hi I'm Rachel - I'm a student at Nova Southeastern University today I'm going to be doing your head I hear it's not a strong example okay I'm gonna step over to wash my hands real quick and then I'll be right back my patient appears a new distress and appears to be a healthy young lady at this point we're also doing a general survey of our patients we're looking at our patients to see if she's in any distress mood for these central cyanosis or any kind of distress to suggest that she's uncomfortable or I'm also making sure that my patient is prepared for my exam for the head eyes nearest appears most on exam it's really about glasses no need glasses baseball caps things that may become an obstacle in regards to our exam and she appears prepared today but inspecting the head for symmetry and when we inspected we're kind of milking another patient they're kind of looking at our patient all the way around we're looking for shape and contour and any deformities and the key indicator for this one would be I'm inspecting for those things or you can also say this is normal so Alec thanks to general parents respecting for symmetry again expression any skin lesions or any obvious abnormalities central cyanosis once again and then all hair distribution actually have to come to my patient I'm touching their hair I'm looking at the texture over here but the contour that even spread or the growth of our hair distribution and here her hair symmetrical hair distribution for her hands Gotham inspecting the ham scalp for infestations and looking at texture any scaling any lesions right and that's all inspection now let's pop eight right so inspections always first but now it's time for palpation gonna palpate the cranium and when we do it's just using both of our hands we're kind of covered all those thoughts all of her scalp we're looking for any tenderness and there are no masses or tenderness is elicited and then also just in this area here is the temporal artery plate so we're going to palpate over the temporal artery and make sure that is non-tender from the cranium the tip arteries who live right down into the sinuses we have the maxillary sinuses as well as the frontal sinuses on our patient right so over those we're going to gently palpate over those sinuses so there's our frontals and then our necks elating any two minutes from the maxillary services we have the product lands the product lands were going to inspect for any redness or tenderness we're going to top pate this parotid glands from the large mint and the product lands are non palpable or you could say that they are without nodules or irregularity rajae clans will go right into the TMJ the temporomandibular joint I'll pop it over first and then I have my patient open her jaw open good close slide side to side and then how to protrude her bottom jaw remained allowed and I note for any clicking which is that crepitus feeling or any tenderness when we moved through those those movements you may also palpate the muscles of mastication and we'll have a patient down so there are two sets right there's the temporal and then there's also the mass enter so clench your teeth for me good I'm gonna palpate relax and again good so here we will say that cranial or five is intact cranial ER seven is spiking for symmetry of facial movement I'm gonna have my patient go through several different movements of our face first is going to be to raise your eyebrows very good and we're looking for symmetry we're gonna have our patient close our eyes keep them tight don't let me open them always like them nice and tight now show me your teeth big smile beautiful and then frown I'll puff out your cheeks very good don't let me express the air okay very good so now cranial 107 is intact I exam again starts with inspection purses the general pens we're inspecting the eyebrows for inspecting the eyelashes and the lids themselves and you're inspecting for symmetry any skin lesions in the periorbital or discolorations or edema we're also looking for any cranial nerve palsy like ptosis which is a kind of about 3 palsy or exophthalmos which is actually the expulsion of the eyes forward from the orbits so noted here as black mold duct glands largest nasally on both sides of the nose and it's just a matter of March my fingers right on up to see if I actually get discharged into the lacrimal area or the medial canvas they will inspect the conjunctiva and the scelera inspecting a bull bar and the perry baller conjunctiva for any splitter at tips clara or a pallet right to look up for me alright so we're just looking at today you can our lab is done with a Rosenbaum chart and if you notice the fine print below it must be 14 inches away in this chart already has a 14 inch measuring device so with the right hand on what should cover your right eye in a cup and then your left hand put this to your left cheek very good and read from left to right the smallest one you can read are four two eight seven three nine okay let's do the other side go ahead from right to left four to eight seven three nine okay four to eight seven three nine okay so with the rosenbaum what's important is that we also if the patient has corrective glasses or lenses and we test them what those lenses on Digital films by confrontation we're going to have our patient look directly at us and I'm going to use my two fingers right and you look right into my eyes I'm going to start behind their shoulders and down their head and I started with doing my fingers the minute did you see my fingers on either side or both sides I want you to point to good another method is this nothing I'll go ahead and grab my pin light I have my patient focus on the tip of life yeah I'm about 12 to 14 inches away from my patient all right move your eyes don't want to be ahead and pull them up in okay so X dr. amendments aren't attacked what I'm looking for there is as my patient follows as I move the lateral aspect of the iris into the lateral canthus I want to hold it there just for a second in each position and I'm looking for the stagnant remember that rotary nystagmus is a normal variant horizontal is fine vertical nystagmus suggests that we might have something going on in the brainstem so we want to make sure that we evaluate the type of nystagmus and the beats of nystagmus he's opinion we're going to have them followed from a far distance to about all they're just from their nose and then we're gonna have them again look on to something on the back wall so I'm gonna help you look at the view box and then I want to bring this pin in so just follow the tip of my opinion this is convergence her eyes are converging together now look back at the box not back to our tent and back to the box and back to a pen what I'm looking for here is actual constriction of the pupil as she focuses on the near object so with that I would say to my patients eyes converge which they do and then the people's accommodated the anterior chamber just like the interior of course to the artists and it's as simple as taking a flashlight or a pin light and I have a look right at me I'm looking at the depth of the interior chamber and your pasties or anything that floats freely into their chamber and then once I get to this point one of the things that kind of people don't really understand is something called the Crescent shadow the Crescent shadows when I take my light my pen light and I shine it across my anterior chamber and I'm looking at my patient if from extra ocular pressure on the from the globe itself it will actually start pushing the lateral aspects of the iris first into the anterior chamber and when it pushes it into the chamber it cast a shadow nasally creating something that looks like a crescent light and then I'll look on this side as well so no crescent shadow is now we're going to look for the position and alignment of our patients eyes so this is done in a couple of ways the first way is get this coil in light reflex and what I do is I have my patient look at me and I try to show the light right down the bridge of her nose look right at me and if you notice the reflection in her eyes from the light it should be symmetrical on both sides right so that is normal alignment she has a very normal alignment so there's no strabismus checking for Layton's true business I'll use an eye occluder when we cover one eye looking right at me and then I'll remove their clutter quickly and I watch for the I to eat a roll from outside back the midline or nasally back to midline that would be something trying to Leighton strabismus so without any stimuli she has a normal alignment but when I add an occlusion by bringing back my Leighton strabismus will roll back into midline very good so no strabismus our people reaction we're going to examine each side separately and then we'll kind of watch for response of both people's so with a direct light stimuli to the I should get constriction on this side and it does and then again on this side and it does now I'm going to shine a light into our left eye but I'm looking in the right eye I should get consensual it should it should also constrict that honey should move together so I should get constriction on the right eye and I did constriction on the left eye pupil and I did so she has peoples that are equal they're very round which is important those people should be very round and they react to light and they must certainly accommodate also if you look most of your pin lights have the measurements on the side and she's about three millimeters in size let's get right into the fundus copy things yeah now let me show you some things briefly about this is a well challenge but some things that we need to know about it the dial this is most certainly obviously the on/off switch but we can increase the illumination of the light sometimes you don't need it to be as bright and if it's constant bright it can actually cause some you know discomfort to your patient so it doesn't always have to be super bright the other things on the back we talked about these filters in lecture so we had this cobalt green filter we had the bullseye that kind of helps us plot out things that we find in the posterior exam and then we most certainly have different sizes I'm going to change it to this and I'll show you that this switch will actually change the lot the size or the shape of my Optima scope there's no cobalt blue right testing with fluorescein all over the cornea and then just various sizes right of the light I usually sit right on the middle of the medium and that usually works well for most of my patients I do from a 45 degree angle to my patient and I kind of brace my hand or head put my thumb on the eyebrow how about center or midline of the eye itself I raise it just a little bit I tell my patient my instruction is blink as much as you want okay just don't move your eyes left or right or up or down but you can blink just stare straight ahead at that whew box so once I've instructed my patient and I'll start with my light I usually start on the cheek so I'll know my position on their face and I've kind of roll right up at 45 degrees at this point I start spinning my doctor will I can see my red eye reflex at this point and once I get my red eye reflex I'll start moving my diopter before I move my face any closer and I can actually see an artery right here and a vein remember I told everybody that you just follow the map into downtown Orlando which is about right here in that area right there is my optic disc in my cup and I'm not really having to move much of the diopter well at this point I go out to my all four quadrants so I can see that she has good arterial and venous sighs that there's no AV nicking at all I'm also looking to make sure that it is a two-to-one regards to a B ratio and then I'm gonna go arrival now I'm gonna follow one out temporally so I get to the macula now what you're looking to the light and that's where I check for the fovea whether we finished our photo scopic exam now go right into the ear exam again remember that all of our exams as you went from system to system or organ to organ when we get to the dominant cardiovascular pulling us off is it's always by the inspection first so here we're going to inspect and palpate the oracles bilaterally this is done together so we're just looking at the ears themselves of a palpate we're looking for any tenderness or inspecting for lesions to Parmen ease any discharge from the external auditory canal it's a trigger sighs you're right but then a year from now they open you know so we're palpating the tragus and the tragus is non-tender the mastoid lies here just behind the ear so we're looking at the mastoid making sure it's not aired images are swollen and then a slight percussion or just palpation bilaterally can tell us about anything that might be going on with the mastoid like an infection and hers are non tender bilaterally let's go ahead and get into our autoscopic exam just changing the head out on this and then we'll use a speculum all right the speculum just kind of sits on top of the instrument and in turns clockwise will lock it patella clockwise opens it so just a brighter slide is probably what you need it's usually works just fine and then what I'll do is I'll come to my patient the important thing here is hand position because you want to protect our patients so I put my hand on top of my patients head with these three fingers embracing my hand these two fingers I'm lifting up and out on an adult's here right again as I bring my light up I'm inspecting one more time then you discharge it you're a theme of that external canal and then I will place my otoscope in ear canal before I do anything else before I bring my face down once I bring my face down I'm looking at the tympanic membrane some folks may ask how far do you need to insert the speculum it's just enough to displace the tragus and to get into the ear canal to visualize the tympanic membrane it really doesn't need to be much further than that but once I get into the patient's ear notice this finger lies on the back of her behind her ear to stabilize my otoscope so if my patient pushes into me or she pulls away from me my hand will actually move with her here so go ahead and lean to me gently notice how my otoscope moves with her because my hand is kind of attached to her head so I look at the tympanic membrane it's pearly gray and translucent I see the parched tense of course flaccid I glow it's known distorted the kind of light or the light reflexes in the anterior inferior quadrant I'm looking for any air here there's no evidence of airflow levels now I want you to gently pinch your nose together and blow very gentle the tympanic membranes now let's go ahead and test for auditory acuity test and I had told you folks in lecture we can do it a couple of ways having a patient close their eyes and tell me where you hear sound left important things we're about 12 inches away for me here did you hear both very good sometimes we can use our watch you can take a little watch we're gonna watch sometimes you can have your patient close your eyes and just whisper what you hear so once our patient passes that exam clinically then we really do not need to advance our exam if there are deficits then we will use our 512 tuning fork and we're going to do a couple of other exams the first one is going to be the whether it's easier if you take your tuning fork pinch it between your fingers and you can activate it this way other ways some people activate it is over a knuckle gently right I think if you do this you're creating too much sound wave and it might distort your findings on your exam so it gentle and then I'm going to place it right cheers of both in both ears equally once I finish that test I'll come behind and only go back to the mastoid I'm how do you bring your head to your right side I'm going to come to the mastoid area I'm gonna activate the tuning fork again and I instruct my patient I want you to tell me when you stop hearing it okay so I've activated we place on the mast away tell me when you can you hear and then I would test it myself lecture still activate it is that tells me that her bone her air conduction is greater than her bone conduction because if if she's still hearing it here and then she can't hear it anymore that bone conduction has stopped but now I can test her sensory here and she can still hear it that tells me that AC is greater than BC our key indicator performance with the weather is midline or it analyzes to one side or the other and then a C is greater than BC bilaterally so we have to test that I'm going to the nose exam at this point I always like to put my gloves on for my patients safety as well as mine if I put my gloves on for the nose in them and the oral exam the first thing that's important here is to make sure that the patient's nasal airway is patent so I'm gonna have my patient to take one of her fingers left or right side include your nostril and breathe in good and let's do the other side so if there's any abnormal findings on my exam it's not not secondary to an occlusion now we're going to test criminal everyone was going to be done bilaterally we have garlic and ground cinnamon each nostril has to be tested differently so I'm gonna have a VGA close your eyes cover your left nostril and I'm going to ask you can you tell me what you see once we finish with the acclaim euler test we get into this septum and we'll start with the determinate you're gonna inspect the septum and the terminates with with the speculum not picking up on the otoscope and we're looking at the condition of the mucosa there is a technique that I want you to learn about looking being able to look in the inferior portion will determine its lie as well as the floor of the nose and a way to look at the septum so first what I do is I put my hand up once again about patient protection and halt controlling her I'm gonna have you look up for me I'm gonna lift the tip of her nose gently with my light RT on em I insert the speculum again I look and make sure to see where I'm at before I put my face down so I don't hurt my patient so I'm sitting here and then I kind of come up and I tipped her head up a little bit this back and look at the mucosa of our nose I'm looking at the middle and the inferior terminus and I'm I have a look down slowly very slowly and I'm looking at the floor and the septum I'm looking for inflammation I'm looking for discharge looking for lesions looking for deviation of the septum or any active bleeding sites of bleeding so the mucus is pink and without any lesions again any time we start an exam it's always about inspection so we're going to inspect the lips for discoloration make sure they're pink and moist there's no cracking there's no lesions and then I'm going to do an oral pharyngeal you know look inside the quickly got too close so our inspection and just looking at the general apparent you can inspect or Frangelico sort for any color and looking for ulcers white patches or modules we're going to use a tongue depressor and a pin line so I'm just kind of looking around right the buccal mucosa the roof of the mouth the soft and hard palate again on this side as well I'm looking at the tongue also we're looking at the gingiva and you're inspecting for any lesions or ulcerations there as well on the teeth exam while we talk about this election it's a matter of distracting the teeth it's about raking the teeth really then I flip it up and then smile for my teeth together and then it's just a gentle tapping on the teeth in that dinner [Music] there is the cranial nerve 10 that we'll look at we're going to look for a rise and fall on phonation so what you do is just open and say oh honey stick your tongue a little bit more and we're looking for the uvula to rise and fall symmetric we're looking at the tonsils I kind of show you where those are at but the tonsils were looking for size and color tonsils lie out here say again tonsils out I'm going to move your tongue over to your right down your left side I'm sorry they kind of sit right back in here then you see this side kind of sit back in here and she's about a 1 we talked about different sizes she's about a 1 on both sides if we met needed to test for the gag reflex it's a matter of just inserting the tongue bite back just for nothing we would initiate the gag reflex which is cranial nerve nine and ten right but we're not going to do that for under 12 I'm going to have my patient extend your tongue straight up right so moving our thumb straight out midline position and there's no deviation that's primitive 12 intact we're gonna select all the service of the tongue and collar for lesions make sure we're wearing their gloves and keeping with you know universal precautions very important and so what we're going to do is we're going to grab the tip of the tongue with a two by two I know but I'm gonna grab it stick your tongue up on me oh my god dude it's the tip of her tongue okay and I'm going to look inspection on both sides of the tongue lip to know and I'm looking for I'm inspecting for any lesions remember we talked a lecture about the lateral margins or the most common areas for neoplasms or cancers so check for that so I'm going to tell her what I'm doing first just to keep so I have to put my fingers in her mouth I'm gonna go along the bottom of your tongue and I'm gonna go up the other side and then I'm gonna kind of okay so on the oral exam when we're doing it by main exam the oral cavity there's some things that we need to look for so first time I patient open their mouth I want to insert two fingers and I know that everyone's mouth is a little different but I'm gonna palpate with this hand my left hand is capturing between these two fingers in my left hand and I'm palpating over the Stinson's Ducks would be here from here I'm going to go under her tongue lift your tongue up here's my Wharton's glance and I'm making sure that those are non tender and then I'm going to move out to her left side against tenses ducks or any inflammation here once I'm done here I'm going to pull my finger one finger out but this finger stays in I'm gonna go along her lip line palpating her lip line any tenderness nope right on around so that we have all of the lip covered as well and then my exam is done okay the next portion of our exam is the neck exam first we're going to come to the front of our patient and we're looking for just tracheal physician we're going to inspect the trachea position how it's aligned in her neck and then just a mobility and it's a gentle just movement of a trachea back and forth and it shouldn't cause any discomfort so we would mentioned that the trachea is midline and it's mobile the scan was inspected skin from the lesions returning moles or nodules or discoloration any scars in the neck as well and there are no lesions or moles here let those we talked about in lecture but I would really like to show you here on how to bring your hair to the right side again and again the occipital lymph nodes actually lie above the hairline they actually up in the occipital region of the scalp and it's a matter of cop hating this whole occipital region right and I'm palpating for any lymph nodes and then from the occipital region I come into the post auricular area so here's poster ich euler so i'll palpate the post wrinkly area this is pre auricular then I'll come to the angle of the jaw which is the tonsillar or southern mandibular and then right into the submental area for lymph nodes so that's the top layer we have talked about and now I'm going to come down to the next layer the next layer is the cervical chains the cervical chains are posterior the deep cervical light underneath the SCM and then there's the anterior chain which lies anterior to the SCM so when I palpate for these lymph nodes I kind of start at the base of the skull and I kind of gently palpate down that posterior chain it's more than one lift though it's to about right here my deep cervical lie around the SCM so my digits to the fingers on my hands actually displace the SEM and then I palpate deeply into for those lymph nodes of the deep cervical chain the anterior chain lies anterior to the sternocleidomastoid and once again I start up high rather at the base of the mandible and I come down the chain palpating no no lymph nodes noted and then I go out to their super look Vic you learn ODEs which lie just over the collarbone supraclavicular and then last but not least just on the inside where the the biceps tendon kind of and there is a epital your note right so I'll gently update this area as well okay those are the lymph nodes in the neck have you looked at the thyroid gland lies here and I know this just from experience but if I needed to there is the cricoid there's that the cricoid cartilage and just inferior to that is my thyroid lobules right the lobes lie left and right side just inferior to the correct weight so once I have palpated and noticed my location I come to the back of my patient I put my hip up on the bed so behind my patient my hands lie just over the thyroid gland I'm gonna have a patient look up this for a minute you can swallow it for me that moves the thyroid gland up and through my hand and now I'm gonna have you look down to the left now what that does is it releases the stomach Lata mastoid on the left and I'm going to take my right hand and I'm going to displace your thyroid gland into my left hand as my left hand does the exam that's the left side now I want you to look over and down to the right now I'm going to do the same I'm going to displace the fabric alone with my left and examine with my right I'm looking for any nodules lesions or any tenderness or swelling in that range of motion because we're here but really this neck range of motion has a lot to do with our musculoskeletal system but I'm only way down my patient go through it I could tell my patient hey what you they do some flexion extension and rotation and a lateral bending but our patients don't know that it's what I typically tell them someone happy' look all the way to the sky oh very good left ear on the left shoulder yeah yeah very good and then you're right here on the right very good know how much it rotate left last not least which is number 60 it's our 1811 we're gonna test the shoulder shrug and the SVM strength against resistance to test they start a cloud a mastoid strength I just place my hand on the side of my patients head I don't really put my hand here because it does undue stress to the TMJ so I put my hand over the TMJ I want you to look to your right against my hand I apply a little pressure and then I come to the other side and I do the same to the right very good and then my hands are here I'm gonna have you raise your shoulders up hold them up and I push down gently to test for cranial nerve