Physical Examination of ENT and History Taking (trans 4)

Question 1

PREPARATION

**It is important to appease the patient and establish a relationship because it elicits trust

Answer 1

It is important to prepare your physical exam instruments before starting the physical examination, such as:
o Headlight
o Head mirror
o Otoscope
o Nasal speculum
o Tuning fork
o Tongue depressors
o Ophthalmoscope
o Nasal and pharyngeal mirrors
o Etc.

Question 2

PATIENT
You need the patient’s trust and cooperation to obtain a very good history
- Ask the patient about his/her F.O.R.M.

Answer 2

o FAMILY
o OCCUPATION
- asking about the occupation helps convey concern and create rapport
o RECREATION
o MESSAGE
- make sure that the patient is relaxed before beginning the physical exam
- do not examine the patient if he/she is agitated (ex: calm a crying child first)

Question 3

POSITION
Refers to how the doctors “position” themselves in the clinics, not a location or place, per se
- Physicians should watch out for RELOS:

Answer 3

RELOS::
o RELAX
o EYE-LEVEL CONTACT
o LEAN FORWARD
o OBSTRUCTION
o SQUARE

Question 4

POSITION - RELAX

Answer 4

 not tense in the workplace
 as a doctor, you need to be relaxed – be prepared and know what you are doing (familiarize yourself with the instruments)

Question 5

POSITION - EYE-LEVEL CONTACT

Answer 5

 to avoid a condescending image subtly elicited by the physician when examining (usually when patient is sitting down and doctor standing and looking down on patient)
 both the physician and patient should be sitting down EXCEPT when the patient is lying down
 elicits a concerned message
 if the patient is a child, you can kneel down to keep eye-level contact

Question 6

POSITION - LEAN FORWARD

Answer 6

 both the patient and examiner should slightly lean forward – more relaxed position
 have the patient lean forward so that it is easier to adjust his/her position according to the body part you want to assess
 use minimal touch while verbally giving instructions to the patient

Question 7

POSITION - OBSTRUCTION

Answer 7

 keep the space between the patient and physician open as much as possible by taking out unnecessary obstruction (i.e. cellphones, handbags, clipboards, etc.)

Question 8

POSITION - SQUARE

Answer 8

 create an imaginary square – the doctor and the patient should sit on opposite corners of the square
 you never sit directly in front of the patient (avoid spreading legs open towards patient)
 you don’t have to move or change your position, you just have to adjust the patient’s head as you proceed with your physical exam

Question 9

INSTRUMENTS - LIGHT BULB

Answer 9

ideally, a 100W light bulb is more preferred than other wattages because it gives the perfect illumination for observing cavities (ex: the commonly used gooseneck lamp)

Question 10

INSTRUMENTS - HEAD MIRROR

Answer 10

the concave mirror is practically used to spread out light used to delve into cavities. In looking for the perfect illumination, it is also important to move the patient rather than move yourself

Question 11

INSTRUMENTS - OTOSCOPE
used to examine the ear
**When using the otoscope and examining the ear. In adults, the examiner pulls the ear UP and back, while for infants 12 months and below pulls the ear DOWN and back to view the ear canal.

Answer 11

o the largest speculum (diameter) should be used for adults, while the smallest should be used for children (*usually asked in the OSCE)
o the usage of the otoscope is NOT the same as that of the ophthalmoscope
o remember OUTSIDE to INSIDE use

Question 12

INSTRUMENTS - NASAL SPECULUM

used to examine the nasal cavity by opening the nostrils

Answer 12

o DO NOT TOTALLY CLOSE INSIDE because you might accidentally pull out some hair strands
o Practice can be done by using it on one’s clenched fists
o Use your non-dominant hand to handle the speculum.

Question 13

INSTRUMENTS - TONGUE DEPRESSOR

Answer 13

o the tongue depressor wrapper should be half-opened: the opened portion is used for handling the tongue depressor, while the unopened portion is the one used for examining the tongue (i.e. for sterility purposes)
o the order in examining the tongue and the oral cavity is as follows: gingival/buccal => teeth (top and bottom) => floor of the mouth (right and left) => tongue (check fasciculation, grooves and texture) => palates => inner cheeks => tonsils
* it is important to follow the correct order during the OSCE
o in holding the tongue depressor, place your fingers in the middle third for easier control and adjustment of applied pressure/force

Question 14

PHYSICAL EXAM - NECK EXAMINATION

consists of three parts

Answer 14

1. Neck palpation
2. Lymph nodes
3. Thyroid exam

Question 15

PHYSICAL EXAM - NECK EXAMINATION

Neck palpation

Answer 15

it is important to make a diagram of the triangles of the neck on the patient, and palpate accordingly
 examine the neck on both sides (hands should move like mirror images)
 use proper palpation technique

Question 16

PHYSICAL EXAM - NECK EXAMINATION

Lymph nodes

Answer 16

for palpation, use the lymph node levels of the neck as guide:
 level 1: submental/submandibular
 level 2: upper jugulo-digastric
 level 3: middle jugulo-digastric
 level 4: lower jugulo-digastric
 level 5: occipital
 level 6: anterior triangle

Question 17

PHYSICAL EXAM - NECK EXAMINATION

Thyroid exam

Answer 17

you can examine the thyroid either from the front or from the back. Ideally, the doctor assesses the thyroid by reaching for it from the back*
*for OSCE purposes, examine the thyroid from the back

Question 18

PHYSICAL EXAM - POSTERIOR RHINOSCOPY AND INDIRECT LARYNGOSCOPY
uses laryngeal and nasopharyngeal mirrors

Answer 18

o prevent accidental aspiration of foreign bodies by:
 making sure the mirror is securely attached to its handle
 removing dentures or ear piercings when examining the oral cavity
o let the patient do a high-pitched ‘e’ with the tongue out when performing indirect laryngoscopy

Question 19

THE HEALTH HISTORY - the head
Headache is one of the most common symptoms in clinical practice, with a lifetime prevalence of 30% in the general population. Among types of headaches, migraine predominates, approaching 80% with careful diagnosis. Headaches are generally classified as primary or secondary. However, every headache warrants careful evaluation for life-threatening causes such as meningitis, subarachnoid hemorrhage, or mass lesion. Elicit a full description of every headache and its seven attributes

Answer 19

Primary headaches include migraine, tension, cluster, and chronic daily headaches; secondary headaches arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life-threatening

Question 20

THE HEALTH HISTORY - the head
Headache Warning Signs
◗◗ Progressively frequent or severe over a 3-month period
◗◗ Sudden onset like a “thunderclap” or “the worst headache of my life”
◗◗ New onset after age 50 years
◗◗ Aggravated or relieved by change in position
◗◗ Precipitated by Valsalva maneuver
◗◗ Associated symptoms of fever, night sweats, or weight loss
◗◗ Presence of cancer, HIV infection, or pregnancy
◗◗ Recent head trauma
◗◗ Associated papilledema, neck stiffness, or focal neurologic deficits

Answer 20

Thunderclap headaches reaching maximal intensity over several minutes occur in 70% of patients with subarachnoid hemorrhage, and are often preceded by a sentinel leak headache from a vascular leak into the subarachnoid space

Question 21

THE HEALTH HISTORY - the head
The most important attributes of headache are its severity and chronologic pattern. Is the headache severe and of sudden onset? Does it intensify over several hours? Is it episodic? Chronic and recurring? Is there a recent change in pattern? Does the headache recur at the same time every day?

Answer 21

If headache is severe and of sudden onset, consider subarachnoid hemorrhage or meningitis.

Migraine and tension headaches are episodic and tend to peak over several hours. New and persisting, progressively severe headaches raise concerns of tumor, abscess, or mass lesion.

Question 22

THE HEALTH HISTORY - the head

After your usual open-ended assessment, ask the patient to point to the area of pain or discomfort.

Answer 22

Unilateral headache occurs in migraine and cluster headaches. Tension headaches often arise in the temporal areas; cluster headaches may be retro-orbital.

Question 23

THE HEALTH HISTORY - the head

Ask about associated symptoms such as nausea and vomiting

Answer 23

Nausea and vomiting are common with migraine but also occur with brain tumors and subarachnoid hemorrhage.

Question 24

THE HEALTH HISTORY - the head
Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Does the patient report an aura with neurologic symptoms, such as change in vision, numbness, or weakness? Note that, due to increased risk of ischemic stroke and cardiovascular disease, the World Health Association advises women with migraines over age 35 and women with migraines with aura avoid use of estrogen-progestin
contraceptives

Answer 24

Approximately 60% to 70% of patients with migraine have a symptom prodrome prior to onset. About a third experience a visual aura, such as spark photopsias (flashes of light), fortifications (zig-zag arcs of light), and scotomata (area of visual loss with surrounding normal vision).

Question 25

THE HEALTH HISTORY - the head

Ask if coughing, sneezing, or changing the position of the head affects the headache.

Answer 25

Valsalva maneuvers may increase pain from acute sinusitis or from mass lesion due to changing intracranial pressure.

Question 26

THE HEALTH HISTORY - the head

Is there any overuse of analgesics, ergotamines, or triptans?

Answer 26

Medication for overuse headache
is indicated if present ≥15 days a
month for three months and reverts
to less than 15 days a month when the medication is discontinued

Question 27

THE HEALTH HISTORY - the head

Ask about family history

Answer 27

Genetic inheritance appears to be present in 30% to 50% of patients with migraine.

Question 28

THE HEALTH HISTORY - the ears
Opening questions are “How is your hearing?” and “Have you had any
trouble with your ears?” If the patient has noticed a hearing loss, does it involve one or both ears? Did it start suddenly or gradually? What are the associated symptoms, if any?

Answer 28

Hearing loss may also be congenital, from single gene mutations

Question 29

THE HEALTH HISTORY - the ears
Distinguish the type of hearing impairment: conductive loss, which results from problems in the external or middle ear, or sensorineural loss, from problems in the inner ear, the cochlear nerve, or its central connections in the brain. Two questions may be helpful: Does the patient have special difficulty understanding people as they talk? What happens in a noisy environment?

Answer 29

People with sensorineural loss have particular trouble understanding speech, often complaining that others mumble; noisy environments make hearing worse. In conductive loss, noisy environments may help.

Question 30

THE HEALTH HISTORY - the ears
Pursue symptoms associated with hearing loss, such as earache or vertigo; these help sort out likely causes. Ask about medications that might affect hearing and about sustained exposure to loud noise.

Answer 30

Medications that affect hearing include aminoglycosides, aspirin, NSAIDs, quinine, and furosemide

Question 31

THE HEALTH HISTORY - the ears
Complaints of earache, or pain in the ear, are especially common. Ask about associated fever, sore throat, cough, and concurrent upper respiratory infection.

Ask about discharge from the ear, especially if associated with earache or trauma.

Answer 31

Pain occurs in the external canal in otitis externa and, if respiratory infection, in the inner ear in otitis media.21 It may also be referred from other structures in the mouth, throat, or neck

Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum is present in acute or chronic otitis media.

Question 32

THE HEALTH HISTORY - the ears
Tinnitus is a perceived sound that has no external stimulus—commonly a musical ringing or a rushing or roaring noise in one or both ears. Tinnitus may accompany hearing loss and often remains unexplained. Occasionally, popping sounds originate in the temporomandibular joint, or vascular noises from the neck may be audible.

Answer 32

Tinnitus is a common symptom, increasing in frequency with age. When associated with hearing loss and vertigo, it suggests Ménière’s disease.

Question 33

THE HEALTH HISTORY - the ears

Answer 33

Vertigo refers to the perception that the patient or the environment is rotating or spinning. These sensations point primarily to a problem in the labyrinths of the inner ear, peripheral lesions of CN VIII, or lesions in its central pathways or nuclei in the brain.

Question 34

THE HEALTH HISTORY - the ears
Complaints of dizziness and light-headedness are challenging because they are often non-specific and can signify a spectrum of conditions ranging from vertigo to presyncope, weakness, unsteadiness and disequilibrium. Clarify by asking what the patient means by dizziness. Then ask, “Do you feel as if the room is spinning or tilting (vertigo)? Do your symptoms get worse when you move your head?” Vertigo is the sensation of true rotational movement of the patient or the surroundings. Ask, “Do you feel as if you are going to fall or pass out (presyncope)? . . . Or do you feel you are unsteady or losing your balance (disequilibrium)?” If there is true vertigo, distinguish peripheral from central neurologic causes. Establish the time-course of symptoms. Check for nausea, vomiting, double vision, and gait disturbance. Review the patient’s medications. Proceed with a careful neurologic examination focusing on presence of nystagmus and focal neurologic signs.

Answer 34

Vertigo represents vestibular disease, usually from peripheral causes in the inner ear such as benign positional vertigo, labyrinthitis, and Ménière’s disease. Ataxia, diplopia, and dysarthria signal central neurologic causes in the cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor; also consider migraine.22 Feeling light-headed, weak in the legs, or about to faint points to presyncope from arrhythmia, orthostatic hypotension, or vasovagal stimulation.

Question 35

THE HEALTH HISTORY - the nose and sinuses
Rhinorrhea refers to drainage from the nose and is often associated with nasal congestion, a sense of stuffiness or obstruction. These symptoms are frequently accompanied by sneezing, watery eyes, and throat discomfort, and itching in the eyes, nose, and throat.

Answer 35

Causes include viral infections, allergic rhinitis (“hay fever”), and vasomotor rhinitis. Itching favors an allergic cause.

Question 36

THE HEALTH HISTORY - the nose and sinuses
Do symptoms occur when colds are prevalent and last less than seven days? Do they occur seasonally when pollens are in the air? Are symptoms triggered by specific animal or environmental exposures?

What remedies has the patient used? For how long? And how well do they work?

Answer 36

Seasonal onset or environmental triggers suggest allergic rhinitis.

Drug-induced rhinitis occurs in excessive use of decongestants, or use of cocaine.

Question 37

THE HEALTH HISTORY - the nose and sinuses
Is nasal or sinus congestion preceded by a viral upper respiratory tract infection (URI)? Is there purulent nasal discharge, loss of smell, tooth pain or facial pain made worse by bending forward, ear pressure, cough, or fever?

Ask about drugs that may induce nasal stuffiness.

Answer 37

Acute bacterial sinusitis is unlikely until viral URI symptoms persist more than 7 days; both purulent drainage and facial pain should be present for diagnosis (sensitivity and specificity are above 50%)

Ask about oral contraceptives, reserpine, guanethidine, alcohol cocaine.

Question 38

THE HEALTH HISTORY - the nose and sinuses

Is the nasal congestion only on one side?

Answer 38

Consider a deviated nasal septum, nasal polyp, foreign body, granuloma (Wegener’s), or carcinoma

Question 39

THE HEALTH HISTORY - the nose and sinuses
Epistaxis is bleeding from the nasal passages. Bleeding can also originate in the paranasal sinuses or nasopharynx. Note that bleeding from posterior nasal structures may pass into the throat instead of out the nostrils. Ask the patient to pinpoint the source of the bleeding. Is it from the nose, or has the patient actually coughed up or vomited blood, termed hematemesis and hemoptysis? These conditions have very different causes.

Is epistaxis a recurrent problem? Has there been easy bruising or bleeding elsewhere in the body?

Answer 39

Local causes of epistaxis include trauma (especially nose-picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies.

Anticoagulants, NSAIDs, and coagulopathies can contribute to epistaxis

Question 40

THE HEALTH HISTORY - the mouth throat and neck
Sore throat or pharyngitis is a frequent complaint, usually associated with an acute URI.

A sore tongue may result from local lesions as well as from systemic illness.

Bleeding from the gums, especially when brushing teeth, is a common symptom. Ask about local lesions and any tendency to bleed or bruise elsewhere.

Answer 40

Centor’s clinical prediction rule for streptococcal and Fusobacterium necrophorum pharyngitis helps guide diagnosis and treatment of bacterial infection: fever history, tonsillar exudates, swollen tender anterior cervical adenopathy, and absence of cough

Aphthous ulcers (p. 245); sore smooth tongue of nutritional deficiency

Bleeding gums are most often caused by gingivitis

Question 41

THE HEALTH HISTORY - the mouth throat and neck
Hoarseness refers to a change in voice quality, often described as husky, rough, harsh, or lower-pitched than usual. Causes range from diseases of the larynx to extralaryngeal lesions that press on the laryngeal nerves. Ask the
patient about environmental allergies, acid reflux, smoking, and inhalation of fumes or other irritants.

Is the problem chronic, lasting more than 2 weeks? Is there prolonged tobacco or alcohol use, cough or hemoptysis, weight loss, or unilateral throat pain?

Answer 41

If hoarseness is acute, voice overuse and acute viral laryngitis are the most likely causes.

If hoarseness lasts more than 2 weeks, refer for laryngoscopy and consider causes such as hypothyroidism, reflux, vocal cord nodules, head and neck cancers, and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis.

Question 42

THE HEALTH HISTORY - the mouth throat and neck
Ask “Have you noticed any swollen glands or lumps in your neck?” because patients are more familiar with the lay terms than with “lymph nodes.”

Assess thyroid function and ask about any evidence of an enlarged thyroid gland or goiter. To evaluate thyroid function, ask about temperature intolerance and sweating. Opening questions include, “Do you prefer hot or cold weather?” “Do you dress more warmly or less warmly than other people?”

Answer 42

Enlarged tender lymph nodes commonly accompany pharyngitis

With goiter, thyroid function may be increased, decreased, or normal

Question 43

THE HEALTH HISTORY - the mouth throat and neck
“What about blankets . . . do you use more or fewer than others at home?” “Do you perspire more or less than others?” “Any new palpitations or change in weight?” Note that as people grow older, they sweat less, have less tolerance for cold, and tend to prefer warmer environments.

Answer 43

Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism

Question 44

THE PHYSICAL EXAMINATION - the ears
Hearing disorders of the external and middle ear cause conductive hearing loss. External ear causes include infection (otitis externa), trauma, squamous cell carcinoma, and benign bony growths such as exostoses or osteomas. Middle ear disorders include congenital conditions, benign cholesteatomas and otosclerosis, tumors, and perforation of the tympanic membrane.

Answer 44

Disorders of the inner ear cause sensorineural hearing loss from congenital and hereditary conditions, presbycusis, viral infections such as rubella and cytomegalovirus, Ménière’s disease, noise exposure, and acoustic neuroma.

Question 45

THE PHYSICAL EXAMINATION - the ears
The Auricle. Inspect the auricle and surrounding tissue for deformities, lumps, or skin lesions. If ear pain, discharge, or inflammation is present, move the auricle up and down, press the tragus, and press firmly just behind the ear.

Answer 45

Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear may be present in otitis media. Nontender nodular swellings covered by normal skin deep in the ear canals suggest exostoses. These are nonmalignant overgrowths which may obscure the drum.

Question 46

THE PHYSICAL EXAMINATION - the ears
Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or swelling. Cerumen, which varies in color and consistency from yellow and flaky to brown and sticky or even to dark and hard, may wholly or partly obscure your view.

Answer 46

In acute otitis externa, the canal is often swollen, narrowed, moist, pale, and tender. It may be reddened. In chronic otitis externa, the skin of the canal is often thickened, red, and itchy.

Question 47

THE PHYSICAL EXAMINATION - the ears

Inspect the eardrum, noting its color and contour. The cone of light — usually easy to see —helps to orient you.

Answer 47

Look for the red bulging drum of acute purulent otitis media. the amber drum of a serous effusion.

Question 48

THE PHYSICAL EXAMINATION - the ears

Identify the handle of the malleus, noting its position, and inspect the short process of the malleus.

Answer 48

An unusually prominent short process and a prominent handle that looks more horizontal suggest a retracted drum.

Question 49

THE PHYSICAL EXAMINATION - the ears

Mobility of the eardrum can be evaluated with a pneumatic otoscope

Answer 49

A serous effusion, a thickened drum, or purulent otitis media may decrease mobility

Question 50

THE PHYSICAL EXAMINATION - the ears
Testing Auditory Acuity—Whispered Voice Test. To begin screening, ask the patient “Do you feel you have a hearing loss or difficulty hearing?” If the patient reports hearing loss, proceed to the whispered voice test.

Answer 50

The whispered voice test is a reliable screening test for hearing loss if examiners use a standard method of testing and exhales before whispering.

Question 51

THE PHYSICAL EXAMINATION - the ears
Whispered Voice Test for Auditory Acuity:
◗◗ Stand 2 feet behind the seated patient so the patient cannot read your lips.
◗◗ Occlude the nontest ear with a finger and gently rub the tragus in a circular motion to prevent transfer of sound to the nontest ear.
◗◗ Exhale a full breath before whispering to ensure a quiet voice.
◗◗ Whisper a combination of three numbers and letters, such as 3-U-1. Use a different number/letter combination for the other ear.
Interpretation:
Normal: patient repeats initial sequence correctly.
Normal: patient responds incorrectly, so test a second time with a different number/letter combination; patient repeats at least three out of the
possible six numbers and letters correctly.
Abnormal: four of the six possible numbers and letters are incorrect. Conduct further testing by audiometry. (Weber and Rinne tests are less accurate and precise.)

Answer 51

Note that older adults with presbycusis have higher frequency hearing loss, making them more likely to miss consonants, which have higher frequency sounds than vowels.

Question 52

THE PHYSICAL EXAMINATION - the ears
Test for lateralization (Weber test). Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the midforehead.

Ask where the patient hears the sound: on one side or both sides? Normally the vibration is heard in the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly on the head. Restrict this test to patients with unilateral hearing loss since patients with normal hearing may lateralize, and patients with bilateral conductive or sensorineural deficits will not lateralize.

Answer 52

In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. Explanations include otosclerosis otitis media, perforation of the eardrum, and cerumen

In unilateral sensorineural hearing loss, sound is heard in the good ear.

Question 53

THE PHYSICAL EXAMINATION - the ears
Compare air conduction (AC) and bone conduction (BC) (Rinne test). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Here the “U” of the fork should face forward, thus maximizing its sound for the patient. Normally the sound is heard longer through air than through bone (AC > BC).

Answer 53

In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air (AC > BC).

Question 54

THE PHYSICAL EXAMINATION - the nose and sinuses
Inspect the anterior and inferior surfaces of the nose. Gentle pressure on the tip of the nose with your thumb usually widens the nostrils and, with the aid of a penlight or otoscope light, you can get a partial view of each nasal vestibule. If the tip is tender, be particularly gentle and manipulate the nose as little as possible.

Answer 54

Tenderness of the nasal tip or alae suggests local infection such as a furuncle.

Question 55

THE PHYSICAL EXAMINATION - the nose and sinuses
Inspect the inside of the nose with an otoscope and the largest ear speculum available. Tilt the patient’s head back a bit and insert the speculum gently into the vestibule of each nostril, avoiding contact with the sensitive nasal septum. Hold the otoscope handle to one side to avoid the patient’s chin and improve your mobility. By directing the speculum posteriorly, then upward in small steps, try to see the inferior and middle turbinates, the nasal septum, and the narrow nasal passage between them. Some asymmetry of the two sides is normal.

Answer 55

Deviation of the lower septum is common and may be easily visible, as illustrated. Deviation seldom obstructs air flow.

Question 56

THE PHYSICAL EXAMINATION - the nose and sinuses
The nasal mucosa that covers the septum and turbinates. Note its color and any swelling, bleeding, or exudate. If exudate is present, note its character: clear, mucopurulent, or purulent. The nasal mucosa is normally
somewhat redder than the oral mucosa.

Answer 56

In viral rhinitis, the mucosa is reddened and swollen; in allergic rhinitis, it may be pale, bluish, or red.

Question 57

THE PHYSICAL EXAMINATION - the nose and sinuses
The nasal septum. Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient’s finger can reach) is a common source of epistaxis (nosebleed).

Any abnormalities such as ulcers or polyps

Answer 57

Fresh blood or crusting may be seen. Causes of septal perforation include trauma, surgery, and intranasal use of cocaine or amphetamines, which also cause septal ulceration.

Nasal polyps are pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses. Conditions conducive to polyps include allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis.

Question 58

THE PHYSICAL EXAMINATION - the nose and sinuses
Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses.

Answer 58

Local tenderness, together with symptoms such as pain, fever, and nasal discharge, suggest acute sinusitis involving the frontal or maxillary sinuses

Question 59

THE PHYSICAL EXAMINATION - the mouth throat and neck
If the patient wears dentures, offer a paper towel and ask the patient to remove them so that you can see the mucosa underneath. If you detect any suspicious ulcers or nodules, put on a glove and palpate any lesions, noting any thickening or infiltration of the tissues that might suggest malignancy.

Answer 59

Bright red edematous mucosa underneath a denture suggests denture sore mouth. There may be ulcers or papillary granulation tissue.

Question 60

THE PHYSICAL EXAMINATION - the mouth throat and neck

The Lips. Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness.

Answer 60

The Oral Mucosa. Look into the patient’s mouth and, with a good light and the help of a tongue blade, inspect the oral mucosa for color, ulcers, white patches, and nodules. The wavy white line on the adjacent buccal mucosa developed where the upper and lower teeth meet, related to irritation from sucking or chewing.

Question 61

THE PHYSICAL EXAMINATION - the mouth throat and neck
The Gums and Teeth. Note the color of the gums, normally pink. Brown patches may be present, especially but not exclusively in black people.

Inspect the gum margins and the interdental papillae for swelling or ulceration.

Answer 61

Redness of gingivitis, black line of lead poisoning

Swollen interdental papillae in gingivitis

Question 62

THE PHYSICAL EXAMINATION - the mouth throat and neck

The Roof of the Mouth. Inspect the color and architecture of the hard palate.

Answer 62

Torus palatinus, a benign midline lump

Question 63

THE PHYSICAL EXAMINATION - the mouth throat and neck
The Tongue and the Floor of the Mouth. Ask the patient to put out his or her tongue. Inspect it for symmetry—a test of the hypoglossal nerve (CN XII).

Answer 63

Inspect the sides and undersurface of the tongue and the floor of the mouth, areas where cancer often develops. Note any white or reddened areas, nodules, or ulcerations

Question 64

THE PHYSICAL EXAMINATION - the mouth throat and neck
Palpate any lesions. Explain what you plan to do and put on gloves. Ask the patient to protrude the tongue. With your right hand, grasp the tip of the tongue with a square of gauze and gently pull it to the patient’s left. Inspect the side of the tongue, and then palpate it with your gloved left hand, feeling for any induration. Reverse the procedure for the other
side

Answer 64

Tongue cancer is a common oral cancer, especially in men older than 50 years, smokers, tobacco chewers, and alcohol drinkers, and usually appears on the side or base of the tongue. Any persistent nodule or ulcer, red or white, is suspect, especially if indurated. These discolored lesions represent erythroplakia and leukoplakia and should be biopsied

Question 65

THE PHYSICAL EXAMINATION - the mouth throat and neck
The Pharynx. With the patient’s mouth open but the tongue not protruded, ask the patient to say “ah” or yawn. This action may let you see the pharynx well. If not, press a tongue blade firmly down upon the midpoint of the arched tongue—far enough back to visualize the pharynx but not so far that you cause gagging. Simultaneously, ask for an “ah” or a yawn. Note the rise of the soft palate—a test of CN X (the vagal nerve).

Answer 65

In CN X paralysis, the soft palate fails to rise and the uvula deviates to the opposite side.

Question 66

THE PHYSICAL EXAMINATION - the mouth throat and neck
Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx. Note their color and symmetry and look for exudate, swelling, ulceration, or tonsillar enlargement. If possible, palpate any suspicious area for induration or tenderness. Tonsils have crypts, or deep infoldings of squamous epithelium. Whitish spots of normal exfoliating epithelium may sometimes be seen in these crypts

Answer 66

Tonsillar exudates are common in streptococcal pharyngitis

Question 67

THE PHYSICAL EXAMINATION - the mouth throat and neck
Inspect the neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes.

Answer 67

A scar of past thyroid surgery is often a clue to unsuspected thyroid disease.

Question 68

THE PHYSICAL EXAMINATION - the mouth throat and neck
The Lymph Nodes. Palpate the lymph nodes. Using the pads of your index and middle fingers, move the skin over the underlying tissues in each area. The patient should be relaxed, with neck flexed slightly forward and, if needed, turned slightly toward the side being examined. You can usually examine both sides at once. For the submental node, however, it is helpful to feel with one hand while bracing the top of the head with the other.

Answer 68

Feel in sequence for the following nodes:

1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of the mandible
7. Superficial cervical—superficial to the sternomastoid
8. Posterior cervical—along the anterior edge of the trapezius
9. Deep cervical chain—deep to the sternomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternomastoid muscle to find them.
10. Supraclavicular—deep in the angle formed by the clavicle and the sternomastoid

Question 69

THE PHYSICAL EXAMINATION - the mouth throat and neck
Using the pads of the second and third fingers, palpate the preauricular nodes with a gentle rotary motion. Then examine the posterior auricular and occipital lymph nodes

Note their size, shape, delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete, nontender nodes, sometimes termed “shotty,” are frequently found in normal people.

Answer 69

Tender nodes suggest inflammation; hard or fixed nodes suggest malignancy. Describe enlarged nodes in two dimensions, maximal length and width, for example, 1 cm × 2 cm.

Occasionally you may mistake a band of muscle or an artery for a lymph node. You should be able to roll a node in two directions: up and down, and side to side. Neither a muscle nor an artery will pass this test.

Question 70

THE PHYSICAL EXAMINATION - the mouth throat and neck
Palpate the anterior superficial and deep cervical chains, located anterior and superficial to the sternomastoid. Then palpate the posterior cervical chain along the trapezius (anterior edge) and along the sternomastoid (posterior edge). Flex the patient’s neck slightly forward toward the side being examined. Examine the supraclavicular nodes in the angle between the clavicle and the sternomastoid.

Answer 70

Enlarged or tender nodes, if unexplained, call for (1) re-examination of the regions they drain and (2) careful assessment of lymph nodes elsewhere so that you can distinguish between regional and generalized lymphadenopathy. Generalized lymphadenopathy is seen in HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis

Question 71

THE PHYSICAL EXAMINATION - the mouth throat and neck
The Trachea and the Thyroid Gland. To orient yourself to the neck, identify the thyroid and cricoid cartilages and the trachea below them. Inspect the trachea for any deviation from its usual midline position. Then feel for any deviation. Place your finger along one side of the trachea and note the space between it and the sternomastoid. Compare it with the other side. The spaces should be symmetric.

Answer 71

Masses in the neck may push the trachea to one side. Tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass, atelectasis, or a large pneumothorax

Question 72

THE PHYSICAL EXAMINATION - the mouth throat and neck
Inspect the neck for the thyroid gland. Tip the patient’s head back a bit. Using tangential lighting directed downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage for the gland. The lower shadowed border of the thyroid glands shown here is outlined
by arrows.

Answer 72

Goiters may be simple, without nodules, or multinodular, and are usually euthyroid

Question 73

THE PHYSICAL EXAMINATION - the mouth throat and neck
Palpate the thyroid gland. This may seem difficult at first. Use the cues from visual inspection. Find your landmarks—the notched thyroid cartilage and the cricoid cartilage below it. Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal. The thyroid gland is usually easier to palpate in a long slender neck. In shorter necks, hyperextension of the neck may be helpful. If the lower pole of the thyroid gland is not palpable, suspect a retrosternal location.
rings.

Answer 73

When the thyroid gland is retrosternal, below the suprasternal notch, it is often not palpable. Retrosternal goiters can cause hoarseness, shortness of breath, stridor, or dysphagia from tracheal compression; neck hyperextension and arm elevation may cause flushing from dilatation of the external jugular veins and obstruction of the thoracic inlet. Usually they present in the fifth decade; over 85% are benign.