HeadandNeckChecklist-2023
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School
Weber State University *
*We aren’t endorsed by this school
Course
MISC
Subject
Medicine
Date
Apr 3, 2024
Type
Pages
5
Uploaded by kellbrown98
Head and Neck Name: Kelly Jamison
Date: 01/31/24
# of minutes:
10
Preceptor Name: Chelsea Ekins
Preceptor Signature:
History
Remember to look at each history component as it relates to the head, face, and neck. Ask
the patient the following:
x Do you have…
x Head pain/headaches?
x Jaw tightness and pain?
x Neck pain and stiffness?
x Do you have problems or complaints related to your head or neck?
x Do you have allergies to any medications, foods, or environmental factors?
x Do you have any health problems?
x Are you on any medications, prescribed, or over the counter?
Physical Assessment
Equipment
Gather equipment needed for exam:
x Gloves
x Penlight
x Stethoscope
x Cup of water
Position
Sitting
Technique
First, scan your patient head to toe checking for speciQic signs of diseases, affecting other
organ systems that might alter the head, face, and neck.
Inspection, Palpation, Percussion, Auscultation
INSPECT
INSPECT
Head
☐
Size, shape, and symmetry
☐
Facial appearance, symmetry of facial
features, lesions, hair distributions, and
abnormal movements
PALPATE
☐
Tenderness, masses
☐
TMI joint
Findings
x WNL or
x WNL or
Findings
x WNL or
x WNL or
Neck
☐
Neutral position, hyperextended, and
as patient swallows
☐
Note ROM, symmetry, condition of skin
PALPATE
☐
Cervical lymph nodes:
Occipital,
postauricular, preauricular, tonsillar,
submandibular, submental, superQicial,
deep, posterior, supraclavicular,
infraclavicular
☐
Thyroid gland:
Anterior or posterior
approach
AUSCULTATE
☐
Thyroid:
If palpable, listen for bruits
with the bell over the thyroid
Findings
x WNL or
x WNL or
Findings
x WNL or
x WNL or
Findings
x WNL or
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Document
Document your @indings and develop your plan of care using “SOAP”:
S
ubjective data,
O
bjective data,
A
ssessment/clinical judgement, and
P
lan.
S
Patient came into the clinic looking for her annual check up and wanting some
advice on what to do for some mild neck pain she has been experiencing.
O
I noticed upon assessment that the patient has the most pain when I turn her
head to the right and she states it is very tight as a move it.
A
Overall she is a healthy individual except for the slight pain in the neck which is
Qixable.
P
The plan is that she will need to see a chiropractor and take Tylenol PRN for pain
as directed on bottle.