Helen McDonald 10/29/09 Head and Neck Assessment H.G. DOB: 10/28/09 CC: I m !e"e #o" a "o$t%ne c!

!eck $&' HO(I: (t %s a )2 *ea" old #emale +!o &"esents to t!e cl%n%c #o" a +ellness ,%s%t. (t states !e" last e-am +as .e&tem/e" o# 2000. 1e,%e+ o# s*stems: (t den%es an* neck &a%n. (t states s!e !as %nte"m%ttent !eadac!es +%t! seasonal alle"2%es. (t states !e" last !eadac!e +as #o$" +eeks a2o a#te" "ece%,%n2 t!e #l$ ,acc%nat%on at 1300 on 10/0/09.. (t states !e" !ead #elt l%ke %t +as #%ll%n2 $&. (t stats !e" last !eadac!e a##ected !e" #o"e!ead and s%n$ses. (t states !e" &a%n +as a ) o$t o# 10 on t!e &a%n scale and +as t!"o//%n2. (t states !e" !eadac!e +as cont%n$o$s and s$/s%ded a#te" slee&%n2 8 !"s. (t states !e" !eadac!es 2et /ette" +!en s!e %s la*%n2 do+n and +o"se +%t! l%2!ts and +!en !e" k%ds a"e *ell%n2. (t den%es #ac%al &a%n and d%##%c$lt* mo,%n2 !e" !ead o" neck. (t !as !ad /asal cell ca"c%noma to !e" le#t c!%n +!%c! +as "emo,ed s$"2%call* %n 4an$a"* o# 2003 need%n2 no #$"t!e" %nte",ent%on. (t den%es not%c%n2 an* "esent l$m&s o" les%ons on !e" !ead o" neck. (t den%es d%55%ness6 l%2!t!eadedness6 s&%nn%n2 sensat%ons o" loss o# consc%o$sness. (t den%es an* "esent c!an2es %n t!e te-t$"e o# !e" sk%n6 !a%" o" na%ls. (t den%es c!an2es %n !e" ene"2* le,el6 slee& !a/%ts and emot%onal sta/%l%t*. (t den%es &al&%tat%ons6 /l$""ed ,%s%on o" c!an2es %n /o+el !a/%ts. (MH: (t den%es an* t"a$ma6 %n7$"* o" #alls. (t den%es "ece%,%n2 "ad%at%on t!e"a&*. 8H: (t den%es #am%l* !%sto"* o# !ead o" neck cance"s. (t den%es #am%l* !%sto"* o# m%2"a%ne !eadac!es. 9%#est*le and !ealt! &"act%ces: (t den%es smok%n2 o" c!e+%n2 to/acco. (t states s!e +ea"s a !elmet +!en "%dd%n2 a /%c*cle. (t states s!e !as 2ood &ost$"e +!en "ela-%n26 d$"%n2 slee& and +!%le +o"k%n2. (!*s%cal Assessment Head and 8ace: :!e !ead %s s*mmet"%c6 "o$nd6 e"ect6 and m%dl%ne. No les%ons a"e ,%s%/le. :!e !ead %s !eld st%ll and $&"%2!t +%t! no t"emo"s noted. :!e !ead %s &al&ated and #o$nd to /e !a"d and smoot! +%t! no les%ons noted. :!e #ace %s s*mmet"%c +%t! an o,al a&&ea"ance. Mo,ements a"e s*mmet"%cal. :!e tem&o"al a"te"* %s &al&ated and %s nontende" and elast%c. :!e tem&o"omand%/$la" 7o%nt %s &al&ated +%t! s+ell%n26 tende"ness o" c"eo%tat%on noted +%t! mo,ements. Mo$t! o&ens and closes ;cm /et+een $&&e" and lo+e" teet!. 9o+e" 7a+ mo,es late"all* 1to 2 cm %n eac! d%"ect%on. Neck: :!e neck %s s*mmet"%c +%t! t!e !ead cente"ed. No /$l2%n2 masses noted. :!e

t!*"o%d ca"t%la2e6 c"%co%d ca"t%la2e and t!*"o%d 2land mo,e $&+a"d s*mmet"%call* +!en t!e cl%ent s+allo+s. :!e cl%ent %s a/le to mo,e t!e neck smoot! and contolled +%t! <3 de2"ee #le-t%on6 33 de2"ee e-tent%on6 <0 de2"ee late"al a/d$ct%on and 00 de2"ee "otat%on. :!e neck %s &al&ated. :!e t"ac!ea %s noted to /e m%dl%ne. 9andma"ks o# t!e t!*"o%d 2land a"e m%dl%ne. :!e t!*"o%d 2land %s not &al&a/le. 9*m&! Nodes o# t!e !ead and neck: No s+ell%n2 o" enla"2ement o" tende"ness noted $&on &al&at%on o# t!e &"ea$"%c$la" nodes6 &osta$"%c$la" nodes6 occ%&%tal nodes6 tons%lla" nodes6 s$/mand%/$la" nodes6 s$/mental nodes6 s$&e"#%c%al ce",%cal nodes6 &oste"%o" ce",%cal nodes6 6 dee& ce",%cal c!a%n nodes6 o" s$&"acla,%c$la" nodes .