Jim: Next, we'll move to examination of the mouth. We start with inspection. The first thing I'm going to do is look at Mary's lips and we'll look for any lesions that may be present along the lips and around the mouth. And then to examine inside we're going to need a light source to be able to see better and so I'm going to use my light source on the wall again. Some people would use a penlight or a pocket light to be able to examine the inner portions of the mouth.
And so, Mary, what I'd like you to do is just to open your mouth and I'll just look inside and I'm looking at the teeth and the tongue, and if you can lift your tongue up I can see underneath it. Very good. And again, if you could stay open I can see over to this side and stick your tongue back out. Very good. And say, “Ah.”
Mary: Ah.
Jim: Good. Now sometimes in order to make this examination a little easier to be able to see we'll use our trusty tongue blade or tongue depressor. Some of our patients are not particularly fond of this instrument and sometimes it's truly not needed, as you can see just fine without it. But to get good visualization with both a light and a tongue blade I'm able to see much better into her mouth by being able to use the tongue blade to deflect various structures within her mouth.
So, Mary, would you open your mouth again and I can then use this to deflect the side wall to be able to see her gums and teeth and the same thing in the upper area, very good, and also, to depress the tongue to be able to see the uvula in the back and the posterior oropharynx. And Mary, say, “Ah” if you would.
Mary: Ah.
Jim: And I can gently depress the tongue to see all the way into the back. Thank you.
Sometimes also a gag reflex will be testy either inadvertently by someone having a sensitive gag reflex or on purpose if that's something that you want to test. We normally don't test the gag reflex unless someone is sedated or for more specific testing.
Next, we'll move to the neck examination and to start out we're going to inspect your neck, and to do that I'm going to need to open the gown a little bit. Mary, I'm just going to untie the gown in the back, if I would.
Mary: Okay.
Jim: If I may. And then would you be able to just kind of bring it forward a little bit? And this allows exposure of the neck structures. And then could you bring your hair back behind your ears? That's great. And so now I can see the neck area and can inspect, looking for asymmetries or skin lesions in this area. And then I could palpate starting back along the occiput posteriorly, and I can palpate back in this area for lymph glands or masses, up behind the ear, or posterior auricular, in the front of the ear, which is called the preauricular region, and this is the area of the parotid gland, and then also into the submandibular area here, or submental, under the chin, region here, and then into the anterior and posterior cervical chain which runs along the sternocleidomastoid muscle. In each of these areas I'm feeling for lymph nodes, lumps, if they're tender, or if they're freely mobile or fixed, and I'll come all the way down here into the supraclavicular region.
As another way to examine this region, and Mary I'd like to ask you to put your hands on your hips and then just bring your shoulders forward, and you can see, I'm going to lift your hair up out of the way, you can see a triangle appear as she does this, which allows you to examine in this supraclavicular region for any lumps, lymph nodes, or abnormalities. Thank you. You can relax your shoulders.
And then I'm going to examine the thyroid gland, and to do this I'm going to step around the back. Sometimes I'll even sit up on the table next to the patient to be able to bring my pads of my fingers over the thyroid gland. You can feel the trachea. You can find the Adam's apple and that's the cricoid cartilage, and just below that is where the thyroid lays, on top of the trachea. The isthmus, or central part, of the thyroid is felt here and then the lobes are felt off to the side. It's normal not to feel the thyroid gland at all, but in many people you can feel thyroid tissue. And it can help to ask them to swallow to see if that helps to move the thyroid gland underneath the trachea. Mary, would you just take a swallow for me, if you would.
Sometimes it's real hard to swallow when you don't have a glass of water and I'll even sometimes give a patient a glass of water and say, “Here, now take a sip of that water and just swallow for me,” and that allows you to feel the thyroid gland moving underneath your fingers.
When you're finished with your exam always remember to replace the gown to make sure that you keep your patient comfortable.
We have just a few more maneuvers to do to complete our head and neck examination and these are maneuvers that are portions of the cranial nerve examination. Many of the maneuvers to test cranial nerves have already been done as we've gone through the head and neck examination thus far. Cranial nerve 1, the olfactory nerve, is oftentimes not tested. Cranial nerve 2, the optic nerve, was tested by our visual acuity, our direct visualization, and our visual fields. Cranial nerves 3, 4, and 6 were tested with our extraocular muscles. Cranial nerve 5, or the trigeminal, can be tested with a couple of maneuvers.
Mary, would you just show me your teeth and then bite down hard? And this allows us to test the masseter muscle, which I'm palpating here. And then I'm going to test for sensation in the three divisions of the trigeminal nerve, V1, over the forehead. Do you feel this here?
Mary: Um hm.
Jim: Good, and is it the same on both sides?
Mary: Yep.
Jim: V2, here. Do you feel that?
Mary: Yep.
Jim: Good, and then V3 down here.
Mary: Um hm.
Jim: Okay. And then the facial nerve, that's tested by looking for asymmetries in her face and any drooping that you might see. Smile for me, Mary. Good, and we look for a symmetrical smile. And then would you puff your cheeks out like this for me? Good, and that allows us to test for the facial nerve.
The 8th nerve is the acoustic nerve, which we've already tested. The 9th, which is the glossopharyngeal, and the 10th, the vagus nerves, we've tested through the gag reflex and also when we asked Mary to say, “Ah,” we watched her palate rise. The 11th nerve is the accessory nerve and to do this, and to test this I'd like you to shrug your shoulders, Mary, and then bring them back down. And shrug them one more time, and then bring them back down. And finally is the glossopharyngeal nerve for which we can test by examining the tongue. Can you stick your tongue out for me, Mary? And can you move it left? Good, and move it right. Very good.
And so that completes our head and neck examination. Thanks very much for watching.