CS - Examination of the neck and mouth Flashcards
What are steps to follow in examining the neck ?
- Introduction
- General Inspection
- Inspection and palpation of hands
- Inspection of face and eyes
- Inspection of neck (neck extended)
- Palpation of neck (from behind) (neck flexed)
- Percussion
- Auscultation
- Reflexes of lower limb
- Conclusion
What do you cover in introduction of in examining the neck ?
Introduction;
A. Ensure adequate hygiene of hands and stethoscope
B. Introduce self and confirm patient’s identity
C. Explain procedure and obtain verbal permission to examine
D Ask if patient in any pain or discomfort
E. Position patient sitting upright on a chair with neck adequately exposed and jewellery removed
What do you cover in General Inspection of the neck ?
General inspection;
A. General whole body inspection
B). Observe patient generally for weight (over and underweight), evidence of tremor,
restlessness or agitation, sweating, hair loss, muscle wasting, anaemia
Patients with hyperthyroidism are generally restless, may have a tremor, sweat heavily and have heat intolerance e.g. may not be warmly dressed despite cold weather. If the patient has had hyperthyroidism for a period of time then they are often thin with little body fat due to the increased basal metabolism.
Patients with hypothyroidism are often inactive, shivering, and have cold intolerance e.g. wrapped up with hats and scarves even in warm weather. These patients may also have increased body fat due to lower metabolism. They also may have coarse dry skin with dry thinning hair.
What do you cover in Inspection and Palpation of Hands when examining the neck ?
Inspection and Palpation of Hands;
A). Inspect and palpate hands
B). Palpate and assess the radial pulse
Inspect both hands
- Ask patient to hold hands outstretched and look for tremor. (A piece of paper placed on the dorsal aspects may reveal a tremor). - The fine tremor of hyperthyroidism can also be detected by palpating the patient’s outstretched fingers with palm of your hand.
- Hold patients hands and feel warmth of circulation.
- Examine the palms for palmar erythema and muscle wasting of the thenar and hypothenar eminences.
- Run your hands over the patient’s palms feeling for excessive moisture.
Inspect the nails; for onycholysis and thyroid acropachy.
- Onycholysis is painless separation of the nail from the nail bed.
- Thyroid acropachy refers to finger clubbing associated with periosteal new bone formation occurring in patients with Graves’ disease.
- Look for evidence of anaemia.
Palpate and assess the radial pulse for tachycardia, bradycardia and irregular pulse (atrial fibrillation). Patients with hyperthyroidism may present with a tachycardia or atrial fibrillation. Hypothyroid patients may have a very slow pulse.
What do you cover in Inspection of face and eyes when doing neck examination ?
A. Inspect face for features of hypothyroidism
B. Inspect eyes for exophthalmos (from front, sides and above)
C. Inspect eyes for lid lag and examine for von-Graefe’s sign (with downward movement of finger), eye
movements and fields
A. Assess face/head for features of hypothyroidism Puffy, coarse facial features, pale, waxy skin Hair loss and loss of outer part of eyebrows
B and C. Inspect eyes for: anaemia, exophthalmos (proptosis) and lid lag.
Exophthalmos is a clinical sign associated with autoimmune thyroid disease and is often associated with hyperthyroidism. In this condition the eyes are seen to protrude from the orbits due to retro- bulbar fat infiltration and oedema. It can be identified by looking at the proportion of sclera (white area) above and below the iris. In a normal patient there will be very little sclera visible above and below the iris, whereas in hyperthyroidism there may be sclera visible all around the iris.
Lid lag is a static sign, referring to a higher than normal upper lid position in downgaze. This is caused by increased sympathetic tone resulting in excessive activity of Muller’s muscle (Superior tarsal muscle).
Then, assess for von-Graefe’s sign, which is a dynamic sign whereby the upper lid moves slower than the globe/eyeball on downward rotation of the eye. You perform this by asking your patient to follow your horizontal finger downwards. (Do not hold your finger too close to their eyes). It is in this position of downgaze that we can inspect for lid lag.
Look at eyes from the side and then go behind the patient and assess for exophthalmos by looking from above the head downwards, looking for protrusion of the eyes. Then, assess eye movements for ophthalmoplegia.
Finally, examine visual fields, as a bitemporal hemianopia can occur due to a pituitary tumour compressing the optic chiasm (secondary hyperthyroidism).
What do you cover in Inspection of neck?
- INSPECTION OF NECK (neck extended)
A. Inspect for scars
B. Inspect for asymmetry or swellings
If swelling present: -
C. Ask the patient to protrude their tongue
D. Ask the patient to swallow a sip of water
A. Inspect for scars
Look carefully for scars of previous surgery as these may be skilfully concealed in skin folds.
B. Inspect for asymmetry or swellings
With head tilted up inspect all areas of the neck from the front and from both sides, and note any asymmetry or swellings that you see. Pay particular attention to swellings in the midline as they occur here most commonly, but may not be immediately obvious. Look in particular for swelling of the thyroid. A visibly enlarged swelling of the thyroid is called a goitre.
If a swelling is noted:- (Sections C and D are not going to be performed)
C. Ask the patient to protrude their tongue
This test should be done if you suspect a midline swelling in the neck as it may help to identify the swelling as a thyroglossal cyst. Make sure that you ask patient to tilt their head up during these tests.
A thyroglossal cyst is a fluid filled remnant of the thyroglossal tract that is formed as the thyroid develops in the foetus. The thyroglossal tract helps to deliver the thyroid from its formation at the base of the tongue to its adult destination between tracheal rings two to four. After the thyroid forms it usually disappears but in some people may persist and become filled with fluid to form a cyst.
Ask the patient to protrude their tongue whilst you observe the swelling.
As a thyroglossal cyst will still be attached to the base of the tongue it will rise with the tongue protrusion. If the swelling does not move then it is unlikely to be a thyroglossal cyst.
D. Ask the patient to swallow (with head tilted up) you may like to offer a sip of water. This is designed to identify swellings of a thyroid nature.
The thyroid gland is anchored to the thyroid cartilage by the pre-tracheal fascia which also surrounds the larynx, and so as the larynx moves up and down the thyroid moves with it during swallowing.
If the patient has a noticeable thyroid swelling, then on swallowing, the mass or swelling will also rise.
Note that a thyroglossal cyst will also move on swallowing.
Any swelling should be assessed for location, size, shape, consistency, mobility, tenderness. See below in palpation.
What do you cover in palpation of neck?
- PALPATION OF NECK (from behind) (neck flexed);
A. Palpate the neck generally for any masses, noting location, size, shape, consistency, mobility and tenderness
B. Palpation for the thyroid specifically:
Identify the cricoid
Palpate for the isthmus of the thyroid gland Palpate the lobes of the thyroid gland
C. Palpate the cervical lymph nodes in a logical sequence
A. Palpate the neck generally for any masses, noting location, size, shape, consistency,
mobility and tenderness.
Palpation of the neck should be done from behind the patient as this enables the examiner to get a more tactile feel of masses or swelling on the pulps of the fingers and allows more control of the fingers when palpating a sensitive area. The neck should be felt using both hands at the same time, palpating in unison to allow comparison of the left and right side of the neck.
Be aware that it might be uncomfortable for the patient, and be gentle with your palpation. Before beginning palpation ask your patient if he has any pain in their neck.
After telling the patient what you are going to do, move to a position standing above and behind the seated patient. Ask them to flex their neck slightly forwards to relax the muscles. Place both hands on the neck and begin gentle palpation.
Identify the laryngeal prominence and the cricoid cartilage first. Then palpate generally for any masses in the anterior triangle then the posterior triangle.
Ensure that you cover all areas of the neck and bear in mind that the neck goes all the way down to the clavicles and posteriorly to the trapezius muscle.
If a mass is found the following points about it should be noted:-
Location – The site of the mass will allow a more accurate assessment to be made as to the source. Relate the mass to other anatomical structures or sites in the neck.
Size – The size of the mass will enable the examiner to monitor the progress of the swelling
Consistency – Determine how soft or hard the mass is. A soft mass suggests a fluid filled swelling. A smooth and firm mass may be an enlarged organ or tissue, often benign in nature. A hard, nodulated mass may be malignant tissue.
Mobility – Some masses may be mobile under the skin and some may be fixed. Mobile masses are more likely to be benign and fixed masses more likely to be malignant. To assess mobility place the thumb and index finger either side of the mass and attempt to gently move the mass from side to side.
Tenderness – A tender mass is more likely to be due to an acute inflammatory or infective process rather than a chronic problem.
B. Palpation specifically for thyroid gland (standing behind patient, with neck relaxed);
The thyroid gland is a two lobe structure connected by an isthmus. In the majority of people the thyroid gland is not easily felt as it is covered by the strap muscles.
First identify your midline structures:-
(i) Identify cricoid
With two fingers of each hand feel and identify the laryngeal prominence (the thyroid cartilage). Move your fingers down to feel and identify the cricoid cartilage.
(ii) Palpate for the isthmus of the thyroid gland.
Visualise in your mind the H shape of the thyroid gland. The isthmus is the band of thyroid tissue lying below the cricoid, approximately anterior to the 2nd 3rd and 4th tracheal cartilages. From the cricoid move your fingers down over the tracheal cartilages. As you move your fingers continue gently palpating (with your index and middle fingers using pulps of fingers of both hands) for the isthmus of the thyroid.
C. Palpate the lobes of the thyroid gland.
Next, move laterally from the midline, palpating with the pulps of your fingers for the lobes of the thyroid. The upper poles extend upwards to the sides of the lateral border of the thyroid cartilage and the lower poles down to the level of the 6th tracheal cartilage.
Asking the patient to swallow a sip of water whilst palpating may help to detect upward movement of the thyroid.
Note that the normal gland is often not palpable. Part of the lobes may be tucked under sternocleidomastoid. If a lobe is bigger than the patient’s thumb it may be considered enlarged.
Note the size, symmetry, and position of the lobes, as well as the presence of any nodules.
E. Palpate the cervical lymph nodes in a logical sequence
The palpation of the cervical lymph nodes is also done from behind the patient as before.
Palpate the chains or groups of lymph nodes in a logical sequence using the tips of 3 fingers, and using both hands at the same time to compare both sides.
It may be helpful to start under the chin and progress in a Zigzag fashion - Down the neck, along and back above the clavicle, back up the neck, ending with the occipital nodes.
The sequence varies from doctor to doctor. But make sure that you palpate for the following chains
or groups of nodes:
- Sub-mental
- Submandibular
- Superficial cervical
- Deep cervical
- Supraclavicular
- Pre-auricular
- Post-auricular / mastoid - Occipital
Assess any palpable nodes for size, tenderness and consistency.
For completeness, in certain situations, you may wish to percuss, auscultate and check reflexes.
What do you cover in percussion of neck?
- PERCUSSION
A. Percuss for suspected retrosternal goitre
Occasionally, a goitre may enlarge inferiorly to lie behind the sternum without a swelling in the neck being visible or palpable.
If you suspect a retrosternal goitre, palpate to check that the trachea is central. (Explain to the patient this may be slightly uncomfortable). Percuss down the sternum beginning at the suprasternal (jugular) notch and ending at the sternal angle.
Normally this area is resonant. If there is dullness, this may suggest a retrosternal goitre.
What do you cover in auscultation of neck?
- AUSCULTATION
A. Auscultate with diaphragm for thyroid bruits if thyroid is enlarged.
Ask the patient to hold their breath (to stop breath sounds being transmitted from the trachea) and auscultate for high pitched bruits with the diaphragm of your stethoscope over each lobe and across the isthmus. (You should hear nothing in the normal patient.)
However if a bruit is heard in the area of the thyroid then this may suggest hyperthyroidism. In this condition there is increased blood supply to the gland due to over activity.
Be aware that bruits heard in the neck may be coming from carotid artery stenosis or be referred from aortic stenosis. Therefore do not take this clinical finding in isolation.
What do you cover in reflexes and lower limb when doing neck examination ?
- REFLEXES and LOWER LIMB;
A. Assess lower limbs for pretibial myxoedema and reflexes (in particular ankle) for hyper reflexia or slow relaxing reflex
B Ask patient to rise from chair without assistance of arms (difficulty in proximal myopathy)
In assessment of the thyroid, consideration should be given to assessment of the reflexes. Reflexes may be brisk in hyperthyroidism and the lower limb reflexes slow relaxing (especially the ankle reflex) in hypothyroidism.
Pretibial myxoedema or, more appropriately, thyroid (Graves) dermopathy is a term used to describe localized lesions of the skin resulting from the deposition of hyaluronic acid. Although the condition is most often confined to the pretibial area, it may occur anywhere on the skin. Pretibial myxoedema is nearly always associated with Graves disease. (nb Graves = hyperthyroidism)
In proximal myopathy weakness may become apparent in a patient, when asked to stand up, being unable to rise from a chair without using power of arms to assist.
How would you conclude the consultation in a neck examination ?
- CONCLUSION
A. Thank patient and ensure appropriate hand hygiene
B. Summarise, and present findings orally and in patient’s notes
What are the steps involved in examining the oral cavity ?
- Introduction
- Inspection of lips, angle of mouth and buccal mucosa
- Inspection of teeth and gums
- Inspection of hard and soft palate and tonsillar region
- Inspection of tongue and floor of mouth
- Palpation of tongue
- Palpation of parotid and neck swellings
- Conclusion
What is involved in the introduction in examining the oral cavity ?
INTRODUCTION
A. Wash hands with water or alcohol gel
B. Obtain necessary equipment (pen torch, tongue depressor, gloves and gauze swabs)
C. Introduce self and confirm patient’s details
D. Ask patient if in any pain, dryness or discomfort e.g. candidiasis (thrush) burning sensation
E. Explain the procedure and obtain consent to examine
F. Put on gloves. Remove patient’s dentures if any.
G. Position patient appropriately and ensure adequate lighting (a head lamp would be ideal)
What is involved in the inspection of lips, angle of mouth and buccal mucosa in examining the oral cavity ?
INSPECTION of LIPS, ANGLE of MOUTH and BUCCAL MUCOSA
A. Look for ulceration, angular stomatitis and any sign of infection of the lips e.g. angular cheilitis may indicate a fungal candida infection.
B. Carefully evert the lips and look at labial mucosa for ulceration, mucocele or swelling
C. Using the tongue depressor and pen torch; look at the buccal mucosa in the vestibule of the oral cavity look for discoloration, inflammation, Koplik spots, nodules, ulceration, candidiasis (thrush:white, cream-coloured, or yellow spots in the mouth. Candida commonest on palate)
What is involved in the inspection of teeth and gums in examining the oral cavity ?
INSPECTION of TEETH and GUMS
A. Look for poor dental hygiene, missing/loose teeth, dental caries, gum disease (gingivitis: bleeding from gums)
