1. Headache.

headaches?

 • Onset. When did this kind of headache start?

 • Gradual, over hours, or a day?

 • Or, suddenly, over minutes, or less than 1 hour?

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This is a more meaningful question than “Do you ever have headaches?” because most people have had at least one headache. Because many conditions have a headache as a symptom, a detailed history is important.

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 Ever had this kind of headache before?

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A red flag is a severe headache in an adult or child who has never had it before.

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 • Location. Where do you feel it: frontal, temporal, behind your eyes, like a band around the head, in the sinus area, or in the occipital area?

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Tension headaches tend to be occipital, frontal, or with bandlike tightness; migraines (vascular) tend to be supraorbital, retro-orbital, or frontotemporal; cluster headaches (vascular) produce pain around the eye, temple, forehead, cheek.

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• Is pain localized on one side, or all over?

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Unilateral or bilateral (e.g., with cluster headaches, pain is always unilateral and always on the same side of the head).

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 • Character. Throbbing (pounding, shooting) or aching (viselike, constant pressure, dull)?

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Character is typically viselike with tension headache, throbbing with migraine or temporal arteritis.

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 • Is it mild, moderate, or severe?

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Pain is often severe with migraine, or excruciating with cluster headache.

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• Course and duration. What time of day do the headaches occur: morning, evening, awaken you from sleep?

  How long do they last? Hours, days?

  Have you noted any daily headaches, or several within a time period?

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Migraines occur about twice per month, each lasting 1 to 3 days; cluster headaches occur once or twice per day, each lasting [image] to 2 hours for 1 to 2 months, and remission may last for months or years.

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 • Precipitating factors. What brings it on: activity or exercise, work environment, emotional upset, anxiety, alcohol? (Also note signs of depression.)

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Alcohol ingestion and daytime napping typically precipitate cluster headaches, whereas alcohol, letdown after stress, menstruation, and eating chocolate or cheese precipitate migraines.

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 • Associated factors. Any relation to other symptoms: any nausea and vomiting? (Note which came first, headache or nausea.) Any vision changes, pain with bright lights, neck pain or stiffness, fever, weakness, moodiness, stomach problems?

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Nausea, vomiting, and visual disturbances are associated with migraines; eye reddening and tearing, eyelid drooping, rhinorrhea, and nasal congestion are associated with cluster headaches; anxiety and stress are associated with tension headaches; nuchal rigidity and fever are associated with meningitis or encephalitis.

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Do you have any other illness?

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Hypertension, fever, hypothyroidism, and vasculitis produce headaches.

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Do you take any medications?

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Oral contraceptives, bronchodilators, alcohol, nitrates, carbon monoxide inhalation produce headaches.

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• Pattern. Any family history of headache?

What is the frequency of your headaches: once a week? Are your headaches occurring closer together?

Are they getting worse? Or are they getting better?

(For females) When do they occur in relation to your menstrual periods?

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Migraines are associated with family history of migraine.

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 Effort to treat. What seems to help: going to sleep, medications, positions, rubbing the area?

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With migraines, people lie down to feel better, whereas with cluster headaches they need to move—even to pace the floor—to feel better.

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Coping strategies. How have these headaches affected your self-care or your ability to function at work, home, and socially?

2. Head injury.

head injury

 • Onset. When? Please describe exactly what happened.

 • Setting. Any hazardous conditions? Were you wearing a helmet or hard hat?

 • How about yourself just before injury: dizzy, light-headed, had a blackout, had a seizure?

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 Lose consciousness and then fall? (Note which came first.)

  Knocked unconscious? Or did you fall and lose consciousness a few minutes later?

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Loss of consciousness before a fall may have a cardiac cause (e.g., heart block).

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Any history of illness (e.g., heart trouble, diabetes, epilepsy)?

 • Location. Exactly where did you hit your head?

 • Duration. How long were you unconscious?

  Any symptoms afterward—headache, vomiting, projectile vomiting?

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Any change in level of consciousness after injury: dazed or sleepy?

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A change in level of consciousness is most important in evaluating a neurologic deficit.

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Associated symptoms. Any pain in the head or the neck, vision change, discharge from ear or nose—is it bloody or watery? Are you able to move all extremities? Any tremors, staggered walk, numbness and tingling?

 • Pattern. Symptoms become worse, better, unchanged since injury?

 • Effort to treat. Emergency department or hospitalized? Any medications?

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3. Dizziness.

dizziness?

(Determine exactly what the person means by dizziness.) Was it a feeling of light-headedness or of falling? Or was it a spinning sensation?

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Dizziness is a light-headed, swimming sensation, feeling of falling. True vertigo is true rotational spinning from neurologic disease (labyrinthine-vestibular apparatus, vestibular nuclei in brainstem).

When vertigo is objective, the person feels like the room spins. When vertigo is subjective, the perception is that the person spins.

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 Onset. Abrupt or gradual? After a change in position, such as sudden standing?

 • Associated factors. Any nausea and vomiting, pallor, immobility, decreased hearing acuity, or tinnitus along with the dizziness?

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Neck pain.

 • Onset. How did the pain start: injury, automobile accident, after lifting, from a fall? Or with fever? Or did it have a gradual onset?

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Acute onset of neck stiffness with headache and fever occurs with meningeal inflammation.

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Location. Does pain radiate? To the shoulders, arms?

 • Associated symptoms. Any limitations to range of motion (ROM), numbness or tingling in shoulders, arms, or hands?

 • Precipitating factors. What movements cause pain? Do you need to lift or bend at work or home?

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• Does stress seem to bring it on?

 • Coping strategies. Able to do your work, to sleep

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Pain creates a vicious circle. Tension increases pain and disability, which produces more anxiety.

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Lumps or swelling.

lumps or swelling

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Any recent infection? Any tenderness?

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Tenderness suggests acute infection.

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For a lump that persists, how long have you had it? Has it changed in size?

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persistent lump arouses suspicion of malignancy. For people older than 40 years, suspect malignancy until proven otherwise

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• Any history of prior irradiation of head, neck, upper chest?

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Increased risk for salivary and thyroid tumors.

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 Any difficulty swallowing?

Dysphagia.

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 • Do you smoke? For how long? How many packs a day? Do you chew tobacco?

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When was your last alcohol drink? How much alcohol do you drink a day?

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Smoking and chewing tobacco increase risk for oral and respiratory cancer.

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Smoking and large alcohol consumption together increase the risk for cancer.

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 • Ever had a thyroid problem? Overfunctioning or underfunctioning? How was it treated: surgery, irradiation, any medication?

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6. History of head or neck surgery.

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Surgery for head and neck cancer often is disfiguring and increases risk for body image disturbance.

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Additional History for the Aging Adult

1.

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2.

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Assess self-care. Assess potential for injury.

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Note the general size and shape. Normocephalic is the term that denotes a round symmetric skull that is appropriately related to body size. Be aware that “normal” includes a wide range of sizes.

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Deformities: microcephaly, abnormally small head; macrocephaly, abnormally large head (hydrocephaly, acromegaly, Paget's disease), see Table 13-2, Abnormalities in Head Size and Contour, p. 271.

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To assess shape, place your fingers in the person's hair and palpate the scalp. The skull normally feels symmetric and smooth. Cranial bones that have normal protrusions are the forehead, the side of each parietal bone, the occipital bone, and the mastoid process behind each ear. There is no tenderness to palpation.

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Note lumps, depressions, or abnormal protrusions.

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Palpate the temporal artery above the zygomatic (cheek) bone between the eye and top of the ear.

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The artery looks tortuous, feels hardened and tender with temporal arteritis.

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The temporomandibular joint is just below the temporal artery and anterior to the tragus. Palpate the joint as the person opens the mouth, and note normally smooth movement with no limitation or tenderness.

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Crepitation, limited ROM, or tenderness.

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Inspect the face, noting the facial expression and its appropriateness to behavior or reported mood. Anxiety is common in the hospitalized or ill person.

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Hostility or aggression.

Tense, rigid muscles may indicate anxiety or pain; a flat affect may indicate depression.

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Although the shape of facial structures may vary somewhat among races, they always should be symmetric. Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth.

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Marked asymmetry with central brain lesion (e.g., stroke) or with peripheral cranial nerve VII damage (Bell's palsy). See Table 13-5, Abnormal Facies with Chronic Illnesses.

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Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation) or any abnormal swelling. Also note any involuntary movements (tics) in the facial muscles. Normally none occur.

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Edema in the face occurs first around the eyes (periorbital) and the cheeks where the subcutaneous tissue is relatively loose.

Note grinding of jaws, tics, fasciculations, or excessive blinking

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Head position is centered in the midline, and the accessory neck muscles should be symmetric. The head should be held erect and still.

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Head tilt occurs with muscle spasm. Rigid head and neck occur with arthritis.

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Note any limitation of movement during active motion. Ask the person to touch the chin to the chest, to turn the head to the right and left, to try to touch each ear to the shoulder (without elevating shoulders), and to extend the head backward. When the neck is supple, motion is smooth and controlled.

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Note pain at any particular movement.

Note ratchety or limited movement from cervical arthritis or inflammation of neck muscles. The arthritic neck is rigid; the person turns at the shoulders rather than at the neck.

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Test muscle strength and the status of cranial nerve XI by trying to resist the person's movements with your hands as the person shrugs the shoulders and turns the head to each side.

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As the person moves the head, note enlargement of the salivary glands and lymph glands. Normally no enlargement is present. Note a swollen parotid gland when the head is extended; look for swelling below the angle of the jaw. Also, note thyroid gland enlargement. Normally none is present.

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Thyroid enlargement may be a unilateral lump, or it may be diffuse and look like a doughnut lying across the lower neck (see Table 13-3, Swellings on the Head or Neck).

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Also note any obvious pulsations. The carotid artery runs medial to the sternomastoid muscle, and it creates a brisk localized pulsation just below the angle of the jaw. Normally, there are no other pulsations while the person is in the sitting position (see `

Using a gentle circular motion of your fingerpads, palpate the lymph nodes (Fig. 13-9). (Normally the salivary glands are not palpable.

When symptoms warrant,

check for parotid tenderness by palpating in a line from the outer corner of the eye to the lobule of the ear.) Beginning with the preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph nodes in a routine order. Many nodes are closely packed, so you must be systematic and thorough in your examination. Once you establish your sequence, do not vary or you may miss some small nodes.

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The parotid is swollen with mumps (see Table 13-3).

Parotid enlargement has been found with AIDS.

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Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically. However, the submental gland under the tip of the chin is easier to explore with one hand. When you palpate with one hand, use your other hand to position the person's head. For the deep cervical chain, tip the person's head toward the side being examined to relax the ipsilateral muscle (Fig. 13-10). Then you can press your fingers under the muscle. Search for the supraclavicular node by having the person hunch the shoulders and elbows forward (Fig. 13-11); this relaxes the skin. The inferior belly of the omohyoid muscle crosses the posterior triangle here; do not mistake it for a lymph node.

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If any nodes are palpable, note their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness. Cervical nodes often are palpable in healthy persons, although this palpability decreases with age (Fig. 13-12). Normal nodes feel movable, discrete, soft, and nontender.

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Lymphadenopathy

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If nodes are enlarged or tender, check the area they drain for the source of the problem. For example, those in the upper cervical or submandibular area often relate to inflammation or a neoplasm in the head and neck. Follow up on or refer your findings. An enlarged lymph node, particularly when you cannot find the source of the problem, deserves prompt attention.

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The following criteria are common clues but are not definitive in all cases:

_ Acute infection—acute onset, <14 days’ duration, nodes are bilateral, enlarged, warm, tender, and firm but freely movable.

_ Chronic inflammation (e.g., in tuberculosis the nodes are clumped).

_ Cancerous nodes are hard, >3 cm, unilateral, nontender, matted, and fixed.

_ Nodes with HIV infection are enlarged, firm, nontender, and mobile. Occipital node enlargement is common with HIV infection.

_ A single enlarged, nontender, hard, left supraclavicular node (Virchow's node) may indicate neoplasm in thorax or abdomen.

_ Painless, rubbery, discrete nodes that gradually appear occur with Hodgkin's lymphoma.

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trachea

Normally, the trachea is midline; palpate for any tracheal shift. Place your index finger on the trachea in the sternal notch, and slip it off to each side (Fig. 13-13). The space should be symmetric on both sides. Note any deviation from the midline.

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Conditions of tracheal shift:

_ The trachea is pushed to the unaffected (or healthy) side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax.

_ The trachea is pulled toward the affected (diseased) side with large atelectasis, pleural adhesions, or fibrosis.

_ Tracheal tug is a rhythmic downward pull that is synchronous with systole and that occurs with aortic arch aneurysm.

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thyroid gland

The thyroid gland is difficult to palpate; arrange your setting to maximize your likelihood of success. Position a standing lamp to shine tangentially across the neck to highlight any possible swelling. Supply the person with a glass of water, and first inspect the neck as the person takes a sip and swallows. Thyroid tissue moves up with a swallow.

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Look for diffuse enlargement or a nodular lump.

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thyroid gland 

Posterior Approach.

Fig. 13-14, A

Then curve your right fingers between the trachea and the sternomastoid muscle, retracting it slightly, and ask the person to take a sip of water. The thyroid moves up under your fingers with the trachea and larynx as the person swallows. Reverse the procedure for the left side.

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thyroid gland

Usually you cannot palpate the normal adult thyroid. If the person has a long, thin neck, you sometimes will feel the isthmus over the tracheal rings. The lateral lobes usually are not palpable; check them for enlargement, consistency, symmetry, and the presence of `

Abnormalities: enlarged lobes that are easily palpated before swallowing or are tender to palpation (see large goiter in Fig. 13-14, B); or the presence of nodules or lumps. See Table 13-3, p. 272.

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thyroid gland

Anterior Approach.

Fig. 13-15

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Auscultate the Thyroid

If the thyroid gland is enlarged, auscultate it for the presence of a bruit. This is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally.

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A bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid (e.g., hyperthyroidism).

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The Pregnant Woman

During the second trimester, chloasma may show on the face. This is a blotchy, hyperpigmented area over the cheeks and forehead that fades after delivery. The thyroid gland may be palpable normally during pregnancy.

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The Aging Adult

The temporal arteries may look twisted and prominent. In some aging adults, a mild rhythmic tremor of the head may be normal. Senile tremors are benign and include head nodding (as if saying yes or no) and tongue protrusion. If some teeth have been lost, the lower face looks unusually small, with the mouth sunken in.

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the neck may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine. During the examination, direct the aging person to perform ROM slowly; he or she may experience dizziness with side movements. An aging person may have prolapse of the submandibular glands, which could be mistaken for a tumor. But drooping submandibular glands will feel soft and be present bilaterally.

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primary headaches

location

Location

tension

Usually both sides, across the frontal, temporal, and/or occipital region of head: forehead, sides, and back of head

migraine

Commonly one-sided but may occur on both sides

Pain is often behind the eyes, the temples, or forehead

cluster

Always one-sided

Often behind or around the eye, temple, forehead, cheek

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primary headaches

character

tension

Bandlike tightness, viselike

Non-throbbing

migraine

Throbbing, pulsating

cluster

Continuous, burning, piercing, excruciating

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primary headaches

duration

tension

Gradual onset, lasts 30 minutes to days

migraine

Rapid onset, peaks 1-2 hr, lasts 4 hr to 72 hr, sometimes longer

cluster

Abrupt onset, peaks in minutes, lasts 45-90 min

primary headaches

quantity and severity

tension

Diffuse, dull, aching pain

Mild to moderate pain

migraine

Moderate to severe pain

cluster

Can occur multiple times a day, in “clusters”

Severe stabbing pain

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primary headaches

timing

tension

Situational, in response to overwork, posture

migraine

About 2/month, lasts 1-3 days

cluster

1-2/day, each lasting [image] to 2 hr, for 1 to 2 months; then remission for months or years

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primary headaches

aggravating symptoms and triggers

tension

Stress, anxiety, depression, poor posture

migraine

Hormonal fluctuations (premenstrual)

Foods (e.g., alcohol, caffeine, MSG, nitrates, chocolate, cheese)

Letdown after stress

Changes in sleep pattern

Sensory stimuli (e.g., flashing lights or perfumes)

Changes in weather

Physical activity

cluster

Exacerbated by alcohol, stress, wind or heat exposure

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primary headaches

associated symptoms

tension

Fatigue, anxiety, stress

Sensation of a band tightening around head, of being gripped like a vice

Sometimes photophobia or phonophobia

migraine

Often preceded by an aura (visual changes such as blind spots or flashes of light, tingling in an arm or leg, vertigo)

Nausea, vomiting, photophobia, abdominal pain

Family history of migraine

 cluster

Nasal congestion or runny nose, watery or reddened eye, eyelid drooping, miosis, feelings of agitation

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primary headaches

relieving factors, efforts to treat

tension

Rest, massaging muscles in area, NSAID

migraine

Lie down, darken room, use eyeshade, sleep, take NSAID or narcotic when severe

cluster

Need to move, pace the floor

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Hydrocephalus

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[image]

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Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head. The face looks small compared with the enlarged cranium. The increasing pressure also produces dilated scalp veins, frontal bossing, and downcast or “setting sun” eyes (sclera visible above iris). The cranial bones thin, sutures separate, and percussion yields a “cracked pot” sound (Macewen's sign).

Paget's Disease of Bone (Osteitis Deformans)

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Askeletal disease of increased bone resorption and formation, which softens, thickens, and deforms bone. It affects 10% of those older than 80 years and occurs more often in males. The disease is characterized by bowed long bones, sudden fractures, frontal bossing, and enlarging skull bones that form an acorn-shaped cranium. Enlarging skull bones press on cranial nerves, causing symptoms of headache, vertigo, tinnitus, progressive deafness, and optic atrophy and compression of the spinal cord.

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Acromegaly

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Excessive secretion of growth hormone from the pituitary gland after puberty creates an enlarged skull and thickened cranial bones. Note the elongated head, massive face, prominent nose and lower jaw, heavy eyebrow ridge, and coarse facial features, especially when compared with the same woman's face on the left pictured several years before she had a pituitary tumor

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Torticollis (Wryneck

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A hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to the opposite side. You will feel a firm, discrete, nontender mass in mid-muscle on the involved side. This requires treatment, or the muscle becomes fibrotic and permanently shortened with permanent limitation of ROM, asymmetry of head and face, and visual problems from a non-horizontal position of the eyes.

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Goiter

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A chronic enlargement of the thyroid gland that occurs in some regions of the world where the soil is low in iodine. Not due to a neoplasm.

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Thyroid—Multiple Nodules

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Multiple nodules usually indicate inflammation or a multinodular goiter rather than a neoplasm. However, suspect any rapidly enlarging or firm nodule.

Single Nodule (not illustrated):

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Pilar Cyst (Wen)

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Smooth, firm, fluctuant swelling on the scalp that contains sebum and keratin. Tense pressure of the contents causes overlying skin to be shiny and taut. It is a benign growth.

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Parotid Gland Enlargement

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Rapid painful inflammation of the parotid occurs with mumps. Parotid swelling also occurs with blockage of a duct, abscess, or tumor. Note swelling anterior to lower ear lobe. Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergics.

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Parkinson Syndrome

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A deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain. The immobility of features produces a face that is flat and expressionless, “masklike,” with elevated eyebrows, staring gaze, oily skin, and drooling.

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Cushing Syndrome

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With excessive secretion of corticotropin hormone (ACTH) and chronic steroid use, the person develops a plethoric, rounded, “moonlike” face; prominent jowls; red cheeks; hirsutism on the upper lip, lower cheeks, and chin; and acneiform rash on the chest.

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Hyperthyroidism

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Goiter

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Myxedema (Hypothyroidism)

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A deficiency of thyroid hormone, when severe, causes a nonpitting edema or myxedema. Note puffy, edematous face, especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows.

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Bell's Palsy (Right Side)

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A lower motor neuron lesion (peripheral), producing cranial nerve VII paralysis, which is almost always unilateral. It has a rapid onset, and its cause is currently thought to be herpes simplex virus (HSV). Note complete paralysis of one half of the face; the person cannot wrinkle forehead, raise eyebrow, close eye, whistle, or show teeth on the right side. Usually presents with smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and pain behind the ear.

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Stroke or Cerebrovascular Accident

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An upper motor neuron lesion (central). A stroke (or brain attack) is an acute neurologic deficit caused by an obstruction of a cerebral vessel, as in atherosclerosis, or a rupture in a cerebral vessel. If you suspect a stroke, ask if the person can smile. Note paralysis of the lower facial muscles, but also note that the upper half of face is not affected because of the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes.

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Cachectic Appearance

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Accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features include sunken eyes; hollow cheeks; and exhausted, defeated expression.

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Scleroderma

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Literally, “hard skin,” this rare connective tissue disease is characterized by chronic hardening and shrinking degenerative changes in the skin, blood vessels, synovium, and skeletal muscles. Changes can occur in the skin, heart, esophagus, kidney, lung. Characteristic facies: hard, shiny skin on forehead and cheeks; thin, pursed lips with radial furrowing; absent skinfolds; muscle atrophy on face and neck; absence of expression.

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Summary Checklist: Head, Face, and Neck, Including Regional Lymphatics Examination

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1 Inspect and palpate the skull

General size and contour

Note any deformities, lumps, tenderness

Palpate temporal artery, temporomandibular joint

2 Inspect the face

Facial expression

Symmetry of movement (cranial nerve VII)

Any involuntary movements, edema, lesions

3 Inspect and palpate the neck

Active ROM

Enlargement of salivary glands, lymph nodes, thyroid gland

Position of the trachea

4 Auscultate the thyroid (if enlarged) for bruit

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