13.1.12

Clinical- neck examination




General Neck Examination
Examine neck? (usually L.N. or Normal neck)

Introduce yourself
Exposure:  to clavicle
Position: Sitting (Push the chair away from wall)
1-         Inspection (From Front) look at front & sides 3 positions
Rest
Tongue protrusion → move/ does not move with tongue protrusion.(skip if lat. swelling)
Swallowing اشرب الماء ولا تبلعه الا لما اقول لك (skip if lat. swelling)
5S ☺”Swelling at (upper/lower), (front/Lat.), at (parotid region/ant.triangle/ post.triangle) of  neck, ….X…cm, … shape, no other sweelings, skin…, not attached to ms, not move with….., not pulsatile”

2-         Palpation (From Front → From back)
From Front · TT (temp. & tenderness)
            · Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)
From Back
Rest
Tongue protrusion → move/ does not move with tongue protrusion. (skip if lat. swelling)
Swallowing for midline swellings (skip if lat. swelling)
Up & Down technique (for masses & Cervical L.N.s)
a-      Start from the chin, along the lower border of the mandible till the ear
b-     Along the anterior border of Sternomastoid → upper border of clavicle (ant.triangle)
c-      Along the posterior border of Sternomastoid (post. Triangle)
d-     Back of the skull (occipital L.N.s)
 → Swelling (TT- ESCRS)

Unilateral Lumps in the NECK

Multiple
Solitary



L.N.s
Anterior Triangle
Posterior Triangle
Midline
Moves with swallowing
Doesn’t move with swallowing

Solid
Cystic
Solid
Cystic
Solid
Cystic
L.N.

1- Pharyngeal pouch
2- Cystic hygroma

Thyroid            
gland
Thyroglossal cyst
1-L.N. 
2-Carotid body tumor
1-Branchail cyst
2-Collar stud abscess

  
  


Thyroid Gland
General Examination (Thyroid Status: Hyper or Hypo)

Hand Signs
Eye Signs (fix head)
Leg Signs
· Fine Tremors ورقة
· Sweaty hands
· Pulse →
    Tachycardia(Hyperthyroidism)   or Bradycardia(Hypothyroidism)
· Water Hammer Pulse (elbow 90° & feel volar forearm)
· Lid Retraction, Staring look & infrequent blinking (Stelwag s)
· True Exophthalmos 1                                                                                           
· Lack of Wrinkling (Joffroy’s)2                                                         
· Lid Lag (VonGrave’s)
- Lack convergance (Mobiu’s)3       
· Exophth by (Naffziger’s) 

Pretibial myxedema
· Examine eyes movements (close one eye)
    to exclude ophthalmoplegia


Neck Examination
Introduce yourself
Exposure:  till clavicle (remove scarf & googles)
1-         Position  (Push the chair away from wall)
2-           Inspection (From Front) look at front & sides in 3 positions
Rest
Tongue protrusion (skip if butterfly swelling) → does not move with tongue protrusion.
Swallowing اشرب الماء ولا تبلعه الا لما اقول لك → moves with swallowing.
     5S Swelling at the lower part of the front of the neck, ….X…cm, butterfly in shape, no other sweelings, moves with swallowing, but not with tongue protrusion
3-         Palpation (From Front 3→ From Back 3) Ask about pain
From Front · TT (temp. & tenderness)
            · Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)
From Back
· Thyroid : TT- ESCRS
- Rest: Edge → well defined/ ill, Surface →Diffuse / Nodular, Consistency → firm/ hard,     not attached to skin (pinch skin) or sternomastoid ms (وشك الناحية الثانية+ feel), Mobility
- Swallowing: moves with swallowing & Lower edge → felt/ not (not= retrosternal extension)
· Cervical Lymph Nodes
       Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital
       Midline gr.: pre-laryngeal, pre-tracheal
       Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.
       Supraclavicular L.N.s (while shrugging shoulder)
· Carotid pulsation (med. to sternomastoid- relax it) → felt & equal/ felt & displaced/ not felt  (for infiltration)
4-         Percussion (over upper sternum) → resonant/ dull (for Retrosternal extension)
5-         Auscultation (over upper pole thyroid) → No bruit/ Bruit (Bruit in Primary Toxic Goiter)
I would like to finish my examination by:
1- Examination of thyroid status (if not done yet)


Causes of thyroid enlargement (Goitre)
Diffuse
Nodular
Toxic
Non-Toxic

Solitary Nodule

Multi Nodular
Grave’s disease

  1- Simple colloid Goiter
   2- Thyroiditis

1 Sclera visible all around the iris    2 Looking up without wrinkling of forehead skin    3 Difficulty in conversion



Parotid Gland

Introduce yourself
Exposure:  till clavicle (remove scarf & googles)
Position the patient (Push the seat away from the wall)
1-           Inspection (From front- Look at front & sides in 2 positions)
Rest
Clench teeth  عض على سنانك
     ☺”Swelling at the parotid region in anterior triangle of the neck (Rt/Lt/Bilat.) elevating the lobule of the ear, more prominent with cont. masseter ms”
2-         Palpation (2 from the back & 3 from front)
From Back
· Parotid: TT- ESCRS عض على سنانك  
  ☺”Swelling at the parotid region, not hot, not tender, measure …X…, edge well defined, surface smooth, firm consistency, not attached to overlying skin or muscle”
· Cervical Lymph Nodes :
       Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital
       Midline gr.: pre-laryngeal, pre-tracheal
       Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.
       Supraclavicular L.N.s (while shrugging shoulder)
From Front
· Facial nerve examination:
     Inspection: face symmetry, nasolabial folds, angle mouth → preserved
     Muscles:
Occiptofrontalis: raise eyebrows ارفع حواجبك (not affected in UMNL)
Orbicularis occuli: close your eyes tightly against resistance اقفل عينك جامد
Orbicularis oris: whistle صفر
Buccinator: blow out your cheeks انفخ خدك 
Depressor angularis: show me your teeth ورينى سنانك 
      → facial muscles symmetrical & intact                            
·  Superficial temporal artery: feel infront tragus by 3 fingers longitudinally → felt
·  Parotid duct: open mouth & inspect opposite upper 2nd molar
     → no inflammation, no discharge  (Donot palpate duct bec. stones rare,  Pain, difficult &)

I would like to finish my examination by:
1- ENT examination
2- examination scalp (if L.N.)
3- examination teeth & tongue (if L.N.)

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