oral diagnosis script3 extraoral examination

7/27/2019 Oral Diagnosis Script3 Extraoral Examination

1/17


2/17

2

Diagnosis Lecture 3

Extraoral Examination

Dr Aceil instructed that the interpretation of numbers what'snormal and what's not- must be memorized and instruments used

to measure vital signs as well.

IntroductionThe 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 externalappearance 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, pulseand 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.


3/17

3

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 signsSome 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

All four of the vital signs increase when the patient is anxious orjust had a heavy meal or so, thus recording of the vital signs will notbe accurate unless they are taken when the patient is at rest.

And now we will go through each one in detail. Please keep in mindthat the interpretation of numbers is important and the Dr will askabout them in the exam

Vital Signs

PulseTemperature Respiration Blood Pressure

Remember that all vital signs should be taken when the patientis at rest; wait 30 minutes if the patient has just eaten, drank a

hot or cold beverage, just smoked, exercised (climbed the stairs

for example) or if even he is anxious.


4/17

4

TemperatureMany 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 believed-

and 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).


5/17

5

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.

When do we say that a patient has fever?

PulseUsually 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.

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.

In adults when the (oral) thermometer records 37.8 C.

In children when the (rectal) thermometer records 38 C.


6/17

6

Bradycardia: Slow pulse (100)

Anxious subjects. Cardiovascular diseases.

Normal Range (60-100 beats/min)

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.

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 beenrecorded 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.


7/17

7

Blood PressureIt 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 stethoscopeon 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 andregister the reading (this is the diastolic).


8/17

8

The systolic (top number) should be less than 130, but it varies withage, 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 BP (mm Hg)

Normal systolic: less than 120

diastolic: less than 80Pre-hypertensive 120-139 (systolic)

80-89 (diastolic)

Stage 1 hypertension 140-159 (systolic)

or

90-99 (diastolic)

Stage 2 hypertension equal or more than 160 (systolic)

equal or more than 100 (diastolic)


9/17

9

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 rateIn 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.


10/17

1

Principles of ExaminationThere 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

SmellingSmelling can be an important diagnostic test in many cases:

1. Acidosis in diabetes2. 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.


11/17

InspectionInspecting starts the moment you see the patient. You can elicit

some features such as:

1. General appearance: Alert, distress, clean, groomed orungroomed.

2. State of nutrition: Thin, temporal wasting, malnourishments orobesity

3. The patient's profile especially in orthodontics and malocclusionto 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 andhands tremor

6. Speech: slurred, hoarse (you detect it when the patient answersyour questions)

7. Skin lesions (moles, vesicles, ulcers, nevus, hyper pigmentationsor 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)


12/17

2

9. Swelling or enlargement in the parotid, sublingual orsubmandibular 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 thereis any enlargement in the thyroid (look at the area below Adam's

apple at the cricoid cartilage)

11.Hair and ears also.

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).

Examples:

In intraoral exam jaundice can be visualized in the

ventral surface of the tongue, and in the junction of

the hard and soft palate.

Blue sclera: osteogenesis imperfecta

Jaundice (Icterus)

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.


13/17

3

Parotid glandsLocation: Behind the masseter, in front of and below the ear

lobes.

Enlargement: Notice it by inspection of the parotid, by lookingfrom 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 nodesPalpate lymph nodes to detect any enlargement, normal nodes are

not palpable but if they are palpable they should be the size of a peaor 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.

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


14/17

4

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 ofpalpation in order not to forget to check any lymph node, and the

order that the Dr wants us to follow is:

1. Preauricular2. Submandibular3. Anterior cervical4. Posterior auricular5. 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 clearerwhen 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.


15/17

5

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

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 youshould consider referral because this

patient might have lymphoma.

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.


16/17

6

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), andthis 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.


17/17

7

Muscles of masticationMasseter: 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 thepatient, 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 anytenderness.

oral diagnosis script3 extraoral examination

Documents