诊断学--Physical-Examination-of-the-Head-and-Neck(头颈部

HeadWangxinjun王新军PEoftheHeadisbyinspectionandpalpationTheinspectionisesp,importantandusefulforPEofheadThisisbecausemanytraitsorfindingsfromthehead,esp,theface,issoattractivelydrawourattentionwhenwefirstlylookatthepatient.ForEx,theemotionalreactions:ThyrotoxicfacesThepatientisoftenthinandwasting,accompaniedbyanalert,startled,flushedandanxiousappearance.CushingoidfaceFeatures:moonface,plethora,acne,hirsutism(over-growthofbodyhair,esp.mustacheofawoman)Inspectforasymmetryoftheskull,ears,eyes,nose,mouth,jaw,andcheeks.Noteanymassesordeformities.ParalysisoffacialHeadexaminationInthegeneralheadexamination,theexaminershould:1.Identifysignsofgeneralizeddisease2.Recognizelocallessionswithinthepurviewofthegeneralist3.RecognizelocallesionsrequiringspecialistcareHAIR,SCALPANDSKULLchangesinthehairAlopecia脱发Clinicaloccurrence:hypothyroidismetalHirsutismandhypertrichosis多毛症和毛发过多polycysticovary,glucocorticoidexcess多囊卵巢、糖皮质激素过多SKULLMALFORMATION头颅畸形Craniosynostosis颅缝早闭:prematureunionofspecialsuturesleadstoskullmalformations.Hydrocephalus脑积水Meningocele脑脊膜膨出EyesEyelids眼睑Conjunctiva结膜Eyeball眼球Cornea角膜Sclera巩膜Irisandlensandpupils虹膜、晶状体、瞳孔eyelidsLidinversion(entropion)睑内翻Lideversion(ectropion)睑外翻Failureoflidclosure(paralysisoforbicularismuscle)眼睑闭合障碍Failureoflidopening(ptosisofthelid)上睑下垂Lidswelling(palpebraledema)眼睑水肿FailureoflidclosureThefacialnerve(CNVII)suppliestheorbicularisoculimuscle眼轮匝肌.Disorderofthisnerve,asinBellpalsy（贝尔麻痹，面神经麻痹）,causespartialorcompleteparalysisoftheorbicularis.FailureoflidopeningThecongenitalformisusuallybilateralfromparalysisorfailuretodevelopthelevatorpalpebraesuperioris提上睑肌.Clinicaloccurrence:encephalitis,Hornersyndrome,paralysisofthelevatormuscle.ptosisofthelid(Hornersyndrome)Interruptionofthecervicalsympatheticchaininteruptssympatheticinnervationoftheeyeandface.Thecompletesyndromehasptosis上睑下垂,miosis瞳孔缩小,andanhydrosisontheaffectedside患侧面部无汗.LidswellingLocalinfectioncauseinflammatoryedemaoftheeyelids.nephritis.ItoccursearlyinthecourseofbothmyxedemaandtheexophthalmosofGravesdisease.EyeballLidlag(VonGraefeSign)(hyperthyroidism)Alagisindicatedbywhitescleraappearingbetweenlidandlimbus.Sclera巩膜Inobstructivejaundice（黄疸）,conjugatedbilirubin胆红素infiltratesallbodytissuesandfluids,itcolorsthescleraevenly.Irisandlensandpupils虹膜、晶状体和瞳孔Notethesize,shape,andequalityofthepupils.pupillaryreactiontolightTestpupillaryreactiontolightbyhavingthepatientfixonadistantobjectsothatthepatientdoesnotfixateonthelightanduseaccommodation.pupillaryreactiontolightShineapenlightintothepupilfromthesidewhileobsevingthedirectpupillaryreaction直接对光反射.pupillaryreactiontolightRemovethelightandrepeattheprocess,thistimelookingattheopposite(unlighted)pupilforconsensualreaction间接对光反射.Repeatthissequenceexposingtheoppositeeyetothelight.earsPinna耳廓Externalacousticmeatus外耳道RoughquantitativetestforhearinglossnoseExternalnasaldeformitiesEpistaxis(nosebleed)鼻出血Suppurativeparanasalsinusitis化脓性鼻窦炎Epistaxis(nosebleed)Nosebleedcanbeaspontaneousandtrivialoccurrenceorasignofseriouslocalorgeneralizeddisease.Inquireabouttrauma,predisposinglocalorsystemicdisease,andtheamountofbloodlost.Blood-tingedfluidsuggestsacerebrospinalfluid脑脊液leak.Mouseandparotidgland腮腺Examinationisbyinspectionandpalpation.Facingthepatient,holdatongueblade压舌板inthelefthandandapenlightintheright.Ifaheadlampormirrorisused,yourrighthandisfreetoholdanasalorlaryngealmirror喉镜.MouseandparotidglandLips口唇Buccalmucosa口腔黏膜Teeth牙齿Gums牙龈Tongue舌Oropharynx口咽Tonsils扁桃体Larynx喉Parotidgland腮腺lipsHavethepatientattempttowhistle,torevealparalysisfromfacialnerve(CNVII)lesions.LabialenlargementThelipsmayappearlargeincretinism克汀病/呆小病,myxedema粘液性水肿,acromegaly肢端肥大症.Buccalpigmentation(Addisondisease)DappledbrownpigmentintheliningofthecheekstronglysuggestsAddisondisease.Oralwhitepatches(口腔白斑，鹅口疮)InfectionoftheoralmucosawithCandidaspp.白色念珠菌occursinpatientswhoareimmunosuppressedorhavereceivedbroadspectrumantibiotics.teethPigmentedteeth(fluoride氟pits)Opaquechalkwhitespots,1~2mmindiameter,areseenscatteredonthesurfaceofmultipleteeth.Thisisaharmlessconditionfoundinpersonswhohaveingestedlargeamountsoffluorideinthewaterduringchildhood.Tongue舌Havethepatientprotrudehistongue.Assessitssize;lookfordeviationfromthemidline.Lingualenlargement舌体增大ThetongueisenlargedinDownsyndrome,cretinism,andadultmyxedema.Itincreasesinsizeduringthedevelopmentofacromegaly.LingualtremorIncreasedsympatheticactivityisassociatedwithfinetremor.Afinetremorofthetongueisoftenpresentinhyperthyroidism.Lingualdeviation(paralysisofthehypoglossalnerve(CNXII)Thetongueprotrudesbytensingthetwolateralmusclebundles,paralysisofonebundlecausesthetonguetodeviatetotheparalyzedside.tonsilsThenormaladulttonsilsseldomprotrudebeyondthefaucialpillars咽腭弓.Hyperplasiaisusuallyattributedtochronicinfection,butitmaybeassociatedwithobesity,hyperthyroidism,orlymphoma.Larynx喉laryngealparalysis喉麻痹Thevocalcords声带areinnervatedbytherecurrentlaryngealnerves喉返神经,whicharesusceptibletoinjuryintheneckandchestinferiortothelarynx.Followingthyroidectomy(eitherorbothsides),an