superficial to the mastoid process
• Occipital, at the base of the skull
• Submental, midline, behind the tip of the mandible
• Submandibular, halfway between the angle and the tip of the mandible
• Jugulodigastric (tonsillar), under the angle of the mandible
• Superficial cervical, overlying the sternomastoid muscle
• Deep cervical, deep under the sternomastoid muscle
• Posterior cervical, in the posterior triangle along the edge of the trapezius muscle
• Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle
Drainage Patterns of Lymph Nodes
Enlarged Lymph Nodes:
 When nodes are enlarged, check the area they drain for the source of the problem.
 Often relate to inflammation or neoplasm (abnormal growth of tissue) in head and neck
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Explore the area proximal (upstream) to the enlarged node.
-an enlarged node indicates inflammation that is upstream from it
All head and neck structures eventually drain into the deep cervical chain.
2. Physical Assessment of Allergies vs Upper Respiratory Infection or Cold
Allergies
 Runny nose
 Sneezing
 Sometimes-fatigue, weakness
 Uncommon headache
 No fever, malaise
URI
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Cold
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Usually viral
Pain areas: in the sinuses
Nasal: congestion, loss of smell, post-nasal drip, or sneezing
Respiratory: sinusitis or wheezing
Whole body: fatigue or fever
Speech: hoarseness or laryngitis
Throat: irritation of the tonsils or soreness
Also common: coughing, headache, inflammation of ear, phlegm, or swollen lymph nodes
Stuffy runny nose
Sneezing
Sore throat
Cough
Fever RARE
HA uncommon
3. Vertigo vs Dizziness
 Dizziness is feeling light-headed or having a feeling of fainting or falling caused by decreased blood
flow.
 Vertigo is true rotational spinning usually from problems with inner ear (CN VIII)
4. How do you assess the ears of an adult vs a child?
 Adult: pull ear up and back
 Child: pull ear down and back
5. How do you know if you are looking at the right or left TM?
 Right ear: cone of light at 5 o’clock position
 Left ear: 7 o’clock position
6. What are some common causes for Hearing loss?
Hearing loss is categorized as conductive, sensorineural, or mixed conductive and sensorineural.
 Conductive hearing loss is caused by any physical obstruction to the transmission of sound waves.
 Sensorineural hearing loss is caused by a defect in the cochlea, eighth cranial nerve, or the brain
itself.
Common causes:
Conductive:
 Cerumen buildup
 Otosclerosis
 Ototoxic
Sensorineural:
 Presbycusis (age relate gradual degeneration of nerve VIII)
 Ototoxic drugs (affect ear cells in cochlea)
7. How do you assess for hearing loss? Special tests for hearing?
 Voice (whisper) test: determines hearing loss has occurred
 Watch test: for high frequency sounds
 Weber test: assess bone conduction; vibrating tuning fork place in middle of top head (should be heard
bilaterally
 Rinne test: compares bone conduction with air conduction; vibrating tuning for placed on mastoid
process (air conduction should be twice as long as air conduction)
8. What would an assessment look like for Otitis Media?
Why:
 Occurs because of an obstruction of the eustachian tube or passage of nasopharyngeal secretions into the
middle ear.
Assessment:
 Can be assessed with an otoscope / weber test
9. What is Nystagmus? ptosis? Pterygium? Exophthalmos?
 Nystagmus: abnormal, involuntary, rapid eye movements
 Ptosis: dropping of upper lid (sleepy appearance)
 Pterygium: bulbar conjunctiva overgrows toward the center of cornea
 Exophthalmos: protruding eyes
10. Accommodation, Pupillary light Reflex, Cornea light Reflex, Snellen Chart interpretation?
 Snellen Eye Chart: most commonly used and accurate measure of visual acuity.
- It has lines of letters arranged in decreasing size
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Corneal Light Reflex: used to assess for parallel alignment of the axes of the eyes
-reflection of the light on the 2 corneas should be in same spot on each eye
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Pupillary Light Reflex: darken room, advance light in from the side and note response
-constriction of the same-sided pupil, simultaneous constriction of other pupil
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Accommodation: asking person to focus on a distant object, this dilates the pupil. Then have person
shift gaze to a near object such as finger held 3 inches from person’s nose
-normal resp. pupillary constriction, convergence of the axes of the eyes
11. What are the common reasons for blindness that were discussed in class?
Common reasons:
 Glaucoma
 Diabetic retinopathy
 Cataracts
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Age-related macular degeneration
12. What are common findings for elderly patients regarding Head, Face, Neck, Ears, Eyes, Nose, Mouth,
Throat?
Eyes:
 Presbyopia (loss of near vision), cataracts, glaucoma, macular degeneration
Head, Neck, and Face:
 Temporal arteries may be twisted and prominent, mild rhythmic tremor of head, senile tremors (head
nodding and tongue protrusion), if teeth are lost, the lower face may look small and sunken, neck may
show concave curve when head and jaw are extended to compensate for kyphosis, may have prolapse
of submandibular glands
Ears:
 Presbycusis: loss of hearing as we get older
Nose and Mouth:
 Diminished smell and taste, atrophic tissues (less saliva and cannot breakdown food as well), dental
changes
13. What structures in the mouth are you assessing?
 Lips
 Teeth and gums
 Tongue (CN XII)
 U-shaped areas under the tongue
 Buccal mucosa
 Uvula (CN X)
 hard and soft palate
 Swallow and gag (CN IX & X)
 Tonsils
14. How do you assess the TMJ and temporal Arteries and what are abnormal findings?
TMJ:
 As person opens mouth, should be with smooth movement with no tenderness or limitation
 Abnormal findings: crepitus feeling
Temporal area:
 Palpate above zygomatic bone b/t eye and top of ear
 Abnormal findings: pulsations
15. What salivary glands can be assessed?
 Parotid glands: in the cheeks over the mandible, anterior to and below the ear
-largest but not normally palpable
 Submandibular glands: beneath the mandible at the angle of the jaw
 Sublingual glands: lie in the floor of the mouth
16. Where four areas on your body are lymph nodes found?
 Head and neck (greatest supply)
 Arms
 Axillae
 Inguinal region
17. What area of the small intestines and other organs are present in each quadrant?
Right Upper Quadrant
 Liver
 Gallbladder
 Duodenum
 Head of pancreas
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Right kidney and adrenal gland
Hepatic flexure of colon
Part of ascending and transverse colon
Left Upper Quadrant
 Stomach
 Spleen
 Left lobe of liver
 Body of pancreas
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Left kidney and adrenal gland
Splenic flexure of colon
Part of transverse and descending colon
Right Lower Quadrant
 Cecum
 Appendix
 Right ovary and tube
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Right ureter
Right spermatic cord
Left Lower Quadrant
 Part of descending colon
 Sigmoid colon
 Left ovary and tube
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Left ureter
Left spermatic cord
18. What is the proper way to do an abdominal exam and what are abnormal findings on an abdominal
exam?
Inspection:
 Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor
Auscultation:
 Bowel sounds; note any vascular sounds
Percussion:
 All four quadrants and borders of liver and spleen
Palpation:
 Light and deep palpation in all four quadrants, and palpate for liver and spleen
Abnormal Findings:
 Abdominal distention (tumor, ascites, cyst, obesity, pregnancy, air or gas)
 Abnormalities on inspection
 Abnormal bowel sounds (hypoactive and hyperactive bowel sounds)
 Friction rubs and vascular sounds (peritoneal friction rub, arterial bruit, venous hum)
 On palpation of enlarged organs
19. Test for appendicitis
 McBurney Point Tenderness
 Iliopsoas Muscle Test
 Blumberg test
20. Test for ascites
Ascites: free fluid in the peritoneal cavity bc of distended bulging flanks, and an umbilicus that is protruding
and displaced downward.
You can differentiate ascites from gaseous with two tests:
 Fluid wave: positive test with ascitic fluid
 Shifting dullness: shifting level of dullness indicates presence of fluid
21. What are common abdominal complaints? What are the medical terms for these complaints?
 Visceral from an internal organ (dull, general, poorly localized)
 Parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by
movement
22. Understand how to assess all Cranial nerves and when they would be assessed.
23. What are abnormal findings of the cranial nerves?
CN I, Olfactory nerve
 Anosmia
CN II, Optic nerve
 Defect or absent central vision
 Defect in peripheral vision, hemianopsia
 Absent light reflex
 Papilledema
CN III, Oculomotor nerve
 Dilated pupil, ptosis, eye turns out and slightly down
 Failure to move eye up, in, down
 Absent light reflex
CN IV, Trochlear nerve
 Failure to turn eye down or out
CN V, Trigeminal nerve
 Absent touch and pain, paresthesias
 No blink
 Weakness of masseter or temporalis muscles
CN VI, Abducens nerve
 Failure to move laterally, diplopia on lateral gaze
CN VII, Facial nerve
 Absent or asymmetric facial movement
 Loss of taste
CN VIII, acoustic nerve
 Decrease or loss of hearing
CN IX, glossopharyngeal nerve
 No, or abnormal rising of soft palate/uvula
CN X, Vagus nerve
 Uvula deviates to side
 No gag reflex
Voice quality:
 Hoarse or brassy
 Nasal twang
 Husky
 Dysphagia (diff swallowing), fluids regurgitate through nose
CN XI, spinal accessory nerve
 Absent movement of sternomastoid or trapezius muscles
CN XII, Hypoglossal nerve
 Tongue deviates to side
 Slowed rate of tongue movement
24. How do you assess cerebellar, cerebral function? What are the special tests?
Cerebellar function:
Cerebral cortex: center of highest funct., governing thought, memory, reasoning, sensation & vol. movements
Balance tests
 Gait
 Tandem walking
 Romberg’s test
 Shallow knee bend
Coordination and skilled movements
 Rapid alternating movements (RAM)
 Finger-to-finger test
 Finger-to-nose test
 Heel-to-shin test
Cerebral function:
 Mental status
 Level of consciousness
 Pupil reaction
 Communication
 Awareness/orientation
25. What are primitive reflexes?
Primitive reflexes: reflexes you are born with
26. Sensory tests for neuro
Spinothalamic Tract
 Sensations of pain
 Temperature
 Crude or light touch
Posterior (dorsal) Column
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Sensations of position
Vibration
Finely localized touch
27. Normal DTR findings and what areas of the spinal column are affected if they are abnormal?
Biceps Reflex: (C5 – C6)
Normal response: contraction of the biceps muscle and flexion of the forearm
Triceps Reflex: (C7 – C6)
Normal response: extension of forearm
Brachioradialis Reflex: (C5 – C6)
Normal response: flexion and supination of forearm
Quadriceps “Knee Jerk” Reflex: (L2 – L4)
Normal response: lower leg extension
Achilles “Ankle Jerk” Reflex: (L5 – S2)
Normal response: plantar flexes against your hand
28. Grading DTRs
4+: very brisk, hyperactive w clonus, indicative of disease
3+: brisker than average, may indicate disease
2+: average, normal
1+: diminished, low normal
0: no response
29. GCS
Glasgow Coma Scale: assesses level of consciousness, motor function, pupillary response, and vital signs
14. Head, Face, Neck
15. Eyes
16. Ears
17. Nose, Mouth, Throat
22. Abdomen
26. Anus, Rectum, Prostate
24. Neuro