Assessment Neck and Nodes

ROS for neck

pain, stiffness, pulsation, limitations of motion, goiter, masses, lymphadenopathy

ROS of nodes

tenderness or enlargement of the cervical, axillary, epitrochlear or inguinal nodes

Sternocleidomastoid muscle

attaches to sternum, clavicle and mastoid

Anterior triangle of the neck

Borders midline of neck, SCM, and mandible

Posterior triangle of neck

borders SCM, clavicle, and trapezius

Trapezius muscle

neck → midback
3 portions: superior, middle, inferior

Supraclavicular fossae

above clavicle
brachial plexus + lymph

Sternal notch

in between clavicle ends

Carotid artery

takes blood to brain
medial to SCM
branches at thyroid cartilage

Lymph nodes

filtration and processing units
preauricular, postauricular, occipital, posterior cervical chain, superficial cervical chain, deep cervical chain, supraclavicular, tonsillar, submandibular, submental

preauricular lymph drains

superficial face and temporal region

postauricular drains

posterior neck, upper ear, and posterior ear canal

occipital drains

occipital area of scalp

posterior cervical chain drains

scalp and neck

superficial anterior cervical chain drains

tongue, larynx, oropharynx, anterior neck

deep cervical chain drains

tongue, larynx, thyroid, trachea

supraclavicular drains

head, abdomen, thorax, breast, arm
Virchow’s node: left supraclavicular node enlargement

tonsillar drains

mouth, throat, superficial tissues

submandibular drains

lateral nose, lips, gums, anterior tongue

submental drains

tip of tongue, lower lip, and floor of mouth

performing lymph node exam

patient should be relaxed with neck slightly flexed forward
used pads of index and middle finger over the node to move the skin underlying tissues
compare bilaterally except for submental and deep / superficial cervical chain

Carotid sinus

location at top of thyroid cartilage
avoid palpation due to sensitivity of pressure

PE of cartoid vessels

inspection: check for visible pulsations
palpitation: 1 side at a time, avoid occluding artery and palpation over carotid sinus
auscultation: have patient hold breath, used diaphragm, listen to bruit / murmur and place stethoscope at upper end of thyroid cartilage which overlies bifurcation of common carotid

Bruit

turbulent blood flow resulting from stenosis (narrowing) of artery
can be caused if pressed too hard

Causes of increased pulsations in neck

increased stroke volume, decreased peripheral resistance, or both (fever, anemia, hyperthryoidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus)
slow heart rates in bradycardia / heart blood
decreased compliance (increased stiffness) of aortic walls in aging or atherosclerosis

Examination of thyroid

inspection: masses, goiter, asymmetry, ask patient to swallow for contour and symmetry
palpation: posterior approach, ring fingers in sternal notch with middle and index fingers just below cricoid cartilage, have patient swallow and palpate for glandular isthmus move up and down, gently displace trachea on right towards the left and palpate left lobe, have patient swallow
auscultation: bruit using bell

Graves disease

hyperactive thyroid, thyroid is very large
thyroid is soft and nodular

Neck flexion

SCM, scalene, prevertebral

Extension

splenius capitis, cervicis, small intrinsic neck muscles

Rotation neck

SCM, small intrinsic neck muscles

lateral bending neck

scalenes and small intrinsic neck muscles

Muslces in neck with accessory breathing

SCM and scalene

Cervical sprain / strain

symptoms: localized neck pain, limited motion
PE: localized tenderness over paravertebral muscles of c spine and pain on movement

cervical disc disorder with radiculopathy

symptoms: neck pain with radiation of pain to one arm (sharp, burning tingling, numbness, weakness)
PE: cervical spine muscle tenderness, limited ROM, sensory loss, weakness, muscle atrophy, decreased reflexes in affected upper extremity because it affects C7 which controls arm movement

Cervical spondylosis with myelopathy

compresses spinal cord
symptoms: neck pain with bilateral weakness and paresthesia in both upper and lower extremities, urinary frequency, pain worsens with neck flexion
PE: hyperreflexia, clonus at wrist, knee, ankle, gait disturbance, lhermitte sign (electrical shock radiation down spine)

Hashimoto Thyroiditis

firm thyroid

Subclinical hypothyroidism vs. subclinical hyperthyroidism

subclinical hypothyroidism: increased risk for cardiovascular disease
subclinical hyperthyroidism: cardiovascular mortality, atrial fibrillation, decreased bone density

Hyperthyroidism

“everything fast”
nervous, weight loss despite increased appetite, excessive sweating, heat intolerance, palpitations, frequent BM, tremors and proximal muscle weakness, warm, smooth, moist skin, Grave’s disease, increased systolic and decreased diastolic BP, tachycardia, atrial fibrillation, hyper dynamic cardiac pulsations with accentuated s1.

Hypothyroidism

“everything slow” fatigue, lethargy, modest weight gain with anorexia, dry coarse skin, cold intolerance, swelling of face, hands, legs, constipation, weakness, muscle cramps, arthralgia, paresthesias, impaired memory and hearing, dry coarse, cool skin with nonpitting myxedema and loss of hair, periorbital myxedema, low pitched speech, decreased systolic and increased diastolic BP, bradycardia, hypothermia, decreased intensity of heart sounds, prolonged relaxation phase during ankle reflex, impaired memory loss, somnolence, peripheral neuropathy, carpal tunnel