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PNP: Physical Assessment > Neck and Lymph > Flashcards

Neck and Lymph Flashcards

1
Q

Normal Exam Findings (3)

A
  1. Normal texture is soft and without nodular
  2. Size of the lateral lobes of the thyroid may be compared to the size of the third phalanx of a child’s thumb.
  3. Thyroid should feel soft and is size of third phalix of child’s thumb; may not be able to feel it
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2
Q

Goiter

A

Enlargement of the thyroid –> can be euthyroid, hypothyroid or hyperthyroid

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3
Q

Thyroid Nodules (3)

A
  1. Nodules in children need referral to endocrine to see if they want to biopsy
  2. Certain females may have higher nodules that are higher risk — ex: radiation therapy for cancer as a children; or any radiation to the neck can cause scatter radiation that increases risk for thyroid disease
  3. NEED TO FOLLOW UP ANY THYROID NODULES!
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4
Q

Congenital Neck Masses (4)

A
  1. Cystic hygroma (lymphangiomas)
  2. Hemangioma; can interfere with the airway; treat with beta blockers
  3. Branchial Cleft Cyst- Most common, 20-30%, Present in late childhood and early adulthood when acutely infected (usually gets picked up in childhood)
  4. Thyroglossal duct cyst - Midline lesion
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5
Q

Cystic hygroma (9)

A
  1. Multiloculated cystic lymphatic malformation
  2. Usually found by second year
  3. 2:1 left side (goes towards the left side)
  4. Discrete, soft, mobile, nontender, cystic masses in posterior triangle of neck
  5. Collection of lymphatic sacs that contain clear, colorless lymph
  6. Congenital and probably represents a cluster of lymph channels that failed to connect into the normal lymphatic pathway
  7. As it grows, may cause tracheal compression and stridor.
  8. Tends to be in posterior triange (sternomastocleido muscle separates these trianges); the mass tends to be in the back of the neck behind these muscles
  9. Occurs in utero and as it grows it causes trachial compression and stridor

*Tends to be diagnosed in utero; pre-natal ultrasound can pick it up

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6
Q

Flatulent Mass

A

will feel very soft and full of fluid; cystic hygroma is usually a flatulent mass

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7
Q

More Info From Cystic Hygroma (4)

A
  1. Located more frequently on the left side of the body.
  2. Diagnosed in the period immediately after birth, with large lesions being noted on prenatal ultrasonography.
  3. Later presentations generally follow a viral infection, which can induce significant expansion of these lesions.
  4. Large lesions can result in airway compromise.
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8
Q

Second Brachial Cleft Cyst (4)

A
  1. Most common congenital neck mass-2-3% of population
  2. Branchial cysts
  3. Smooth, nontender, fluctuant masses, which occur along the lower one third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin
  4. Brachial cleft cyst occurs at 2nd or 3rd brachial arches; will feel like end of pencil point- is a protruding type of mass that comes on the lower part of the sternocleidomastoid
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9
Q

Branchial Cleft Cyst (3)

A
  1. Presents as a solitary, painless mass in the neck of a child or a young adult
  2. May retract with swallowing, tends to get infected
  3. Typical presentation is small cartilaginous horn in lower anterior border of sternocleidomastoid
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10
Q

Thyroglossal Duct Cyst (8)

A
  1. Usuallyfoundbelowthelevel of hyoid bone in mid line or off center
  2. Seenbestwhenneckis hyperextended
  3. Cystmayrisewithtongue protrusion and swallowing since it is connected to base of tongue
  4. Usually occurs midline, right where the thyroid is
  5. May be attached to the tongue, so it may move when the tongue moves; Can go up and down
  6. If it is taken out and there is no other thyroid, the child will have hypothyroidism
  7. Only thyroid tissue patient has can occur anywhere from the base of tongue to diaphragm
  8. High incidence of thyroid carcinoma in adulthood
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11
Q

Lymphadenopathy

A
  1. Body has 600 lymph nodes
  2. Can enlarge by proliferation of normal cells; Infiltration by foreign or abnormal cells
  3. Cannot see the chest lymph nodes; only way you can picture lymphadenopathy in the chest is via X-RAY
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12
Q

Types of Lymph Nodes (5)

A
  1. Deep abdominal mesenteric nodes (lots of lymph nodes in belly) usually cannot be felt, but when they are felt it is worrisome
  2. Not uncommon to feel small nodes under inguinal region (birds eye, pea size); if you palpate inguinal region you can feel it (if not too muscular); easily felt in children unless they are severely obese
  3. Axillary nodes found in armpit; need to relax muscles underneath; take hand and feel inward and note how deep you go; relax hand on something to get a deep feel in the axilla
  4. Epitrochlear node —> follows the radial artery; best felt as arm is relaxed and slightly bent; feel where you palpate the brachial artery; enlargement of these or axillary nodes is never normal
  5. Popliteal nodes can sometimes be felt if you don’t have well-developed calf muscles (medially behind the knee, felt where you feel popliteal pulses)
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13
Q

How is the lymph system shaped?

A

Bean-shaped; Covered thickly with the fibrous capsule Inward pointing trabeculae

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14
Q

Cortex Part of the Lymph System (6)

A
  1. Populated with lymphocytes
  2. Primary resting place for B Cell • undergo mitosis and divide.
  3. Produce immunoglobulins
  4. T lymphocytes circulate lymph nodes
  5. Blood stream
  6. Lymphatic ducts
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15
Q

Medulla part of lymph system

A

Made up of macrophages attached to reticular fibers

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16
Q

Cervical Lymph Nodes (2)

A
  1. Tender on physical examination is a reassuring
  2. Diameter greater than 2 cm or that are firm and matted - More likely to be malignant
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17
Q

Size of the Nodule (4)

A
  1. Normal for axillary and cervical region to have up to 1 cm
  2. Inguinal region up to 1.5
  3. Epitrochlear region up to .5
  4. Risk of underlying malignancy: Greater than 2 cm
18
Q

Location and Quality of the Nodes (5)

A
  1. Palpable node in supraclavicular fossa
  2. Inguinal and axillary lymph nodes less likely of

malignant disease

  1. Tender is more likely to be infection
  2. If there is hemorrhage in the node due to

malignancy, may be painful

  1. Nodes that are fixed and matted to each other: Cancers, Invasive inflammations like TB or sarcoidosis
19
Q

Newborn Lymph Nodes (2)

A
  1. Not palpable in newborn
  2. Congenital lesions that can be confused include: Cystic hygroma, Branchial cleft cyst, Thyroglossal duct cyst, Cervical rib
  3. Lymph nodes should never be palpable in newborn, if they are, suspect HIV, syphillis, congenital infections (TORCH viruses) Toxoplasmosis, other, rubella, cytomegalovirus, and Herpes
20
Q

Shotty Node (5)

A
  • Buckshot under the skin
  • Nodes that small mobile, soft and non tender are called SHOTTY
  • Most common between 3-5
  • Freely movable
  • By age of 2 all children have had an infection, with URI they get shotty node on sternocleidomastoid on anterior chain
21
Q

Hodgkin Nodes

A

Hodgkin’s more indolent in course and there can be 6-12 months of lymphadenopathy

22
Q

Symptoms assocaited with nodes (6)

A
  1. Night sweats
  2. Fever
  3. Weight loss
  4. Pruritus
  5. Arthralgias
  6. Fatigue
23
Q

Anterior Triange Lymph Nodes

A

Bound superiorly by mandibular border and extends along the sternocleidomastoid muscle to the mid line of the neck anteriorly.

*Can reveal reactive lymph nodes and infections

24
Q

Posterior Triangle Lymph Nodes (5)

A
  1. Bounded by the sternocleidomastoid muscle, the distal two thirds of the clavicle and the posterior mid line of the neck.
  2. 50% of adenopathy in posterior triangle is malignant, but the most common reason to see it there is due to head lice
    *When the lice beads on them, the child scratches a lot which brings staph into the skin and the nodes react to it (reactive adenopathy)
  3. Tinnea capitis causes reactive adenopathy in posterior triangle
  4. Can have reactive adenopathy by pulling on the hair line too much
  5. Worry about adenopathy when there was no infection
25
Q

How to Palpate Lymph Nodes

A

Palpate with the pads of your index and middle fingers for the various lymph node groups.

26
Q

Preauricular Nodes (4)

A
  • In front of theear
  • Drains anterior and temporal scalp, anteriorear canal and pinna, conjunctiva
  • Slightly anterior from this is set of carotid nodes; rarely enlarged in kids
  • Enlarged preauricular nodes occurs with conjuncitivits
27
Q

Postauricular Nodes (3)

A
  • Behind the ear
  • Drains Temporal and parietal scalp
  • Enlarged commonly occurs with head lice
28
Q

Occipital Nodes (4)

A
  • At the base of the skull
  • Drains the posterior scalp
  • Enlarges with lice
  • Nodes should be on both sides and travel down
29
Q

Tonsillar and Super Cervical Nodes (3)

A
  1. At the angle of the jaw
  2. Lower larynx, lower ear canal, and parotid
  3. Right at angle of jaw = tonsilar and anteriror cervical chain follows in a line
30
Q

Submandibular Nodes (2)

A
  • Under the jaw on the side
  • Drain cheek, nose, lips, tongue, submandibular gland, buccal mucosa
31
Q

Submental Nodes (3)

A
  1. Under the jaw in the mid line
  2. Drains lower lip and floor of the mouth
  3. Dental disease frequently enlarges lymph nodes in submental or submandibular
32
Q

Supraclavicular Nodes (4)

A
  1. In the angle of the sternomastoid and the clavicle
  2. Drains the right side, mediastinum and lungs
  3. Drains the left side abdomen
  4. ASK CHILD TO SHRUG UPWARD AND FOREWARD WHEN ASSESSING
33
Q

Deep Cervical Chain Nodes (5)

A
  1. lies below the sternomastoid
  2. cannot be palpated without getting underneath the muscle
  3. Hook your fingers under the anterior edge of the sternomastoid muscle
  4. Drains the tonsils, adenoids, posterior scalp and neck, tongue, larynx, thyroid, palate, nose, esophagus, paranasal sinuses
  5. This muscle group interferes with deep palpation of the cervical chain; to relax the muscle, you should tilt the head to the side during examining
34
Q

Where do axillary nodes drain? (4)

A
  1. Arm
  2. breast
  3. thorax
  4. neck
35
Q

Where do epitrochlear nodes drain? (1)

A
  1. medial arm below elbow
36
Q

Where do inguinal nodes drain? (4)

A
  1. Lower extremity,
  2. genitalia,
  3. buttocks,
  4. abdominal wall below umbilicus
37
Q

Where do popliteal nodes drain? (1)

A

Lower leg

38
Q

Reactive Adenopathy (2)

A
  1. Reaction to an infection in the drainage area
  2. Pharyngitis, otitis media, conjunctivitis
39
Q

Lymphadenitis (7)

A
  1. Inflamed, enlarged, tender lymph node
  2. Acute onset
  3. Associated with tender, erythematous , warm lymph noces with fever
  4. Ultrasound identifies abscess
  5. If a node gets an overwhelming amount of bacteria in it, it becomes an adentitis; it is not reacting to an infection (adenopathy), it IS an infection (lymphadenitis)
  6. Lymphadenitis: the B, T, and macrophage cells became overwhelmed and the lymph is infected
  7. All adenitis gets ultrasound prior to starting treatment to see if it needs to be drained (looking at abscess)
40
Q

Lymphadenopathy (2 with 3 major causes)

A
  1. Less common than localized adenitis
  2. Can be a sign of serious underlying systemic disease
  3. Major causes of non infectious lymphadenopathy
    1. Medication (as part of serum sickness; includes cephalosporins)
    2. Malignancy
    3. Autoimmune diseases
41
Q

Lymphadenopathy Assessment (3 with 6 differential)

A
  1. Abnormal in size
  2. Abnormal in number
  3. Abnormal in consistency
  4. Differential of Lymphadenopathy
    1. Age of the patient
    2. Size of the node
    3. Location of the node
    4. Quality of the node
    5. Localized or generalized
    6. Time course of the lymphadenopathy and associated symptoms

PNP: Physical Assessment (21 decks)

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