Acer Case

Head and Face | Findings | Analysis | Inspect the head: Size, Shape and Configuration. | Upon inspection patient’s head is symmetric, round, erect and in midline. No lesions are visible. | Normal | Inspect for involuntary movement. | Upon inspection patient’s head is held still and up right. | Normal | Palpate the head: palpate for consistency | Upon palpation patient’s head is hard and smooth without lesions. | Normal | Inspect the face: symmetry, features, movement, expressions and skin condition. | Upon inspection the face is symmetric with an elongated appearance. No abnormal movement. | Normal | Palpate the temporal artery. | Upon palpation the temporal artery is elastic and non tender. | Normal | Palpate the temporomandibular joint. | Upon palpation there is no swelling, tenderness or crepitation with movement. Mouth opens and closes fully (3-6 cm between upper and lower teeth). Lower jaw moves laterally 1-2 cm in each direction. | Normal | Inspect the neck. | Upon inspection patient’s neck is symmetric with head centered without bulging masses/ | Normal | Inspect movement of the neck structures. | Upon inspection the thyroid cartilage, criroid cartilage and thyroid gland move upward symmetrically as the patient swallows. | Normal | Inspect the cervical vertebrae. | Upon inspection C7 (vertebrae prominens) is visible and palpable | Normal | Inspect the range of motion | Upon inspection neck movement is smooth and controlled with 45 degree flexion, 55 degree extension, 40 degree lateral abduction and 70 degree rotation | Normal | Palpate the trachea | Upon palpation patient’s trachea is located midline | Normal | Palpate the thyroid gland | Upon palpation landmarks are position midline. | Normal | Palpate the preauricular nodes, postauricular nodes and occipital nodes. | Upon palpation there is no swelling or enlargement and non tender. | Normal | Palpate the tonsillar nodes. | Upon palpation there