1. Head & Neck (Mouth, Pharynx,Thyroid,L.N.,Neck)

2. Mouth & Pharynx anatomy

3. The mouth, pharynx and neck: Health history:  Sore throat How frequent? Since when? Cough, fever, fatigue, headache, hoarseness, postnasal drip Worse when arising? Humidity, dryness?  Sores or lesions in mouth or tongue For how long? Single or multiple? Stress, food, season change?  Altered taste  Bleeding gums--gingivitis  Toothache

4. The mouth, pharynx and neck: Health history:  Hoarseness—Acute or chronic  Altered quality voice; rough or harsh Overuse of voice Allergy, smoking, other inhaled irritants Hypothyroidism Tumors  Dysphagia—difficulty swallowing Gastroesophageal reflux disease, neurological, esophageal cancer  Pharyngitis-- Swollen glands or lumps in neck

5. The mouth, pharynx and neck: Health history:  Enlarged thyroid gland—goiter  Thyroid function— Temperature intolerance  Do you prefer hot or cold weather  Do you dress more warmly or less warmly than other people? Palpitations? Change in weight?

6. PE: The mouth, pharynx and neck: The Lips Color, moisture, cracking, Scaliness, lesions.( herpes simplex) Angular chelitis, softening of the skin at the angles of mouth followed by fissuring. The oral mucosa: Inspect using penlight Mucosa—  color: pallor anemia, cyanosis  if structures are intact, any lesions, ulcer, white patches and nodules.

7. PE: The mouth, gum, teeth Gum: Note the colour of the gum, swelling or ulceration Teeth: Condition of teeth, missing, discolored, absent, abnormally positioned teeth, dentures, check for loosening The roof of the mouth: colour, architecture of the hard palate

8. PE: The mouth, gum, teeth Tongue: colour, texture, symmetry, Ask the patient to protrude the tongue (cranial nerve 12; hypoglossal ). A symmetry suggest lesion of the cranial nerve. Inspect the sides and under-surface of the tongue and the floor of mouth. ( wear gloves & grasp the tip of tongue with gauze) Note any white or reddened area, nodules, or ulcerations Palpate for hardiness( induration)

9. The mouth and pharynx Abnormalities:  Herpes simplex (cold sore, fever blister)  Fissured tongue:  Smooth tongue;

10. The Pharynx Ask the patient to say ‘ah’ or yawn or use tongue blade. normally you will see the movement of Pharynx and the soft palate the (test for Vagus nerve (CN10). Inspect soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx — color, symmetry, exudates, swelling, ulceration, tonsillar enlargement If possible palpate for tenderness

11. Pharynx Enlarged Tonsils (Normal, Tonsillitis, Lymphoma) Unilateral red bulge and painful: (Peritonsillar abscess) Grade tonsils  (1+) visible,  (2+) halfway between tonsillar pillars and uvula,  (3+) Touching the uvula,  (4+) touching each other (1+) and (2+) sometimes in healthy people

12. The Neck Inspect the neck :  Noting symmetry  Any masses  Scars  Enlargement of the parotid or submandibular glands  Any visible lymph node.

13. The parotid and submandibular glands

14. Lymph nodes

15. Palpate the lymph nodes using your index and middle fingers, move the skin over the underlying tissue in each area. The patient should be relaxed, with neck flexed slightly forward or toward the side being examined. You can examine both sides at once

16. PE: Lymph Nodes Palpate and note Size Shape Delimitation( discrete or matted) Mobility Consistency( firm, soft, hard) Tenderness

17. PE: Lymph Nodes Small, mobile, discrete, soft, non-tender nodes are common finding Enlarged or tender nodes:  Re-examine of the regions they drain  Careful assessment of the lymph nodes else where to distinguish between localized from generalised Do not mistaken the nodes with muscles or any artery!

18. The Trachea and The Thyroid gland: Anatomy Thyroid gland Thyroid cartilage Hyoid bone Trachea

19. Trachea : PE Inspect the trachea for any deviation from the midline position Feel for any deviation  Place your finger along one side of the trachea and note the space between it and the sternomastiod: the space should be symmetric.  Examples of deviation; atelectasis, large pneumothrax

20. PE: Thyroid gland Inspect the neck for the thyroid gland  Tip the patient’s head back a bit  Inspect the region below the cricoid cartilage for the gland/ use pin light  Ask the patient to sip some water and to extend the neck again and swallow; watch for upward movement of the thyroid gland.  Noting its contour and symmetry  Note that : the thyroid gland, thyroid cartilage and the cricoid cartilage will all rise with swallowing and then fall to their resting positions.

21. PE: Thyroid gland palpate the thyroid gland  Find your landmarks: the cricoid and the thyroid cartilage.  Flex the neck slightly forward  Place your both hands on the patient’s neck  Ask the patient to swallow sips of water  To palpate the lobes;  Displace the trachea to the right by fingers of left hand and palpate by the right hand.  Repeat for the other side.

22. Note the size, shape, consistency of the gland and identify any nodules or tenderness. Soft in Graves disease, firm in hashimotos thyrioditis, and malignancy Benign and malignant nodules, tenderness in thyroiditis. If thyroid gland is enlarged, listen over lateral lobes with a stethoscope to detect bruits, a sound similar to cardiac murmur but of noncardiac origin.

23. Thyroid gland