Transcript—Lymph Nodes and Thyroid Examination (NUR 600, Week 4)

Doctor: This next segment will be the lymph nodes of the head and neck, followed by the thyroid exam. When you’re examining the lymph nodes, you’ll be using the tips or pads of probably your second, third, and fourth finger, and using skin moving stokes that I’ll demonstrate for you, kind of skin moving circles. Remember that when you’re doing the lymph node exam, you’re basically covering geographic areas where lymph nodes might be enlarged.

You may well do this exam and have nothing that you feel abnormal, but you’re attempting to cover the spaces and the geographic areas where the lymph nodes might be enlarged. You’ll start with the preauricular, which is the area right in front of the ear and, again, notice the skin moving circles with the fingertips of your hands. Move backwards to the occipital nodes, and a good way to have the patient relax that skin for you in have them tip their head back and then you can feel that better. You want to make sure that your patient has good exposure of their supraclavicular areas so that you can do the posterior and anterior cervical lymph nodes. Remember the boundaries of the posterior triangle are the trapezius, the clavicle, and the posterior border of the sternocleidomastoid. So on both sides, simultaneously, you’ll cover the border of the trapezius, across the clavicles, and then the behind the sternocleidomastoids, and then fill in whatever space you haven’t already covered.

The next lymph node group is over the sternocleidomastoids, and again with skin moving circles you’ll cover that space. When you do the anterior triangles, you’ll want to do them separately because we’re going to have our patient turn their head toward the side that you’re examining to loosen up that skin a little. The borders of the anterior triangle are the front of the sternocleidomastoid, the midline, and the angle of the chin. So now you’re going to come down the front of the sternocleidomastoid, up the midline to the angle of the chin, and then fill in. Then, you can do the submandibular and submental node on that side. And then you have your patient turn their head to the other side, like that, and use your other hand to go do the front of the sternocleidomastoid, up the midline to the angle of the chin, fill in. Then, turn your finger for the submandibulars, and we’re done with that part of the exam.

The next exam is the re-examination of the supraclavicular nodes, and to do that you have your patient take one hand, put it on their hip, and roll their shoulder forward. This opens up the supraclavicular fascia. You can feel over that clavicle again, and then hook you fingers over, and have the patient bear down, and feel if you see anything present to your fingertips. Same thing on the other side.

(To patient) That hand on your hip, roll your shoulder forward.

Feel over the clavicle, hook your fingers over the clavicle, and have patient bear down.

(To patient) Good. Perfect.

Next we’ll move to the thyroid. For this your patient is going to swallow numerous time and so they get a cup of water to take some sips.

(To patient) Go ahead and take a sip and swallow.

And the first thing we’re going to do is light the neck during a swallow.

(To patient) Take another sip, hold it until I tell you to swallow. And go ahead and light.

(To patient) Swallow.

When I light the neck with this sort of transverse light, it casts shadows so that you may be able to see an abnormality, a difference from one side to the other.

Now were going to do the palpation for the isthmus of the thyroid. Go ahead and have your patient take a sip.

(To patient) Hold it in your mouth until I tell you to swallow.

The isthmus of the thyroid is below the thyroid cartilage. So get your landmarks, thyroid, cricoid, and then slip right under, and go ahead and have your patient swallow. See if you can feel that very thin structure go under your finger. The isthmus of the thyroid is the only structure that rises on swallowing, the only soft issue structure. So that’s actually what you’re feeling for.

(To patient) Take another sip.

Thyroid, cricoid, right underneath it, one finger

(To patient) Go ahead and swallow.

Feel for that very thin structure. Then you have your patient tip their head toward to side of the thyroid that you’re going to be examining. Have them take another sip.

(To patient) Hold it until I tell you to swallow.

This time you want to bring a little skin over the sternocleidomastoid muscles and then tuck in under them, quite low on the neck, and have your patient swallow to see if you can feel the lobes.

(To patient) So go ahead and swallow. Good. Take another sip. I hope we have enough. Keep your head turned.

Again, bring some skin of the other sternocleidomastoid, tuck your fingers underneath that muscle, low on the neck, and go ahead and have your patient swallow.

(To patient) Good.

You’re going to do the same thing from the other side, except you’re going to have your patient turn their head away from you, from the side that you’re going to be examining. Have them take a sip of water, you want to bring your fingers around the sternocleidomastoid, and then tuck underneath them, have your patient swallow.

(To patient) Great. Okay.

I’m going to show you a second way of doing that, another approach that you may decide you prefer or you may see other people use. And I’m going to get some extra water for our patient because we’re just about out.

(To patient) Here’s the new supply.

For this particular technique you actually sit up behind the patient and then feel your landmarks from around the back and basically use the same hand motions.

So I’m going to sit up behind the patient if there was a tremendous size difference between me and my patient or if I couldn’t make this happen, you could turn the patient on the table so that you could stand and do this from the posterior approach. You’re, again, finding your landmarks, cricoid, slipping right under that lower cartilage, and having your patient take a sip and swallow.

Now I’m going to feel the left lobe with my right hand. Have the patient turn their head, get some skin over, and tuck in under that sternocleidomastoid. And have the patient swallow again.

(To patient) You’ve got water? Go ahead and swallow. Good.

To feel the right lobe, I’m going to use my left hand. Find my landmark again, go ahead and see if I can feel the isthmus.

(To patient) Go ahead and take a sip and swallow.

And then have your patient turn their head and then put your hand around, tuck under that sternocleidomastoid and have them sip and swallow again.

(To patient) Good. Okay.

So that’s another technique that you can use if you prefer it.