Alright, so let's review the case of a patient with sore throat. So this is a 34-year-old woman
who is presenting to her physician with a sore throat that has been worsening for the last
2 days. Her 4-year-old daughter has recently had similar symptoms. So certainly right off the
bat I'm thinking that this is likely infectious, we have a sick contact in the house, and the
presentation of sore throat over 2 days leads me towards infection. However, we should
really review the complete structure and anatomy of what we're going to be examining
because that may lead us towards thinking about some other etiologies as well. So we're
going to talk about the overall structure of the sinuses and the bones of the skull. We're
going to review some lymph nodes and how we can distinguish from infection versus
malignancy. We'll be examining the ears, the nose, the oral cavity, and the thyroid. First off,
it's important to know the basic anatomy of the skull remembering where the frontal bone is,
zygomatic bones are actually some of the more common bones of the face that are fractured
as well as the nasal bone. And then we have the maxillary portion of the frontal part of the
face and the mandibular portion and certainly folks who have issues with a trigeminal nerve
as we'll discuss and then on neurologic exam similarly have V1 and V2 and V3 broken up by
the frontal bones, the maxillary bones, and the mandibular bones in a similar fashion. The
sinuses as well in terms of being able to palpate or percuss over sinuses, all we have access
to is the frontal sinus. More posteriorly is the ethmoid and sphenoid sinuses which we don't
really have access to. Otherwise, we can tap on the maxillary sinuses as we'll discuss. In
terms of the lymph node exam, we're going to want to be able to tease apart whether the
lymph nodes are simply reactive in the setting of infection or if there are more concerning
findings that would suggest the beginnings of a malignancy. We're also going to be talking
about different types of ear infections starting off with otitis media involving problems with
the middle ear and trying to compare and contrast that with patients who have an external
ear infection of the external acoustic meatus. We're going to be looking for exam findings
that can help us to distinguish between conductive hearing loss and sensorineural hearing
loss. In terms of nose anatomy, remember that the nasal turbinates are broken up into 3
groups; the superior, the middle, and the inferior and they are directly perpendicular to the
plane of the face rather than being upwards and pointing towards the eye sockets. When
you're examining the turbinates, you may find evidence of polyps which sometimes we see in
aspirin-exacerbated respiratory disease. You may be seeing some evidence of an infection
with some nasal discharge. And then looking at the nasal mucosa, it may be boggy or
erythematous depending upon what's going on as well. Moving on to the oral cavity, we'll be
looking at the hard and soft palate. We'll be looking in the back of the throat to see if there
are signs of allergic rhinitis with some postnasal drip or cobblestoning in the back of the
throat. Anemia can also be detected through looking at the gingiva and looking for other
ancillary findings that suggest a low hemoglobin. Pharyngitis, we'll try and distinguish
between viral versus bacterial pharyngitis. The latter of which more often would have
tonsillar exudates. And now we're going to briefly review the anatomy of the thyroid gland.
Remember that the thyroid gland is actually not attached to the thyroid cartilage and we'll
talk about, on the physical exam, how to locate where the thyroid is best found. The structure
of the thyroid gland, if it's enlarged you can actually end up having compression of the small
airways or potentially even at the great vessels. And you're also going to be looking for
systemic manifestations of thyroid disease and on palpation potentially just trying to identify
small nodules within the gland itself. So returning to our case, there are a lot of different
things that could present in this 34-year-old woman with sore throat. Perhaps it's just
something straightforward like pharyngitis, streptococcal most notably or viral, maybe she
has allergic rhinitis with a postnasal drip or potentially otitis media that is causing referred
pain to the back of the throat. Either way, we're going to need to use our physical exam to
tease apart what exactly is going on with our patient.