بسم الله الحمن الرحيم

1. بسم الله الحمن الرحيم (قل ان صلاتي و نسكي و محياي ومماتي لله رب العالمين لا شريك له وبدلك امرت وأنا اول المسلمين) قال رب اشرح لى صدرى ويسر لى أمرى واحلل عقدة من لسانى يفقهوا قولى طه25-28

2. The History and Physical Examination of H&N Dr. Abdussalam M jahan ENT depart, Misurata university, faculty of medicine

3. The History • Welcome the patient - ensure comfort and privacy. • Know and use the patient's name. • introduce and identify yourself. • Set the Agenda for the questioning.

4. Personal history: Age, sex , place, occupation, marital state, religion.

5. Main Complaint • This is why the patient in our OPD. • Examples: • Headache. • Otalgia. • Dental pain.

6. History of Present Illness • This is the detailed reason why the patient is here • It is the why, when and where, etc…

7. Onset • When did the main complaint occur • Progression • Is this problem getting worse or better • Is there anything that the patient does that makes it better or worse. • Quality • Is there pain, and if so what type—how would the patient describe it. • For example: • - aching.

8. - Throbbing ( like pulsation).- burning.- Stabbing: sudden, severe, sharp & short duration.- distention.- colicky: comes & disappear in sinusoidal way.

9. Radiation • Do the symptoms radiate to anywhere in the body, and if so, where? • Scale • On a scale of 1 to 10, how bad are the symptoms. • Timing • When do the symptoms occur? • At night, all the time, in the mornings, etc…

10. Associated symptoms • Any other information about the main complaint that has not already been covered • Ask if there is anything else that the patient has to tell about the main complaint

11. Past Medical History • These are the medical conditions that the patient has chronically and that they see a doctor for. • Examples: • Hypertension, GERD, Depression, Congestive heart failure, hyperlipidemia, Diabetes, Asthma, Allergies, Thyroid problems, etc…

12. Past Surgical History • These are any previous operations that the patient may have had • Make sure to put how old the patient was when they occurred • Include even those that occurred in childhood • Examples: • Tonsillectomy,Hysterectomy,Appendectomy, Hernias, Cholecystectomy

13. Systems review (history): • The review of systems is just that, a series of questions grouped by organ system including: • General/Constitutional • Skin/Breast • Eyes/Ears/Nose/Mouth/Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Neurologic/Psychiatric • Allergic/Immunologic/Lymphatic/Endocrine

14. Drug history: • Try to include the dosages if the patient knows them • Include how often the patient takes them

15. Social History: • Things to include: • Occupation • Marriage status • Tobacco use—how much and for how long • Alcohol use • Immunization status • Life style • Travel abroad.

16. Family History … finally • Ask if the patient’s parents, grandparents, siblings or other family members had any major medical conditions • Examples: • Heart disease, heart attacks, hypertension, hyperlipidemia, diabetes, sickle cell disease

17. History of a lump or mass - Onset: when it appear. - Any symptom with the lump. - Change in size. - Disappearance or no. - History of same or other lump.

18. Examination of a lump or mass • - Site : location. • Size : diameter. • shape : oval, round, irregular,.. • tenderness. • composition: • 1- consistence: hard, rubbery, soft, cystic. • 2- fluctuation: pressure on one side makes all surfaces protruded. ( indicate fluid – filled cavity)

19. 3- fluid thrill: tap one side & feel the transmitted vibration when reach the other side.4- translucensy: using pin point light source. +ve in fluid: (water, serume, lymph, plasma )-ve in case of solid or blood.5- resonance: fluid & solid→ dull gas →resonant.6- pulsation.7- compressibility.8- reducibility.

20. Examination of cranial nerves: Cranial Nerve I: Olfactory • Arises from the olfactory epithelium • Passes through the cribriform plate of the Ethmoidal bone • Fibers run through the olfactory bulb and terminate in the primary olfactory cortex Ask the pt about smell

21. Cranial Nerve II: Optic • Arises from the retina of the eye • Optic nerves pass through the optic canals and converge at the optic chiasm • They continue to the thalamus where they synapse • From there, the optic radiation fibers run to the visual cortex • Function: carrying afferent impulses for vision • Visual acuity & visual fields • Papillary reflexes (II and III) • Fundoscopy (papilloedema )

22. Cranial Nerve III: Oculomotor • Fibers extend from the ventral midbrain, pass through the superior orbital fissure, and go to the extrinsic eye muscles • Functions : eye movements. raising the eyelid, directing the eyeball, constricting the iris

23. Cranial Nerve IV: Trochlear • Fibers emerge from the dorsal midbrain and enter the orbits via the superior orbital fissures; innervate the superior oblique muscle • Primarily a motor nerve that directs the eyeball Turns the eye down ward & out ward

24. Cranial Nerve V: Trigeminal • Composed of 3 divisions • Ophthalmic (V1) • Maxillary (V2) • Mandibular (V3) • Fibers run from the face to the pons via the superior orbital fissure (V1), the foramen rotundum (V2), and the foramen ovale (V3) • Conveys sensory impulses from various areas of the face (V1) and (V2), and supplies motor fibers (V3) for mastication Tested by: absent corneal reflex, loss of superficial sensation of the half of the face, weakness of mastication.

25. Cranial Nerve VI: Abducens • Fibers leave the inferior pons and enter the orbit via the superior orbital fissure • Primarily a motor nerve innervating the lateral rectus muscle (abducts the eye; thus the name Abducens) Turns the eye out ward ; diplopia

26. Cranial Nerve VII: Facial • Fibers leave the pons, travel through the internal acoustic meatus, and emerge through the stylomastoid foramen to the lateral aspect of the face

27. Motor functions include; • Facial expression • Transmittal of parasympathetic impulses to lacrimal and salivary glands (submandibular and sublingual glands) • Sensory function is taste from taste buds of anterior two-thirds of the tongue

28. Cranial Nerve VIII: Vestibulocochlear • Fibers arise from the hearing and equilibrium apparatus of the inner ear, pass through the internal acoustic meatus, and enter the brainstem at the pons-medulla border • Two divisions – cochlear (hearing) and vestibular (balance) → Examine the equilibrium and hearing

29. Cranial Nerve IX: Glossopharyngeal • Fibers emerge from the medulla, leave the skull via the jugular foramen, and run to the throat • Nerve IX is a mixed nerve . • Motor – innervates part of the tongue and pharynx, and provides motor fibers to the parotid SG. • Sensory – fibers conduct taste and general sensory impulses from the tongue and pharynx Absent gag reflex

30. Cranial Nerve X: Vagus • The only cranial nerve that extends beyond the head and neck • Fibers emerge from the medulla via the jugular foramen • The vagus is a mixed nerve • Most motor fibers are parasympathetic fibers to the heart, lungs, and visceral organs • Its sensory function is in taste • Paralysis leads to HOV, aspiration. IDL→ VC paralysis.

31. Cranial Nerve XI: Accessory • Formed from a cranial root emerging from the medulla and a spinal root arising from the superior region of the spinal cord • The spinal root passes upward into the cranium via the foramen magnum • The accessory nerve leaves the cranium via the jugular foramen • Primarily a motor nerve • Supplies fibers to the larynx, pharynx, and soft palate • Innervates the trapezius and SMM Ask the pt to elevate the shoulders.

32. Cranial Nerve XII: Hypoglossal • Fibers arise from the medulla and exit the skull via the hypoglossal canal • Innervates both extrinsic and intrinsic muscles of the tongue, which contribute to swallowing and speech If damaged, difficulties in speech and swallowing; inability to protrude tongue (deviated to affected side)

33. TRIANGLES of NECK • Anterior Triangle: • Bounders: • Ant. border of smm (post) • Lower edge of the jaw( sup) • Midline ( ant). • It su divided into: • 1- digastric • 2-carotid • 3- muscular.

34. TRIANGLES of NECK • posterior Triangle: Bounders: post. border of smm (ant) ant edge of the Tr M( post) clavicle ( inf).

35. Lymph nodes of NECK 1- deep CLN: upper, middle & lower. 2- supraclavicular LN. 3- submental & submandibular. 4- post. Triangle LN. 5- occipital LN. 6- prelaryngeal, pretracheal & paratracheal. 7- upper mediastinum LN.

36. Lymph nodes of NECK Levels of Lymph nodes of NECK -L I: submental & submadibular. -L II: upper deep CLN. -L III: middle deep CLN. -L IV: lower deep CLN. - L V: post. Triangle LN. -L VI: prelaryngeal, pretracheal & paratracheal. - L VII : upper mediastinum LN.

37. Special examination I- examination of throat: • teeth. • Tongue: mass, ulcer,.. • Tonsils: size, pus, inflam. • Posterior pharyngeal wall: redness, cobble stone app, post nasal discharge,…. • Floor of mouth: ranulla, tongue tie,.. • Ulcerations: aphtus, malignant ulcer,..

38. II – examination of the nose: Using anterior rhinoscopy • Color of mucosa: pink ( allergy), red (inflam). • Nasal septum: deviation, bleeding, perforation, swelling. • Inferior turbinate: if it is swollen. • Nasal cavity: polyposis, discharge, FB..

39. III- examination of the ear: • Examine hearing. • Ext ear: (auricle, EAC) inflam, discharge, mass,.. • Tympanic membrane: using otoscope discharge, retraction, perforation,.. - Tuning fork test.

40. Salivary Glands • Minor salivary glands • Major salivary glands: • Parotid • Serous • Sublingual • Mucous • Submandibular • Mixed

41. - parotid gland: neck swelling just bellow the auricle. Most common cause mumps ( viral) • Submandibular: most common site of calcoli, presented by submand neck swelling, pain with eating. palpation (bimanual) - sublingual: swelling in the floor of the mouth.

42. T H Y R O I D G L A N D • Body’s largest endocrine organ • Has two lobes joined by isthmus • Right lobe is larger than the left • Moves upward on swallowing

43. THYROID GLANDDisorders • Thyroid enlargement – diffuse or nodular • Hypothyroidism • Hyperthyroidism • Simple Goiter • Thyroid Malignancies

44. History Taking- Hyperthyroidism • Goiter • Anxiety & Irritability • Nervousness • Insomnia • Excessive sweating • Heat intolerance • Weight loss despite good appetite • Increase gut motility • Palpitations • Symptoms of Heart failure • Tremor • Proximal myopathy • Eye symptoms: - Prominence of Eyes - Diplopia - Decreased visual acuity

45. History Taking- Hypothyroidism • Onset: Usually Gradual • ± Goiter • Constitutional Symptoms: • Cold Intolerance • Fatigue, Lethargy • Hoarseness • Integument: • Thickened/yellowed, Dry, Non-pitting Edema (Myxedema) of hands/feet/periorbital region, Cool,  Perspiration, Alopecia. • Cardiovascular: •  contractility,  rate,  cardiac output, pericardial/pleural effusions,  peripheral vascular resistance. CHF rare.

46. Examination of Thyroid Gland • Inspection - Thyroid enlargement - Moves with swallowing • Palpation - Examine from behind using three fingers - Size, Shape, Consistency - Diffuse / Nodular - Confirm movement with swallowing

47. Enlarged Thyroid Gland is called Goiter • Generalized enlargement is Diffuse Goiter • Irregular lumpy enlargement is called Nodular • Palpate for Lymph Nodes

48. Percussion - Sub-sternal extension • Auscultation - For any bruits

49. D\D of swelling in the neck: You have to answer 4 questions: 1- one or more than one lump. 2- site. 3- solid or cystic. 4- movement with swallowing.

50. Multiple lumps → means LN • Single lump: 1- in ant triangle + not move with swallowing: - solid: LN, carotid body tumor. - cystic: cold abscess, branchial cyst. 2- post triangle + not move with swallowing: - solid: LN - cystic: cystic hygroma, pharyngeal pouch. - pulsatile: subclavian aneurysm. 3- ant triangle + move with swallowing: - solid: LN, thyroid gland. - cystic: thyroglossal cyst.