FOR DIAGRAM CHECK NORMAN BROWSE FIGURE 6.6 PAGE 167

THIS IS AGAIN A VERY IMPORTANT AND COMMON CASE IN THE ORTHOPAEDICS BAY OF MRCS CLINICAL EXAM. LOOK CAREFULLY ESPECIALLY FOR SCARS. AND TREATMENT IS VERY IMPORTANT IN THIS.

TO PATIENT:

HELLO MR. PETER. MY NAME IS DR NAZISH. HOW ARE YOU FEELING TODAY.REPLY ACCORDINGLY?

MAY I EXAMINE YOUR FEET PLEASE?

THANK YOU. LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE ROLL UP YOUR TROUSERS TO EXPOSE BOTH ANKLES AND FEET? AND NOW PLEASE SIT DOWN FACING ME.

ARE YOU COMFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS.

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

KNEEL DOWN AND BE AT LEVEL OF PATIENT AND OBSERVE.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS GENTLEMAN MARKED/ MODERATE/SLIGHT LATERAL DEVIATION AND MEDIAL ROTATION OF HALLUX BILATERALLY/ ON RT OR LF SIDE WITH PROMINENCE OF MEDIAL SIDE OF HEAD OF FIRST METATARSAL BONE WORSE ON THE RIGHT SIDE.

TYPICAL ASSOCIATED FEATURES SEEN HERE INCLUDE WIDENING OF FOREFOOT, BUNION, CROWDING OF TOES AND OVERLAPPING OF 2^ND TOE.

THE THIRD TOE IS HAMMER TOE WITH FIXED FLEXION OF PIPJ AND WITH MIDDLE PHALANX POINTING DOWNWARDS. THE SKIN OVERLYING THE MEDIAL SIDE OF HEAD OF FIRST METATARSAL BONE IS/ IS NOT RED AND THERE IS/ IS NO EVIDENCE OF CORNS AND CALLOSITIES OVER THE SKIN OF THE FLEXED PIPJ. THE REST OF THE FOOT APPEARS TO BE NORMAL AND THERE IS/ IS NO EVIDENCE OF ANY SCAR.

AND NOW I WOULD LIKE TO LOOK AT THE OTHER FOOT.

TO PATIENT:

NOW SIR PLEASE RAISE YOUR FOOT SO THAT I CAN SEE THE UNDERSIDE OF IT.

TO EXAMINER:

THE SKIN ON SOLE OF FOOT UNDER METATARSAL HEADS SHOWS/ SHOWS NO EVIDENCE OF CALLOSITIES.

AND NOW THE OTHER FOOT.

TO PATIENT:

I AM JUST GOING TO FEEL YOUR FOOT. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.

ACT: CHECK TEMPERATURE WITH BACK OF YOUR HAND OVER BUNION AND COMPARE WITH SURROUNDING SKIN.

TO EXAMINER:

THE OVERLYING SKIN IS NOT WARM.

ACT:

NOW PLACE ONE HAND ON DORSUM OF FOOT AND COMPRESS MTPJ. LOOK AT PATIENTS FACE AND ALSO ASK IF IT IS TENDER.

NOTE:

IF YOU CANNOT UNDERSTAND HOW TO DO THIS CHECK BARBARA BATES CLINICAL EXAMINTION CD.

TO PATIENT:

IS IT TENDER SIR?

AND NOW THE OTHER FOOT.

TO EXAMINER:

TENDERNESS OVER MTPJ IS NOT PRESENT.

TO PATIENT:

I WILL NOW CHECK FOR MOVEMEMNTS. LET ME JUST STABILIZE THE ANKLE WITH ONE HAND AND SUPPORT YOUR HEEL WITH MY OTHER HAND. NOW PLEASE TURN YOUR HEEL INWARDS AND OUTWARDS.

NOTE:

IF YOU DON’T KNOW HOW TO DO IT. PLEASE CHECK OUT BARBARA BATES CLINICAL EXAMINATION CD WHICH IS EASILY AVAILABLE AT WINCO BOOK STALL OPPOSITE DOW MEDICAL COLLEGE IN KARACHI.

TO EXAMINER:

I AM TESTING FOR INVERSION AND EVERSION AT SUBTALAR JOINT.

AND NOW THE OTHER SIDE.

INVERSION AND EVERSION AT SUBTALAR JOINTS IS NORMAL.

TO PATIENT:

LET ME JUST HOLD/STABILIZE YOUR HEEL AND NOW PLEASE MOVE REST OF YOUR FOREFOOT INWARDS AND OUTWARDS. THANK YOU.

I AM ASSESSING INVERSION AND EVERSION OF FOREFOOT AND NOW THE OTHER FOOT.

TO EXAMINER:

INVERSION AND EVERSION AT FOREFOOT IS NORMAL.

TO PATIENT:

FINALLY PLEASE BEND YOUR TOES DOWNWARDS AND NOW UPWARDS.

I AM ASSESSING ANY HYPER MOBILITY.

AND NOW THE OTHER SIDE.

TO EXAMINER:

NO HYPERMOBILITY IS SEEN. HENCE INSTABILITY IS NOT PRESENT.

TO PATIENT:

THANK YOU SIR.

TO EXAMINER:

TO COMPLETE MY EAMINATION I WOULD LIKE TO EXAMINE SHOES OF PATIENT AS ANY ABNORMALITY OF WEIGHTBEARING WILL BE EVIDENT FROM THE TYPE OF SHOES THE PATIENT WEARS. I WOULD ALSO LIKE TO SEE THE PATIENT WALK AND ASK FEW QUESTIONS TO ASSESS THE EFFECT OF THIS CONDITION ON PATIENTS LIFE.

THIS PATIENT HAS MARKED HALLUX VALGUS WITH NO FUNCTIONAL IMPAIRMENT.

I WOULD LIKE TO WASH MY HANDS.

NOTE:

CLAW TOES: HYPER EXTENSION OF MTPJ AND FLEXION OF IPJ.

FOR DIAGRAM CHECK NORMAN BROWSE FIGURE 3.31 PAGE 80.

HELLO MR. BROWN. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

DO YOU MIND IF I EXAMINE YOU.

THANK YOU. LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. MY HANDS ARE ALREADY WASHED.

COULD YOU PLEASE SIT ON THIS CHAIR AND ROLL YOUR SLEEVES UP. THE OTHER SIDE ALSO. AND NOW PLEASE PLACE BOTH YOUR HANDS PALMS UPWARDS ON YOUR LAP.

ARE YOU COMFORTABLE SIR.

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

COME CLOSE TO LEVEL OF LUMP AND LOOK FOR APPROXIMATE SIZE, SITE AND EXACT SIZE ALWAYS IN 2 DIMENSIONS, SHAPE, OVERLYING SKIN AND SURROUNDING SKIN.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS GENTLEMAN A SMALL/ LARGE LUMP ON FLEXOR ASPECT OF WRIST JOINT JUST OVER DISTAL PART OF RIGHT FOREARM. IT IS 3 BY 2 CMS IN SIZE AND IS HEMISPHERICAL IN SHAPE. THERE IS NO EVIDENCE OF ANY REDNESS, SCAR IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL. THE CONTRALATERAL HAND APPEARS TO BE NORMAL.

TO PATIENT:

I AM NOW GOING TO GENTLY FEEL IT. IS IT TENDER? I WILL BE VERY GENTLE.

ACT:

CHECK TEMPERATURE WITH BACK OF HAND AND COMPARE WITH SURROUNDING SKIN. THEN TENDERNESS (LOOK AT APTIENTS FACE AND ALSO ASK IF IT IS TENDER), SURFACE, EDGE, CONSISTENCY, FLUCTUATION, COMPRESSIBILITY AND LAYER OF ORIGIN ALONG WITH LYMPH NODES.

TO EXAMINER:

THE OVERLYING SKIN IS NOT WARM. IT IS A NON TENDER LUMP WITH A SMOOTH SURFACE AND WELL DEFINED EDGE. IT IS FIRM IN CONSISTENCY AND IS NON FLUCTUANT AND NON COMPRESSIBLE.

TO PATIENT:

I AM NOW GOING TO PINCH THE OVERLYING SKIN AND MOVE THE LUMP IN 2 PLANES.

TO EXAMINER:

THE OVERLYING SKIN IS FREELY MOBILE AND THE LUMP FREELY MOVES OVER THE UNDERLYING TISSUES.

TO PATIENT:

COULD YOU PLEASE TENSE THAT MUSCLE AGAINST MY HAND. I AM GOING TO REASSESS THE MOBILITY OF LUMP IN 2 PLANES.

ACT:

IF LUMP IS ON FLEXOR ASPECT, PLACE YOUR HAND ON PALMAR ASPECT OF PATIENTS HAND AND PRESS DOWN NOW TELL PATIENT PLEASE BEND YOUR WRIST PUSHING AGAINST MY HAND.

IF LUMP IS ON EXTENSOR ASPECT, TELL PATIENT PLEASE GIVE ME YOUR HAND PALMS DOWNWARDS. NOW MAKE A FIST. TRY TO MOVE YOUR FIST BACKWARDS. DON’T LET ME PULL IT DOWN.

TO EXAMINER:

THE LUMP BECOMES MORE PROMINENT ON TENSING THE MUSCLE AND ITS MOBILITY IS NOT AFFECTED. THEREFORE IT ARISES FROM THE SUBCUTANEOUS TISSUES.

TO PATIENT:

THANK YOU SIR. YOU MAY ROLL DOWN YOUR SLEEVES NOW. LET ME HELP YOU WITH IT. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASK THE PATIENT SOME QUESTIONS:

1. HOW THE GANGLION AFFECTS THEIR LIVES
2. WHETHER THEY HAVE NOTICED SIMILAR LUMPS ELSEWHERE
3. WHICH HAND IS DOMINANT KEEPING TREATMENT OPTIONS IN MIND?
4. WHAT IS THEIR OCCUPATION AGAIN KEEPING TREATMENT IN MIND?

THIS IS A GANGLION.

I WOULD LIKE TO WASH MY HANDS.

INSTRUCTION:  EXAMINE THIS GENTLEMANS BACK.

TO PATIENT:

HELLO MR.SAM. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOU? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE TAKE OFF UR TROUSERS KEEPING UR UNDERWEAR ON? CAN U PLZ STAND WITH UR BACK TO ME.? THANK U.

ARE YOU COMFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT: LOOK AT PTS BACK.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS GENTLEMAN NO EVIDENCE OF ANY CAFÉ AU LAIT SPOTS, ERYTHEMA, SCARS OF PREVIOUS THORACOTOMY OR TRAUMA, HAIRY PATCH (SPINA BIFIDA), SWELLING OR SCOLIOSIS.

FIG. 8, 9 MC RAE PG 131.

TO PT:

NOW SIR COULD U PLZ TURN TO UR SIDE.

TO EXAMINER:

THIS YOUNG MAN HAS LOSS OF NORMAL LUMBAR LORDOSIS AND INCREASED THORACIC KYPHOSIS WITH FORWARD THRUST OF NECK PRODUCING A STOOPED QUESTION MARK POSTURE.

FIG. 1, 4, 6 PG 130 MC RAE.

I WOULD LIKE TO DETERMINE WHETHER THIS KYPHOSIS IS FIXED OR MOBILE.

NOTE:

MOBILE KYPHOSIS IS FOUND IN POSTURAL KYPHOSIS WHILE FIXED KYPHOSIS IS PRESENT INS ENILE KYPHOSIS, ANKYLOSING SPONDILITIS.

TO PT:

COULD U PLZ BEND FORWARDS? I AM CHECKING FOR FLOW OF MOVEMENT IN SPINE AND WHETHER THE CURVATURE INCREASES. THANK U. U MAY STRAIGHTEN UP NOW. NOW STANDING UPRIGHT PLZ BRACE BACK UR SHOULDERS. I AM CHECKING FOR MOBILITY OF KYPHOSIS. THANK U. U MAY RELAX NOW.

FIG. 2, 3, 4 PG. 130 MC RAE.

TO EXAMINER:

A FIXED KYPHOSIS IS PRESENT.

TO PT:

COULD U PLZ SIT ON THIS CHAIR WITH UR BACK TO ME AND LEAN FORWARDS. I AM NOW GOING TO GENTLY FEEL UR BACK. I WILL BE VERY GENTLE.

ACT:

CHECK TEMP WITH BACK OF HAND FROM TOP TO DOWN IN MIDLINE OF BACK.

TO EXAMINER:

THE OVERLYING SKIN IS NOT WARM.

ACT:

CHECK FOR TENDERNESS: BW SPINES OF LUMBAR VERTEBRAE AND LUMBOSACRAL JUNCTION, OVER LUMBAR MUSCLES, OVER SACROILIAC JOINT.

FIG. 15, 16 PG 132 MC RAE.

TO PT:

PLZ LET ME KNOW IF IT HURTS AT ALL.

NOW SIR PLZ STAND UP WITH UR BACK TO ME. I AM JUST GOING TO SLIDE MY FINGERS DOWN LUMBAR SPINE ON TO THE SACRUM TO FEEL FOR A PALPABLE STEP AT LUMBOSACRAL JUNCTION.

FEATURE OF SPONDYLOLITHESIS.

FIG. 17 PG. 132 MC RAE.

TO EXAMINER:

TENDERNESS IS PRESENT OVER SPINE AND SACROILIAC JOINTS. I CANNOT FEEL A PALPABLE STEP AT LUMBOSACRAL JUNCTION.

TO PT:

COULD U PLZ BEND FORWARDS? I AM JUST GOING TO GENTLY TAP OVER UR SPINE WITH MY FIST FROM THE NECK TO SACRUM. PLZ LET ME KNOW IF IT HURTS.

FIG. 18, PG. 132 MC RAE.

TO EXAMINER:

THERE IS NO MARKED PAIN ON PERCUSSION OVER SPINE.

TO PT:

I AM NOW GOING TO ASSESS MOVEMENTS. CAN U PLZ LEAN FORWARDS AS FAR AS U CAN KEEPING UR KNEES UNBENT, TRY TO TOUCH UR TOES. THANK U.

FIG 20 PG 133 MC RAE

NOTE:

MAJORITY CAN REACH WITHIN 7 CMS OF FLOOR. (NORMAL).

NOW COULD U PLZ ARCH UR BACK. LET ME HELP U BY PLACING MY HAND ON THE SMALL OF UR BACK TO STEADY PELVIS. WITH MY OTHER HAND I WILL GENTLY STEADY PELVIS. WITH MY OTHER HAND I WILL GENTLY PULL BACK UR SHOULDERS. PLZ DO LET ME KNOW IF IT HURTS AT ALL. THANK U.

FIG 26 PG 134 MC RAE

THIS TESTS EXTENSION WHICH IS NORMALLY ABOUT 30 DEGREES.

AND NOW PLZ STAND UP STRAIGHT AGAIN AND REST UR HANDS AGAINST THIGHS. NOW LEAN TO LEFT AND SLIDE UR HAND DOWN THE SIDE OF UR LEFT LEG. DO NOT LEAN FORWARDS OR BACK.

AND NOW THE RT SIDE. THANK U.

FIG 27 PG 134 MC RAE

THIS TESTS LATERAL FLEXION WHICH IS NORMALLY ABOUT 30 DEGREES.

NOW COULD U PLZ SIT DOWN SO AS TO FIX THE PELVIS. CROSS UR ARMS OVER UR CHEST AND NOW TWIST UR SHOULDERS AS FAR BACK AS U CAN. FIRST TO THE RT AND NOW TO THE LT. THANK U.

THIS CHECKS ROTATION WHICH IS NORMALLY ABOUT 40 DEGREES.

FIG 29 PG 134 MC RAE

TO EXAMINER:

THE RANGE OF MOVEMENT OF SPINE IS REDUCED IN ALL DIRECTIONS ESPECIALLY EXTENSION.

TO PT:

I WOULD LIKE TO ASSESS MOVEMENTS AT THE NECK.

COUL U PLZ BEND UR HEAD FORWARDS AND TRY TO PUT UR CHIN TO UR CHEST. THIS TESTS FORWARD FLEXION. THANK U.

FIG 7 PG 32 MC RAE

AND NOW TILT UR HEAD BACKWARDS AS FAR BACK AS IT CAN GO. THIS TEST EXTENSION. THANK U.

FIG 8 PG 32 MC RAE

NOW PLZ TILT UR HEAD AND TRY TO TOUCH UR EARS TO UR SHOULDER. AND NOW THE OTHER SIDE. THANK U. THIS TESTS LATERAL FLEXION.

FIG 11 PG 32 MC RAE

NOW PLZ LOOK OVER UR SHOULDER. LET ME JUST PUT ONE HAND ON SHOULDER TO RESTRICT ITS MOVEMENT. AND NOW THE OTHER SIDE. THANK U. THIS TESTS ROTATION.

TO EXAMINER:

THERE IS LOSS OF CERVICAL EXTENSION.

TO PT:

NOW I WOULD LIKE TO PERFORM WALL TEST. PLZ STAND WITH UR BACK AGAINST THE WALL. HEELS, BUTTOCKS, SCAPULA AND OCCIPUT MUST ALL TOUCH WALL SIMULTANEOUSLY.

TO EXAMINER:

THE WALL TEST IS POSITIVE AS REDUCTION IN SPINE EXTENSION MAKES ABOVE IMPOSSIBLE.

TO PT:

NOW I WULD LIKE TO TEST FOR IRRITATION OF ROOTS OF SCIATIC NERVE WITH THE STRAIGHT LEG RAISING TEST (SLR).

PLZ LIE DOWN COMFORTABLY STRAIGHT ON THIS BED. CAN U PLZ STARIGHTEN UR LEG.? LET ME JUST LIFT IT. WATCH PTS FACE. PLZ LET ME KNOW WHEN U FEEL PAIN.

ACT: KEEPING KNEE STRAIGHT LIFT LEG BY HEEL.

TO PT:

PLZ LET ME KNOW WHEN U FEEL BACK OR LEG PAIN.

FIG 31 PG 135 MC RAE

NOTE:

BACK PAIN SUGGESTS CENTARL DISC PROLAPSE WHILE LEG PAIN SUGGESTS LATERAL PROTRUSION.

TO PT:

NOW WITH THE STRAIGHT LEG STILL RAISED, I AM JUST GOING TO BEND UR FOOT FORWARDS (TOWARDS UR LEG). PLZ LET ME KNOW IF IT INCRESES PAIN.

ACT:

PASSIVELY DORSIFLEX FOOT.

NOTE:

THIS INCREASES TENSION ON NERVE ROOTS INCREASING PAIN.

FIG 33 PG 135 MC RAE

TO EXAMINER:

SCIATIC NERVE IS NOT INVOLVED AND THERE IS NO EVIDENCE OF PROLAPSED INTERVERTEBRAL DISC.

TO PT:

THANK U SIR. U MAY WEAR UR TROUSERS. LET ME HELP U WITH IT. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO EXAMINE CHEST (AS CHEST EXPANSION IS DECREASED BC OF INVOLVEMENT OF COSTOVERTEBRAL JOINTA), DO A FULL NEUROLOGICAL EXAMINATION OF LEGS, CHECK FEMORAL PULSES TO EXCLUDE VASCULAR CAUSE, EXAMINE ABDOMEN AND PERFORM DRE TO EXCLUDE INTRA ABDOMINAL AND PELVIC PATHOLOGY THAT MAY CAUSE BACK PAIN.

ALSO I WOULD LIKE TO CHECK ESR AND AP AND LATERAL THORACIC AND LUMBAR SPINE XRAYS.

DIAGNOSIS IS ANKYLOSING SPONDYLITIS.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM: APLEY PG 58.

INSTRUCTION: EXAMINE THIS LUMP.

TO PATIENT:

HELLO MR.JOHN MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOU? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH YOUR SHIRT OFF.? LET ME HELP YOU WITH IT.

ARE YOU COMFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

LOOK CLOSELY AT THE LUMPON THE SHOULDER AND SAY.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS GENTLEMAN A SMALL/LARGE LUMP ON THE FRONT OF RIGHT SHOULDER/ BACK/ARM/FOREARM/NECK/TRUNK.IT IS ABOUT 3 BY 4 CMS IN SIZE AND IS HEMISPHERICAL IN SHAPE. THERE IS/ IS NO EVIDENCE OF ANY SCAR, REDNESS, VISIBLE VEINS IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL.

TO PATIENT:

I AM NOW GOING TO GENTLY FEEL THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.

TO EXAMINER:

THE OVERLYING SKIN IS NOT WARM (COMPARE WITH SURROUNDING SKIN). IT IS A NON TENDER LUMP (LOOK AT PATIENTS FACE AND ALSO ASK PATIENT IF IT HURTS WHEN I TOUCH YOU HERE) WITH A SMOOTH LOBULATED SURFACE. THE EDGES ARE ALSO LOBULATED AND SLIP AWAY FROM THE FINGERS (SLIP SIGN). IT IS SOFT IN CONSISTENCY AND IS FLUCTUANT (CHECK IN TWO PLANES) (LARGE LIPOMA)/ DOES NOT FLUCTUATE (SMALL LIPOMA).

TO PATIENT:

I AM NOW GOING TO MOVE THE SKIN OVER THE LUMP AND ALSO MOVE THE LUMP IN TWO PLANES IN THE DIRCETION OF THE UNDERLYING MUSCLE AND AT RIGHT ANGLES TO IT. NOW COULD YOU PLEASE TENSE THAT MUSCLE AGAINST MY HAND, I AM REASSESSING THE MOBILITY OF LUMP IN TWO PLANES TO CHECK IF THE LUMP BECOMES LESS PROMINENT OR LESS MOBILE.

ACT:

IN SHOULDER LUMP PUSH ELBOW DOWN AND ASK PATIENT TO TENSE MUSCLE AGAINST MY HAND AND REASSESS MOBILITY IN TWO PLANES.

CAN CHECK DIAGRAM IN CLINICAL DAS.

TO EXAMINER:

THE LUMP LIES SUPERFICIAL TO MUSCLE AS IT BECOMES MORE DISTINCT ON CONTRACTION OF UNDERLYING MUSCLE AND THE SKIN MOVES EASILY OVER IT. IT THEREFORE ARISES FROM SUBCUTANEOUS TISSUES AND IS NEITHER TETHERED TO THE SKIN NOR FIXED TO THE DEEP TISSUES.

NOTE: IF LUMP BECOMES LESS PROMINENT AND LESS MOBILE ON TENSING THE MUSCLE IT MEANS THAT IT IS ARISING FROM MUSCLES.

 TO PATIENT:

I AM JUST GOING TO FEEL THE LYMPH GLANDS IN YOUR ARMPIT. JUST RELAX YOUR ARM AND LET ME TAKE YOUR ELBOW. HAVE YOU NOTICED ANY LUMPS HERE YOURSELF.

CAN CHECK BARBARA BATES CLINICAL CD ON BREAST EXAMINATION ON HOW TO CHECK AXILLARY LYMPH NODES.

TO EXAMINER:

THE REGIONAL LYMPH NODES ARE NOT ENLARGED.

TO PATIENT:

THANK YOU SIR. LET ME HELP YOU WITH YOUR SHIRT. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASK PATIENT A FEW QUESTIONS:

HOW THE LUMP AFFECTS THEIR LIVES/ HOW DOES IT BOTHER THEM.

WHETHER THEY HAVE NOTICED SIMILAR LUMPS ELSEWHERE.

HOW LONG HAS THE LUMP BEEN PRESENT FOR?

MY DIAGNOSIS IS LIPOMA.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM:

NORMAN BROWSE FIGURE 3.29 PAGE 79.

INSTRUCTION: EXAMINE THIS LUMP.

TO PATIENT:

HELLO MR.JOHN MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOU? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH THE BUTTONS OF YOUR SHIRT UNDONE?

ARE YOU CONFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

LOOK CLOSELY AT THE LUMP AND SAY..

TO EXAMINER:

THERE IS IN THIS GENTLEMAN, ON INSPECTION A SMALL LUMP ON THE RIGHT SCALP WHICH IS ABOUT 3 BY 2 CMS IN SIZE. IT IS SPHERICAL IN SHAPE. THERE IS/ IS NO EVIDENCE OF PUNCTUM, SCAR, REDNESS, HAIRLOSS OR DISCHARGE IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL.

TO PATIENT:

I AM NOW GOING TO GENTLY FEEL THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.

TO EXAMINER:

THE OVERLYING SKIN IS NOT WARM (COMPARE WITH SURROUNDING SKIN). IT IS A NON TENDER LUMP (LOOK AT PATIENTS FACE AND ALSO ASK PATIENT IF IT HURTS WHEN I TOUCH YOU HERE) WITH A SMOOTH SURFACE AND WELL DEFINED EDGE. IT IS HARD IN CONSISTENCY AND IS NON FLUCTUANT (CHECK IN TWO PLANES).

TO PATIENT:

I AM NOW GOING TO MOVE THE SKIN OVER THE LUMP AND ALSO MOVE THE LUMP IN TWO PLANES.

TO EXAMINER:

THE LUMP MOVES WITH THE SKIN FREELY OVER THE UNDERLYING STRUCTURES HENCE IT ARISES FROM THE SKIN. IT IS NEITHER TETHERED NOR FIXED.

 TO PATIENT:

I AM JUST GOING TO FEEL THE LYMPH GLANDS IN YOUR NECK. JUST BEND YOUR NECK SLIGHTLY PLEASE.

ACT:

FEEL BOTH HORIZONTAL AND VERTICAL CHAIN OF LYMPH NODES.

TO EXAMINER:

THE REGIONAL LYMPH NODES ARE NOT ENLARGED.

TO PATIENT:

THANK YOU SIR. LET ME HELP YOU WITH YOUR BUTTONS. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASK PATIENT A FEW QUESTIONS:

HOW THE LUMP AFFECTS THEIR LIVES/ HOW DOES IT BOTHER THEM.

WHETHER THEY HAVE NOTICED SIMILAR LUMPS ELSEWHERE.

HOW LONG HAS THE LUMP BEEN PRESENT FOR?

MY DIAGNOSIS IS SEBACEOUS CYST/ EPIDERMAL CYST.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM:

NORMAN BROWSE FIGURE 3.26 A PAGE 73

CATHERINE PARCHMENT SMITH CLINICAL BOOK PAGE 57.

INSTRUCTION: EXAMINE THYROID GLAND/ NECK OF THIS LADY.

TO PATIENT:

HELLO MRS. SMITH. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOUR NECK? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH THE BUTTONS OF YOUR SHIRT UNDONE (EXPOSE UPTO CLAVICLE).

ARE YOU CONFORTABLE MADAM.

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

KNEEL; COME CLOSE TO LUMP, HANDS ON SIDE. LOOK AT LUMP FROM FRONT AND ITS SIDES.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS LADY A MODERATELY ENLARGED SWELLING IN THE ANTERIOR TRIANGLE OF NECK WHICH IS NODULAR AND ASYMMETRICALLY ENLARGED AND MORE PROMINENT ON RIGHT/LEFT SIDE. IT IS HEMISPHERICAL IN SHAPE. THERE IS NO EVIDENCE OF REDNESS, SCAR, VISIBLE NECK VEINS OR DISCHARGE IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL.

ACT: GIVE PATIENT A GLASS OF WATER.

TO PATIENT:

COULD YOU PLEASE TAKE A SIP OF WATER AND HOLD IT IN YOUR MOUTH UNTIL I ASK YOU TO SWALLOW.

ACT: STEP BACK, KNEEL (BE ON LEVEL OF LUMP) AND LOOK AT NECK OF PATIENT.

TO PATIENT:

COULD YOU PLEASE LOOK UP SLIGHTLY AND NOW SWALLOW PLEASE.

TO EXAMINER:

THE LUMP MOVES UPWARDS ON SWALLOWING.

NOTE:

THYROID GLAND IS INVESTED BY PRE TRACHEAL FASCIA AND IS ATTACHED FIRMLY TO CRICOID CARTILAGE AND SUPERIOR TRACHEAL RINGS BY THE SUSPENSORY LIGAMENT OF BERRY. THIS CAUSES IT TO MOVE UPWARDS ON SWALLOWING.

TO PATIENT:

I WOULD NOW LIKE TO PALPATE THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.JUST HOLD THIS GLASS OF WATER AND TAKE A SIP WHEN I ASK YOU TO.

ACT:

KNEEL IN FRONT OF PATIENT, CHECK TEMPERATURE WITH BACK OF HAND AND COMPARE IT WITH SURROUNDING SKIN. NOW CHECK FOR TENDERNESS. LOOK AT PATIENTS FACE AND ASK IF IT IS TENDER AT ALL. NEXT PINCH OVERLYING SKIN AND TELL PATIENT THAT YOU ARE JUST GOING TO PINCH THE OVERLYING SKIN. KEEP PATIENT INFORMED AT ALL TIMES.

NOW MOVE TO BEHIND PATIENT. ASK PATIENT TO BEND/ FLEX NECK SLIGHTLY AND PLACE THUMBS OF BOTH HANDS BEHIND NECK AND FINGERS OF BOTH HANDS ON FRONT OF LUMP.

TO EXAMINER:

I AM NOW PALPATING THYROID GLAND.

THE OVERLYING SKIN IS NOT WARM. IT IS NON TENDER WITH A SMOOTH SURFACE BUT IS NODULAR. IT IS FIRM TO SOFT IN CONSISTENCY.

NOTE: NODULE COMPOSED OF THYROID TISSUE IS SOFT WHILE A NODULE FULL OF BLOOD VESSELS HARD. TENDERNESS IS PRESENT ONLY WHEN THERE IS A RECENT HEMORRHAGE INTO A NODULE.

TO PATIENT:

NOW SWALLOW PLEASE.

ACT:

DETERMINE IF LUMP MOVES UPWARDS ON SWALLOWING AND ALSO KEEP ONE FINGER OF EACH HAND JUST ABOVE SUPRASTERNAL NOTCH TO FEEL LOWER BORDER OF THYROID TO EXCLUDE RETROSTERNAL EXTENSION.

TO EXAMINER:

THE OVERLYING SKIN MOVES EASILY OVER IT AND THE LUMP MOVES UPWARDS ON SWALLOWING WITH THE THYROID GLAND. IT IS NOT TETHERED TO THE OVERLYING SKIN. THERE IS/ IS NO EVIDENCE OF RETROSTERNAL EXTENSION.

AND NOW I WILL FEEL THE CAROTID ARTERY, ONE SIDE AT A TIME.

ACT:

FLEX NECK OF PATIENT TO SAME SIDE TO RELAX STERNOCEIDOMASTOID MUSCLE OF THAT SIDE. THEN FEEL CAROTID PULSATIONS JUST MEDIAL TO A WELL RELAXED SCM MUSCLE AT LEVEL OF CRICOID CARTILAGE.(LATERAL TO IT) IN LOWER THIRD OF NECK.

AND NOW THE OTHER SIDE ALSO.

NOTE:

MALIGNANT THYROID MAY ENGULF CAROTID SHEATH SO THAT NO PULSATIONS CAN BE FELT. CAROTID SHEATH MAY BE PUSHED BACKWARDS BY A BENIGN ENLARGEMENT OF THYROID GLAND WHERE PULSATIONS OF CAROTID ARTERY MAY BE FELT.

TO EXAMINER:

THE CAROTID ARTERY IS NOT DISPLACED AND ITS PULSATIONS CAN BE FELT LATERAL TO CRICOID CARTILAGE.

TO PATIENT:

I WOULD NOW LIKE TO EXAMINE LYMPH NODES IN YOUR NECK. COULD YOU PLEASE BEND YOUR NECK SLIGHTLY? THANK YOU.

ACT:

FEEL HORIZONTAL CHAIN (SUBMENTAL, SUBMANDIBULAR, PREAURICULAR, POST AURICULAR OVER MASTOID, OCCIPITAL) AND VERTICAL CHAIN (POSTERIOR CERVICAL IN POSTERIOR TRIANGLE, SUPERFICIAL OVER SCM IN ITS UPPER PART, TONSILLAR BELOW ANGLE OF MANDIBLE, DEEP CERVICAL INSIDE ANTERIOR BORDER OF SCM MUSCLE.)

AND NOW THE SUPRACLAVICULAR LYMPH NODES.

TO PATIENT:

COULD YOU PLEASE BEND YOUR CHIN FORWARDS AND TAKE A DEEP BREATH AND HOLD IT.PALPATE IN SUPRACLAVICULAR FOOSA WITH PULP OF FINGERS FOR ENLARGED LYMPH NODES.

YOU MAY BREATHE NORMALLY NOW. THANK YOU.

TO EXAMINER:

THE REGIONAL LYMPH NODES (CERVICAL AND SUPRA CLAVICULAR) ARE NOT ENLARGED.

TO PATIENT:

MADAM,

I AM JUST GOING TO FEEL YOUR WIND PIPE. SORRY IT IS GOING TO CAUSE YOU A LITTLE BIT OF DISCOMFORT. PARDON ME FOR THAT. PLEASE MOVE YOUR NECK SLIGHTLY BACK.

ACT:

MOVE TO FRONT OF PATIENT. WITH PATIENTS NECK SLIGHTLY EXTENDED, KNEEL DOWN AND PLACE INDEX AND RING FINGERS ON MEDIAL ENDS OF CLAVICLE, WITH MIDDLE FINGER IN CENTRE…JUST SLIDE MIDDLE FINGER TO ONE SIDE AND THEN THE OTHER SIDE FOR TRACHEAL DEVIATION.

TO EXAMINER:

THE TRACHEA IS CENTRAL AND IS NOT DEVIATED.

NOTE: TRACHEA MAY BE COMPRESSED AND/ OR DEVIATED DEPENDING ON SITE OF NODULES.

TO PATIENT:

I AM NOW GOING TO TAP ON YOUR CHEST.

ACT:

IDEALLY BUTTONS OF SHIRT SHOULD BE OPENED. START TAPPING (PERCUSSION) MIDDLE OF STERNUM AT LEVEL OF NIPPLE REGION THAT IS 4^TH INTERCOSTAL SPACE TO SUPRA STERNAL NOTCH (ALWAYS FROM RESONANT TO DULL) FOR EVIDENCE OF RETROSTERNAL EXTENSION.(ONLY DO IN LARGE GOITRES WHERE LOWER BORDER IS NOT PALPABLE).

TO EXAMINER:

THERE IS NO EVIDENCE OF RETRO STERNAL EXTENSION.

TO PATIENT:

I AM JUST GOING TO LISTEN OVER YOUR THYROID FOR ANY BRUIT.

ACT:

AUSCULTATE WITH BELL OF STETHOSCOPE FOR BRUIT JUST BELOW ANGLE OF JAW ON SUPERIOR POLES OF LATERAL LOBES.

TO PATIENT:

COULD YOU PLEASE TAKE A DEEP BREATH AND HOLD IT. THANK YOU. AND NOW THE OTHER SIDE. AGAIN PLEASE TAKE A DEEP BREATH AND HOLD IT. THANK YOU. YOU MAY BREATHE NORMALLY NOW.

NOTE:

THIS IS DONE SO THAT THE BREATH SOUNDS DO NOT OBSCURE THE VASCULAR SOUNDS.

TO EXAMINER:

THERE IS NO EVIDENCE OF ANY BRUIT.

NOTE: SYSTOLIC BRUIT IS HEARD OVER LARGE GOITRES DUE TO INCREASED VASCULARITY ON SUPERIOR POLES OF LATERAL LOBES.

TO PATIENT:

THANK YOU MADAM. I WILL SEE YOU LATER. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASSESS THIS PATIENTS THYROID STATUS.

THIS IS A MULTI NODULAR GOITRE.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM:

NORMAN BROWSE FIGURE 11.36 B PAGE 296.

                   EXAMINATION OF SOLITARY THYROID NODULE:

INSTRUCTION: EXAMINE THYROID GLAND/ NECK OF THIS LADY.

TO PATIENT:

HELLO MRS. SMITH. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOUR NECK? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH THE BUTTONS OF YOUR SHIRT UNDONE (EXPOSE UPTO CLAVICLE).

ARE YOU CONFORTABLE MADAM.

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

KNEEL; COME CLOSE TO LUMP, HANDS ON SIDE. LOOK AT LUMP FROM FRONT AND ITS SIDES.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS LADY A SMALL LUMP IN THE ANTERIOR TRIANGLE OF NECK WHICH IS NODULAR ANDIS PRESENT ON RIGHT/LEFT SIDE OF MIDLINE. THERE IS NO EVIDENCE OF REDNESS, SCAR, VISIBLE NECK VEINS OR DISCHARGE IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL.

ACT: GIVE PATIENT A GLASS OF WATER.

TO PATIENT:

COULD YOU PLEASE TAKE A SIP OF WATER AND HOLD IT IN YOUR MOUTH UNTIL I ASK YOU TO SWALLOW.

ACT: STEP BACK, KNEEL (BE ON LEVEL OF LUMP) AND LOOK AT NECK OF PATIENT.

TO PATIENT:

COULD YOU PLEASE LOOK UP SLIGHTLY AND NOW SWALLOW PLEASE.

TO EXAMINER:

THE LUMP MOVES UPWARDS ON SWALLOWING.

IN CASE OF SMALL MIDLINE LUMP:

TO PATIENT: COULD YOU PLEASE OPEN YOUR MOUTH. NOW PRESS YOUR INDEX FINGER AGAINST LOWER BORDER OF JAW TO KEEP JAW STILL. KEEPING YOUR JAW STILL NOW STICK OUT YOUR TONGUE.

ACT: LOOK AT LUMP IN NECK.

TO EXAMINER:

THE LUMP DOES NOT MOVE UPWARDS ON STICKING OUT THE TONGUE.

NOTE: THIS IS DONE TO EXCLUDE THYROGLOSSAL CYST. THYROGLOSSAL CYST MOVES UPWARDS ON STICKING OUT TONGUE BECAUSE TH THYROGLOSSAL DUCT EXTENDS DOWNWARDS FROM FORAMEN CAECUM OF TONGUE TO ISTHMUS OF THYROID GLAND.

NOTE:

THYROID GLAND IS INVESTED BY PRE TRACHEAL FASCIA AND IS ATTACHED FIRMLY TO CRICOID CARTILAGE AND SUPERIOR TRACHEAL RINGS BY THE SUSPENSORY LIGAMENT OF BERRY. THIS CAUSES IT TO MOVE UPWARDS ON SWALLOWING.

OTHER SWELLINGS WHICH MOVE UPWARDS ON SWALLOWING ARE:

1. THYROID GLAND
2. THYROGLOSSAL CYST
3. SUBHYOID BURSITIS
4. PRE LARYNGEAL OR PRE TRACHEAL LYMPH NODES FIXED TO LARYNX OR TRACHEA.

TO PATIENT:

I WOULD NOW LIKE TO PALPATE THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.JUST HOLD THIS GLASS OF WATER AND TAKE A SIP WHEN I ASK YOU TO.

ACT:

KNEEL IN FRONT OF PATIENT, CHECK TEMPERATURE WITH BACK OF HAND AND COMPARE IT WITH SURROUNDING SKIN. NOW CHECK FOR TENDERNESS. LOOK AT PATIENTS FACE AND ASK IF IT IS TENDER AT ALL. NEXT PINCH OVERLYING SKIN AND TELL PATIENT THAT YOU ARE JUST GOING TO PINCH THE OVERLYING SKIN. KEEP PATIENT INFORMED AT ALL TIMES.

NOW MOVE TO BEHIND PATIENT. ASK PATIENT TO BEND/ FLEX NECK SLIGHTLY AND PLACE THUMBS OF BOTH HANDS BEHIND NECK AND FINGERS OF BOTH HANDS ON FRONT OF LUMP. AND PALPATE THYROID GLAND/ LUMP.

TO EXAMINER:

I AM NOW PALPATING THYROID GLAND.

THE OVERLYING SKIN IS NOT WARM. IT IS NON TENDER WITH A SMOOTH SURFACE. IT IS FIRM IN CONSISTENCY.

TO PATIENT:

NOW SWALLOW PLEASE.

ACT:

DETERMINE IF LUMP MOVES UPWARDS ON SWALLOWING AND ALSO KEEP ONE FINGER OF EACH HAND JUST ABOVE SUPRASTERNAL NOTCH TO FEEL LOWER BORDER OF THYROID TO EXCLUDE RETROSTERNAL EXTENSION.

TO EXAMINER:

THE OVERLYING SKIN MOVES EASILY OVER IT AND THE LUMP MOVES UPWARDS ON SWALLOWING WITH THE THYROID GLAND. IT IS NOT TETHERED TO THE OVERLYING SKIN. THERE IS NO EVIDENCE OF RETROSTERNAL EXTENSION.

AND NOW I WILL FEEL THE CAROTID ARTERY, ONE SIDE AT A TIME.

ACT:

FLEX NECK OF PATIENT TO SAME SIDE TO RELAX STERNOCEIDOMASTOID MUSCLE OF THAT SIDE. THEN FEEL CAROTID PULSATIONS JUST MEDIAL TO A WELL RELAXED SCM MUSCLE AT LEVEL OF CRICOID CARTILAGE.(LATERAL TO IT) IN LOWER THIRD OF NECK.

AND NOW THE OTHER SIDE ALSO.

NOTE:

MALIGNANT THYROID MAY ENGULF CAROTID SHEATH SO THAT NO PULSATIONS CAN BE FELT. CAROTID SHEATH MAY BE PUSHED BACKWARDS BY A BENIGN ENLARGEMENT OF THYROID GLAND WHERE PULSATIONS OF CAROTID ARTERY MAY BE FELT.

TO EXAMINER:

THE CAROTID ARTERY IS NOT DISPLACED AND ITS PULSATIONS CAN BE FELT LATERAL TO CRICOID CARTILAGE.

TO PATIENT:

I WOULD NOW LIKE TO EXAMINE LYMPH NODES IN YOUR NECK. COULD YOU PLEASE BEND YOUR NECK SLIGHTLY? THANK YOU.

ACT:

FEEL HORIZONTAL CHAIN (SUBMENTAL, SUBMANDIBULAR, PREAURICULAR, POST AURICULAR OVER MASTOID, OCCIPITAL) AND VERTICAL CHAIN (POSTERIOR CERVICAL IN POSTERIOR TRIANGLE, SUPERFICIAL OVER SCM IN ITS UPPER PART, TONSILLAR BELOW ANGLE OF MANDIBLE, DEEP CERVICAL INSIDE ANTERIOR BORDER OF SCM MUSCLE.)

AND NOW THE SUPRACLAVICULAR LYMPH NODES.

TO PATIENT:

COULD YOU PLEASE BEND YOUR CHIN FORWARDS AND TAKE A DEEP BREATH AND HOLD IT.PALPATE IN SUPRACLAVICULAR FOOSA WITH PULP OF FINGERS FOR ENLARGED LYMPH NODES.

YOU MAY BREATHE NORMALLY NOW. THANK YOU.

TO EXAMINER:

THE REGIONAL LYMPH NODES (CERVICAL AND SUPRA CLAVICULAR) ARE NOT ENLARGED.

TO PATIENT:

MADAM,

I AM JUST GOING TO FEEL YOUR WIND PIPE. SORRY IT IS GOING TO CAUSE YOU A LITTLE BIT OF DISCOMFORT. PARDON ME FOR THAT. PLEASE MOVE YOUR NECK SLIGHTLY BACK.

ACT:

MOVE TO FRONT OF PATIENT. WITH PATIENTS NECK SLIGHTLY EXTENDED, KNEEL DOWN AND PLACE INDEX AND RING FINGERS ON MEDIAL ENDS OF CLAVICLE, WITH MIDDLE FINGER IN CENTRE…JUST SLIDE MIDDLE FINGER TO ONE SIDE AND THEN THE OTHER SIDE FOR TRACHEAL DEVIATION.

TO EXAMINER:

THE TRACHEA IS CENTRAL AND IS NOT DEVIATED.

NOTE: TRACHEA MAY BE COMPRESSED AND/ OR DEVIATED DEPENDING ON SITE OF NODULES.

TO PATIENT:

THANK YOU MADAM. I WILL SEE YOU LATER. THANK YOU AGAIN.

TO EXAMINER:

IF THIS WAS A DIFFUSE ENLARGEMENT OF THYROID GLAND RATHER THAN A PROMINENT LUMP I WOULD THEN PERCUSS FOR RETROSTERNAL EXTENSON AND AUSCULTATE FOR A BRUIT.

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASSESS THIS PATIENTS THYROID STATUS.

THIS IS A SOLITARY THYROID NODULE.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM:

NORMAN BROWSE FIGURE 11.36 C PAGE 296.

:

INSTRUCTION: EXAMINE THYROID GLAND/ NECK OF THIS LADY.

TO PATIENT:

HELLO MRS. SMITH. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOUR NECK? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH THE BUTTONS OF YOUR SHIRT UNDONE (EXPOSE UPTO CLAVICLE).

ARE YOU COMFORTABLE MADAM.

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.

ACT:

KNEEL; COME CLOSE TO LUMP, HANDS ON SIDE. LOOK AT LUMP FROM FRONT AND ITS SIDES.

TO EXAMINER:

THERE IS ON INSPECTION IN THIS LADY A MODERATELY ENLARGED SWELLING IN THE ANTERIOR TRIANGLE OF NECK WHICH IS DIFFUSELY AND SYMMETRICALLY ENLARGED. THERE IS NO EVIDENCE OF REDNESS, SCAR, VISIBLE NECK VEINS OR DISCHARGE IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL.

ACT: GIVE PATIENT A GLASS OF WATER.

TO PATIENT:

COULD YOU PLEASE TAKE A SIP OF WATER AND HOLD IT IN YOUR MOUTH UNTIL I ASK YOU TO SWALLOW.

ACT: STEP BACK, KNEEL (BE ON LEVEL OF LUMP) AND LOOK AT NECK OF PATIENT.

TO PATIENT:

COULD YOU PLEASE LOOK UP SLIGHTLY AND NOW SWALLOW PLEASE.

TO EXAMINER:

THE LUMP MOVES UPWARDS ON SWALLOWING.

NOTE:

THYROID GLAND IS INVESTED BY PRE TRACHEAL FASCIA AND IS ATTACHED FIRMLY TO CRICOID CARTILAGE AND SUPERIOR TRACHEAL RINGS BY THE SUSPENSORY LIGAMENT OF BERRY. THIS CAUSES IT TO MOVE UPWARDS ON SWALLOWING.

TO PATIENT:

I WOULD NOW LIKE TO PALPATE THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.JUST HOLD THIS GLASS OF WATER AND TAKE A SIP WHEN I ASK YOU TO.

ACT:

CHECK TEMPERATURE WITH BACK OF HAND AND COMPARE IT WITH SURROUNDING SKIN. STAY IN FRONT OF PATIENT. NOW CHECK FOR TENDERNESS. LOOK AT PATIENTS FACE AND ASK IF IT IS TENDER AT ALL. NEXT PINCH SKIN AND TELL PATIENT THAT YOU ARE JUST GOING TO PINCH THE OVERLYING SKIN.

NOW MOVE TO BEHIND PATIENT. ASK PATIENT TO BEND/ FLEX NECK SLIGHTLY AND PLACE THUMBS OF BOTH HANDS BEHIND NECK AND FINGERS OF BOTH HANDS ON FRONT OF LUMP.

TO EXAMINER:

I AM NOW PALPATING THYROID GLAND.

THE OVERLYING SKIN IS NOT WARM. IT IS NON TENDER WITH A SMOOTH SURFACE AND DIFFUSE EDGES. IT IS FIRM IN CONSISTENCY.

TO PATIENT:

SWALLOW PLEASE.

ACT:

DETERMINE IF LUMP MOVES UPWARDS ON SWALLOWING AND ALSO KEEP ONE FINGER OF EACH HAND JUST ABOVE SUPRASTERNAL NOTCH TO FEEL LOWER BORDER OF THYROID TO EXCLUDE RETROSTERNAL EXTENSION.

TO EXAMINER:

THE OVERLYING SKIN MOVES EASILY OVER IT AND THE LUMP MOVES UPWARDS ON SWALLOWING WITH THE THYROID GLAND FROM WHICH IT IS MOST LIKELY TO ARISE.IT IS NOT TETHERED TO THE OVERLYING SKIN. THERE IS/ IS NO EVIDENCE OF RETROSTERNAL EXTENSION.

AND NOW I WILL FEEL THE CAROTID ARTERY, ONE SIDE AT A TIME.

ACT:

FLEX NECK OF PATIENT TO SAME SIDE TO RELAX STERNOCEIDOMASTOID MUSCLE OF THAT SIDE. THEN FEEL CAROTID PULSATIONS JUST MEDIAL TO A WELL RELAXED SCM MUSCLE AT LEVEL OF CRICOID CARTILAGE.(LATERAL TO IT) IN LOWER THIRD OF NECK.

AND NOW THE OTHER SIDE ALSO.

NOTE:

MALIGNANT THYROID MAY ENGULF CAROTID SHEATH SO THAT NO PULSATIONS CAN BE FELT. CAROTID SHEATH MAY BE PUSHED BACKWARDS BY A BENIGN ENLARGEMENT OF THYROID GLAND WHERE PULSATIONS OF CAROTID ARTERY MAY BE FELT.

TO EXAMINER:

THE CAROTID ARTERY IS NOT DISPLACED AND ITS PULSATIONS CAN BE FELT LATERAL TO CRICOID CARTILAGE.

TO PATIENT:

I WOULD NOW LIKE TO EXAMINE LYMPH NODES IN YOUR NECK. COULD YOU PLEASE BEND YOUR NECK SLIGHTLY? THANK YOU.

ACT:

FEEL HORIZONTAL CHAIN (SUBMENTAL, SUBMANDIBULAR, PREAURICULAR, POST AURICULAR OVER MASTOID, OCCIPITAL) AND VERTICAL CHAIN (POSTERIOR CERVICAL IN POSTERIOR TRIANGLE, SUPERFICIAL OVER SCM IN ITS UPPER PART, TONSILLAR BELOW ANGLE OF MANDIBLE, DEEP CERVICAL INSIDE ANTERIOR BORDER OF SCM MUSCLE.)

AND NOW THE SUPRACLAVICULAR LYMPH NODES.

TO PATIENT:

COULD YOU PLEASE BEND YOUR CHIN FORWARDS AND TAKE A DEEP BREATH AND HOLD IT.PALPATE IN SUPRACLAVICULAR FOOSA WITH PULP OF FINGERS FOR ENLARGED LYMPH NODES.

YOU MAY BREATHE NORMALLY NOW. THANK YOU.

TO EXAMINER:

THE REGIONAL LYMPH NODES (CERVICAL AND SUPRA CLAVICULAR) ARE NOT ENLARGED.

TO PATIENT:

MADAM,

I AM JUST GOING TO FEEL YOUR WIND PIPE. SORRY IT IS GOING TO CAUSE YOU A LITTLE BIT OF DISCOMFORT. PARDON ME FOR THAT. PLEASE MOVE YOUR NECK SLIGHTLY BACK.

ACT:

MOVE TO FRONT OF PATIENT. WITH PATIENTS NECK SLIGHTLY EXTENDED, KNEEL DOWN AND PLACE INDEX AND RING FINGERS ON MEDIAL ENDS OF CLAVICLE, WITH MIDDLE FINGER IN CENTRE…JUST SLIDE MIDDLE FINGER TO ONE SIDE AND THEN THE OTHER SIDE FOR TRACHEAL DEVIATION.

TO EXAMINER:

THE TRACHEA IS CENTRAL AND IS NOT DEVIATED.

TO PATIENT:

I AM NOW GOING TO TAP ON YOUR CHEST.

ACT:

IDEALLY BUTTONS OF SHIRT SHOULD BE OPENED. START TAPPING (PERCUSSION) MIDDLE OF STERNUM AT LEVEL OF NIPPLE REGION THAT IS 4^TH INTERCOSTAL SPACE TO SUPRA STERNAL NOTCH (ALWAYS FROM RESONANT TO DULL) FOR EVIDENCE OF RETROSTERNAL EXTENSION.(ONLY DO IN LARGE GOITRES WHERE LOWER BORDER IS NOT PALPABLE).

TO EXAMINER:

THERE IS NO EVIDENCE OF RETRO STERNAL EXTENSION.

TO PATIENT:

I AM JUST GOING TO LISTEN OVER YOUR THYROID FOR ANY BRUIT.

ACT:

AUSCULTATE WITH BELL OF STETHOSCOPE FOR BRUIT JUST BELOW ANGLE OF JAW ON SUPERIOR POLES OF LATERAL LOBES.

TO PATIENT:

COULD YOU PLEASE TAKE A DEEP BREATH AND HOLD IT. THANK YOU. AND NOW THE OTHER SIDE. AGAIN PLEASE TAKE A DEEP BREATH AND HOLD IT. THANK YOU. YOU MAY BREATHE NORMALLY NOW.

NOTE:

THIS IS DONE SO THAT THE BREATH SOUNDS DO NOT OBSCURE THE VASCULAR SOUNDS.

TO EXAMINER:

THERE IS NO EVIDENCE OF ANY BRUIT.

TO PATIENT:

THANK YOU MADAM. I WILL SEE YOU LATER. THANK YOU AGAIN.

TO EXAMINER:

TO COMPLETE MY EXAMINATION I WOULD LIKE TO ASSESS THIS PATIENTS THYROID STATUS.

THIS IS A DIFFUSE GOITRE.

I WOULD LIKE TO WASH MY HANDS.

FOR DIAGRAM:

NORMAN BROWSE FIGURE 11.36 A PAGE 236.

Sjögren’s Syndrome (Autoimmune Sialadenitis)
Primary Sjögren’s syndrome is characterized by severe dry mouth (xerostomia) and dry eyes without an associated connective tissue disorder.

Secondary Sjögren’s syndrome is associated with connective tissue abnormalities such as:

• rheumatoid arthritis (50% of cases)
• sarcoidosis
• systematic lupus erythematosus
• scleroderma
• amyloid
• polymyositis

It is predominantly a disease found in females (10:1) and the middle aged and is characterized by:

• enlargement of salivary and lacrimal glands
• nasal crusting
• epistaxis
• chronic bronchitis
• recurrent pneumonia

Other systemic disturbances such as pernicious anemia, vasculitis, myasthenia gravis and thyroiditis may be present.

Sjögren’s Syndrome (Autoimmune Sialadenitis)
Diagnosis is made by obtaining a biopsy of minor salivary glands (usually from the lower lip), which shows lymphoreticular hyperplasia. Serum auto-antibodies, characteristically Sjögren Syndrome A and B (SSA and SSB) are positive, while the ESR may also be raised.

Malignant change (lymphoma, sarcoma) may occur in a sixth of cases, manifested by:

• rapid swelling
• the presence of palpable lymph nodes
• weight loss

The mainstay of treatment is steroids and, rarely, immunosuppressants. Artificial tears and saliva are used to counteract dryness of the eyes and mouth. A three-month follow up to check for lymphoma is recommended.

Mickulicz disease is a variant of Sjögren’s syndrome where there is symmetrical enlargement of salivary and lacrimal glands with dry mouth and narrowed palpebral fissures.

Other Salivary Gland Conditions
Enlargement of salivary glands, especially the parotids, may accompanydiabetes mellitus and acromegaly. In obese patients, the glands may be infiltrated with adipose tissue. You should bear this in mind and not mistake obesity for parotid disease. In general, this should be bilateral.

Parotid swelling — usually bilateral — is also seen in alcoholics and bulimics. There is little that can be done except symptomatic treatment and attention to oral hygiene, together with treating the underlying condition.

Calcium phosphate is the predominant component of these stones. The disorder is usually localized to one gland, and is not associated with generalized stone formation.

Patients present with a painful swelling of the gland, usually brought on by eating. Initially the swelling may resolve completely after a few hours; later it may remain enlarged and tender due to chronic inflammation. The patient may pass a stone, or sometimes gravel.

Examination often reveals a swollen gland, and a stone may be palpable by bimanual palpation. Sometimes, turbid saliva may be expressed from the duct. Asking the patient to suck on a lemon drop may cause the gland to enlarge as saliva production is stimulated.

Investigations
Plain films (occlusal view for the submandibular gland) show 90% of all calculi, most submandibular stones being radiopaque, unlike parotid stones. Sialography, ultrasound and CT are all helpful in the diagnosis.

Treatment
If the stone is palpable in the duct, it can be removed by dilating the orifice. In some cases, it is necessary to make an incision over the duct and express the stone but this is not common. If the stone is in the deep duct, the parenchyma of the gland or if the problem is recurrent, excise the gland.