1

Diagnosis

Lecture 3

Extraoral Examination
Dr Aceil instructed that the interpretation of numbers what's normal and what's not- must be memorized and instruments used to measure vital signs as well.

Introduction
The last two lectures discussed how to meet the patient, get to know his name, introduce yourself and escort him to the clinic, and when you're escorting him you observe his general external appearance as that is the first time you see him. This lecture will discuss how to perform extraoral examination and its components and principles. The book talks about things that we dont routinely do in the clinic for many reasons. When a patient comes for head and neck examination in a hospital we should check his vital signs (temperature, blood pressure, pulse and respiratory rate), so if you are working at a hospital setting the ideal extraoral exam includes head and neck complete examination and recording of the vital signs in the patient's report. In a hospital setting recording the vital signs is the job of the nurse. This is time consuming, plus the fact that you need enough instruments for all patients so every patient will take 15 more minutes, and this is not practical in a busy practice, thats why the nurse does that job.

However in the clinics we dont record vital signs unless if we are to perform oral surgical procedures (including extraction or any other invasive procedure), in that case, it's a must to record the blood pressure and pulse before we proceed especially if the patient is medically compromised.

Vital signs
Some people say that consciousness itself is one of the vital signs that should be recorded; this is if the patient was in an emergency situation. In general the vital signs are four, as follows Vital Signs

Temperature

Pulse

Respiration

Blood Pressure

Remember that all vital signs should be taken when the patient is at rest; wait 30 minutes if the patient has just eate n, drank a hot or cold beverage, just smoked, exercised (climbed the stairs for example) or if even he is anxious.

All four of the vital signs increase when the patient is anxious or just had a heavy meal or so, thus recording of the vital signs will not be accurate unless they are taken when the patient is at rest.

And now we will go through each one in detail. Please keep in mind that the interpretation of numbers is important and the Dr will ask about them in the exam

Temperature
Many studies were made to find out the normal temperature. The first person who studied temperature claimed that he had recorded the temperature of 1 million people which is hard to be believedand said that the normal body temperature is 37C (98.6), so lots of other studies point out that this 37C is not a cut point, meaning that some people might have a temperature of 36C or even 32C or 33C and is considered normal and they do not have hypothermia. In the clinics, Dr assumed that we all know how to measure temperature, but said that if you dont know and would like to learn bring a thermometer with you. We put the thermometer orally under the tongue for three minutes to get an accurate reading. In children and patients with psychiatric disorders we dont put the thermometer orally, because they might bite and break it endangering themselves because of the mercury, so avoid placing a thermometer in their mouths. The most accurate is the rectal and it usually records a higher temperature, the normal range there is 98.6 100.6 (37.6 C), however the axillary and the strips placed on the forehead usually record a lower temperature and its normal range is 96.6 98.6 (36.4 C). The tympanic which can be measured by placing an electronic thermometer in the ear is similar to the rectal with a normal range of 99.5 (37.5C).

When do we say that a patient has fever?

In adults In children

when the (oral) thermometer records 37.8 C. when the (rectal) thermometer records 38 C.

Pulse
Usually athletes have a lot of experience on how to measure pulse, because when they reach the optimum level of exercise they should have high pulse, to know that they have reached an adequate level of cardiac load. We usually measure pulse in more than one artery (radial, carotid and apical), the easiest one is the radial which is on the wrist. In the clinic you will measure the pulse so read about it before your clinical session to be ready. Remember when measuring pulse using the radial artery: Use the index and middle finger, not the thumb because there is a pulse in it. Place those two fingers on the base of patient's thumb.

We use the carotid artery if the patient fainted, because the pulse will be stronger in the carotid. We measure it by placing two fingers below the angle of the mandible and anterior the sternocliedomastoid.
5

For how much time do we measure it? The answer is 1 minute (60 seconds). Some books claim that it can be measured within 15 seconds and then multiplied by four or 30 seconds multiplied by two, but that is not accurate, because feeling pulse is not only counting the rhythm, but also feeling the strength and irregularity of the rhythm. In order to detect strength and irregularity you need experience, and 15 seconds are not enough to do so. Normal Range (60-100 beats/min)

Bradycardia: Slow pulse (<60) Hypothyroidism. Dedicated athletes. Tachycardia: Fast pulse (>100) Anxious subjects. Cardiovascular diseases. Hyperthyroidism. It's common to see pulse less than 60 especially in athletes, because the heart pump is stronger than in individuals who are not physically fit (the heart works slower because the pump is stronger), in addition to that, athletes tend to have bigger hearts (that may be misinterpreted as cardiomegally if the physician didnt know that that person is a indurant athlete) to the extent that a pulse rate as low as 37 has been recorded in athletic individuals. That 37 may be misinterpreted as Bradycardia but it's actually normal for him (It's important to know if your patient is an athlete). However the average heart rate is 72 beats/min and of course there is variation between individuals.
6

Blood Pressure
It assesses pressure within the arteries during cardiac contraction (systole) which is the first recording, and pressure during cardiac pause (diastole). The instrument used to measure blood pressure is called a sphygmomanometer (memorize names of instruments). Any artery can be used but doctors use the brachial artery because it's at the level of the heart and it is easy to access (we use the right arm). Also it should be recorded supine and sitting (?? Record 16:14). Blood pressure should be measured by an expert. If the patient has two high recordings of high blood pressure (taken by the same person) over a certain period of time he should be placed on medications because he has hypertension. You should learn how to measure blood pressure but in the clinics they dont have enough sphygmomanometers so ask someone to teach you either in the hospital or at home.

How to measure blood pressure: 1. Detect pulse in the brachial artery before you place the stethoscope on the arm, and then place the diaphragm over the area where you were able to auscult the pulse (in the "antecubital fossa"). 2. Inflate the cuff until the indicator reaches 200 or 250. 3. Start deflating it until you hear the first sound of pulse and register the reading (this is the systolic). 4. Continue deflating until the sound of pulse disappears and register the reading (this is the diastolic).
7

The systolic (top number) should be less than 130, but it varies with age, it could be around 147. The diastolic (bottom number) should be less than 80, but if the patient is 50 or 55 years of age, it could be up to 90, or even 91 if the patient is sixty. There are lots of references, some say the diastolic should be 80 or 85, but if the patient is above 50 years, 90 is considered within the range of normal. You dont have to know stage 1 or 2 hypertension, but you have to know the normal range and that it varies with age. If both systolic and diastolic readings are high, the diastolic is more important. However a patient is considered hypertensive if either one is high. In the slides you can see the 'National Joint Committee' classification, and there are many other classifications that do not agree with these readings. Although Dr said that you dont need to know the stages, she read them anyways so here are they Classification
Normal

BP (mm Hg)
systolic: less than 120 diastolic: less than 80 120-139 (systolic) 80-89 (diastolic) 140-159 (systolic) or 90-99 (diastolic) equal or more than 160 (systolic) equal or more than 100 (diastolic)

Pre-hypertensive

Stage 1 hypertension

Stage 2 hypertension

Keep in mind that if you look at the classification, a patient is considered in stage 1 for example if his BP was 140-159 over 90-99 that is if he is young, but if he is old the 90 is considered normal. As mentioned, two readings of high blood pressure mandate treatment and exercise.

Respiration rate
In the clinic a patient may be admitted as an emergency due to Hyperpnea (hyperventilation), and you will learn how to manage such an emergency if it occurs at your clinic.

How do we record the respiratory rate? We observe the inhaling and exhaling (1 inhale + 1 exhale = 1 breath) or the elevations and depressions of the patient's chest (if he is unconscious), for 60 seconds or 30 multiplied by two. The respiration rate should be 12-28 (the book says 12-20). Of course variation exists (children has higher respiration rates). Hyperpnea (increased rate of respiration) occurs in acidosis when an increase in carbon dioxide exhalation occurs as a physiologic compensatory process to increase blood pH. Tachypnea (increased shallow respirations), may be encountered in anxious patients. Metabolic alkalosis results in a decreased rate of respiration. Acidosis: Happens in diabetic patients.

Principles of Examination
There are mainly four principles of examination (considered 5 sometimes):

Inspection (visualization using eyes) Palpation Percussion Auscultation (using a stethoscope to hear sounds in TMJ) Smelling
We will start off with Smelling

Smelling Smelling can be an important diagnostic test in many cases: 1. Acidosis in diabetes 2. Patients with liver failure. 3. Patient with renal failure. 4. Differentiation between puss and keratin in a cystic lesion (you aspirate and if that aspirate is smelly it's puss, if not, it's keratin) because both have the same appearance but puss have a foul smell.

11

Inspection Inspecting starts the moment you see the patient. You can elicit some features such as: 1. General appearance: Alert, distress, clean, groomed or ungroomed. 2. State of nutrition: Thin, temporal wasting, malnourishments or obesity 3. The patient's profile especially in orthodontics and malocclusion to determine the skeletal relationship of the patient (class II or III). 4. Symmetry: mild asymmetry is a variation of normal (if the patient has asymmetry you have to indicate which side of the face is more prominent, right or left). 5. Posture and gait: shuffle (Parkinsons), foot drag, limp, lips and hands tremor 6. Speech: slurred, hoarse (you detect it when the patient answers your questions) 7. Skin lesions (moles, vesicles, ulcers, nevus, hyper pigmentations or erosions) or jaundice (icterus). 8. Eyes: Blue sclera (sometimes it's normal, but it could be a manifestation of osteogenesis imperfecta). Jaundice (icterus) Exophthalmos (clue that the patient has grave's disease or hyperthyroidism)

11

9. Swelling or enlargement in the parotid, sublingual or submandibular gland can be noted visually, or you can see erythema in the sinus area in patients with acute sinusitis. 10. Neck inspection: Ask the patient to swallow and inspect if there is any enlargement in the thyroid (look at the area below Adam's apple at the cricoid cartilage) 11. Hair and ears also. For religious considerations we do not usually inspect the neck and hair in females wearing hijab unless the history is relevant and the exam is necessary, so in the clinic you will inspect skin, eyes, acne, scars. There are lots of other clinical features that can be detected by inspection, so from now on practice to inspect patients thoroughly, and document everything in the patient record. Other features include: Nail clubbing (seen in iron deficiency anemia) Nail biting (seen in stressed patients).

In intraoral exam jaundice can be visualized in the ventral surface of the tongue, and in the junction of the hard and soft palate.

Examples:
Blue sclera: osteogenesis imperfecta

Jaundice (Icterus)

12

Notice the scar on this patient, and the pimples. (Pustules are puss-filled pimple) (Vesicles are fluid-filled 2mm)

Parotid glands Location: Behind the masseter, in front of and below the ear lobes. Enlargement: Notice it by inspection of the parotid, by looking from behind the patient especially in obese patients (who have fat pads in the cheeks), so if you stand behind the patient you can distinguish if there is enlargement or not (if enlarged it may elevate the ear lobe). Remember that in the clinic you will apply inspection on your partner and you should know what to look for and what abnormalities to asses. And now what about Palpation?...

Palpation of lymph nodes Palpate lymph nodes to detect any enlargement, normal nodes are not palpable but if they are palpable they should be the size of a pea or lentil (they are palpable especially in skinny people at the furcation of the carotid artery). If they are bigger than a pea it's an abnormal finding. It's common to see patients with enlargement of lymph nodes.
13

If you palpate a lymph node, you need to determine if this node is mobile or fixed, because mobile and tender lymph nodes are usually inflammatory while hard and fixed lymph nodes are usually malignant. When you want to palpate lymph nodes, establish an order of palpation in order not to forget to check any lymph node, and the order that the Dr wants us to follow is: 1. Preauricular 2. Submandibular 3. Anterior cervical 4. Posterior auricular 5. Posterior cervical

You start palpation from behind the patient, and you examine the lymph nodes with your fingers starting with the Preauricular: which is located anterior to the ear Submandibular: you ask the patient to move his head to the side and downward, and you move your fingers against the inferior border of the mandible, you may feel this node moving against the bone, sometimes you feel the submandibular gland so you have to differentiate between the lymph node and the gland, and if you are suspicious you place a finger inside the patient's mouth and two fingers outside (bimanual) and you feel the gland (it will be clearer when we discuss the glands).
Submandibular gland is larger than submandibular lymph node. (the gland is around 2 cm) If you can palpate more than one it's for sure lymph nodes not gland.
14

Submental: you ask the patient to tilt his head forward, and you palpate against the inner surface of the mandible.

Soft, tender, moveable lymph node is more likely associated with an infection (inflammatory). Hard, nontender, nonmoveable (fixed) lymph node may be more characteristic of a neoplastic process (malignant) and rubbery firm they most likely Hodgkin's lymphoma.

Notice the size of the normal lymph nodes. Remember to distinguish between enlarged submandibular lymph nodes and submandibular gland. Notice that at the area of the parotid gland you can find the preauricular lymph nodes. Buccal lymph nodes can be found in the patient's cheeks, so if the history is relevant or if you see localized enlargement in the cheeks suspect that those are enlarged lymph nodes. If you found a patient that has all these groups of lymph nodes enlarged you should consider referral because this patient might have lymphoma.

15

Temporomandibular joint (TMJ) For now in the clinic you should only know how to make a brief examination, but later on when you take TMJ disorders you will make a detailed examination. The temporomandibular joint (TMJ) is examined by palpation and auscultation, you ask the patient to open and close his mouth and we see if there is pain or tenderness to palpation. We also watch for deviation, limitation or pain associated with opening. Normal mouth opening is 35-55 mm, and it varies, but less than 30mm means there is limitation in opening. And you also ask the patient to move his mandible to the sides (lateral excursions), and this movement is normally 8-10mm. We place a stethoscope at the TMJ to hear any clicking as the patient opens and closes, and you can also feel the click with your fingers (if its hard and this usually require treatment) so in the clinic we dont use a stethoscope, because the click that you hear with a stethoscope is very common and require no treatment (50% of people have joint click), but if its hard you can palpate it. The recording might be is that the patient's joint is tender to palpation, and there is clicking in the joint also, or there is crepitation on opening for example. The TMJ is examined from preauricular and intra auricular (finger inside the ear) approach from behind the patient, and you record whether there is pain or joint sound upon opening and closing. We measure the maximum opening and lateral excursions with a special ruler. In the clinic you don't have to record numbers but you need to do the palpation.
16

Muscles of mastication

Masseter: You ask the patient to clench his teeth (notice how the
masseter hardens), then you palpate it at the origin and insertion, unless there are trigger points. And we use bimanual or bidigital examination and see if there is pain on clenching.

Temporalis: You examine it at the temporal fossa from behind the

patient, detecting any tenderness to palpation, and you ask the patient to clench his teeth so you can palpate the temporalis. Trapezius and Sternocleidomastoid: You palpate to see if there is any tenderness.

17