After a long break, I am rejoining the tour of the human body as examined by a physician. To view the previous posts on physical exam, please follow this link.
We now move down the body to the neck. The neck seems to simply be a connection of the head to the torso. It seems to be just a transportation system between the command center and the main workers. Steve Martin seemed to have this in mind when he said.
I want a woman with a good head on her shoulders. I Hate Necks!!
![\"zimmer_g\"](\"http://distractible.org/wp-content/uploads/2008/03/zimmer-g.jpg\")
While it seems that there are some professional athletes and cartoon characters who have no necks, the neck is actually quite a hapnin\’ place when it comes to the physical exam and when it comes to the function of the body. I actually examine the neck on nearly every visit, and generally note it as follows:
Neck: Supple, without LAD or TMG
Dang. That football player really has no neck.
The exam translates to mean: The neck bends easily. There are no lymph nodes present and the thyroid does not feel abnormally large.
Smooth and Supple
The use of the word "supple" to describe the neck is referring to the fact that it can be easily bent. Stiff necks are the most common physical signs in meningitis, and so I have always felt that the inclusion of the word "supple" was more for defensive purposes than anything.
![\"fred-and-barney\"](\"http://distractible.org/wp-content/uploads/2008/03/fred-and-barney.jpg\")
Meningitis, or an infection of the fluid that surrounds the brain and the spinal cord, will classically present with a fever and a stiff neck. For younger infants, the stiff neck is much less reliable, and so many infants with unexplained fevers will get a spinal tap to rule out meningitis as a cause. Also, meningitis is not the most common cause of neck pain and fever. Many common problems (such as mononucleosis or strep throat) can also cause this. A careful exam will usually rule out meningitis, as the pain is usually on the back of the neck and is worse with full flexion forward.
The good news is that we see relatively little meningitis these days. In the past, meningitis was much more common, but two vaccines: the one against the bacteria hemophylus influenza, and the one against streptococcus pneumoniae, have greatly reduced its incidence. Score one for the value of immunizations. I have to say that I have never seen a child with h. influenza meningitis since I started practice but just recently diagnosed a child with streptococcal meningitis. It is of interest that she had not gotten the vaccine against that bacteria. My guess is that they are being paid off by the big drug companies to convince us to throw lots of money at their vaccines that cause autism.
There is also a vaccine against the most scary form of meningitis, Meningococcal meningitis. This disease is rare, but is probably one of the most frightening disease around in that it happens in young and healthy people and it can kill in hours. Meningococcal infection has up to a 50% death rate. My kids are being immunized for this one.
![\"John](\"http://distractible.org/wp-content/uploads/2008/03/john-supple2.jpg\")
This is one of the pictures that came up when I Goggled the word "Supple." I would like to introduce you to Mr. John Supple. He has a neck.
A Pain in the Neck
![](\"http://upload.wikimedia.org/wikipedia/commons/6/60/Trapezius.png\")
More often, a cause of neck stiffness is a strain of the trapezius muscles at the back of the neck. This causes pain when the neck is flexed forward or is turned toward the side of the trapezius muscle affected. This can be caused by sleeping on a bad pillow or by flexing the neck for too long of a time (getting a "crick").
The trapezius has also been a veritable gold mine for personal injury attorneys in the form of Whiplash. Whiplash is a common consequence of being in an auto accident, especially from being rear-ended. While it is clear that the insurance companies want to close auto claims far too quickly (I usually recommend that people don\’t sign off on the claim until they feel better), there are also many abuses.
![\"rotator\"](\"http://distractible.org/wp-content/uploads/2008/03/rotator.jpg\")
I don\’t see many primary care physicians advertising on the back cover of the phone book.
![\"collar\"](\"http://distractible.org/wp-content/uploads/2008/03/collar.gif\")
In general, neck strains take a while to heal, and are best treated with physical therapy and anti-inflamatories. If a person has a lot of pain, immobilization of the neck through the use of a soft neck collar is appropriate, although they should not be over-used as they can actually increase stiffness if used excessively (especially by dogs).
So this raises the interesting question: what would that football player or Fred Flintstone do if they were in an accident? How would you put a cervical collar on them? It seems that they have a built-in collar by their own anatomy.
Sometimes the complaint of stiff neck comes from tonsillitis or pharyngitis. Young children with sore throats will often say that their neck hurts, and the swelling of the lymph nodes (that will be covered in part 2) can make a neck stiff.
Torticollis
Torticollis is a condition where the neck is stuck in a position bent to one side and back. The most common form happens in infants from birth and generally resolves with physical therapy. Torticollis happening later in life may simply be due to muscle spasm, or may be a sign of more serious problems.
Torticollis has nothing to do with these guys:
![\"no-tortoise-behind\"](\"http://distractible.org/wp-content/uploads/2008/03/no-tortoise-behind.jpg\")
Nor is it a gate for a Medieval Castle
![\"Portcullis_Bucharest\"](\"http://distractible.org/wp-content/uploads/2008/03/portcullis-bucharest.jpg\")
Finally, there is the whole issue of someone being a "pain in the neck." I suppose it is a more polite part of the anatomy to use than the more southern area of pain; whatever the case, it bears some thought as to why this should be used in this expression. There is a reason. People won\’t say "He was a pain in the Uvula." I guess they could in very rare circumstances, but my imagination is getting the best of me.
While I could not find a definitive reason for the inclusion of the neck, it must be pointed out that stress will often cause the neck muscles to tighten and hurt – often resulting in a tension-type headache. This means that something that is a pain in the neck figuratively could be a pain in the neck literally. The same does not hold true for the more southern site of pain.
![\"OL-Donkey-Cart\"](\"http://distractible.org/wp-content/uploads/2008/03/ol-donkey-cart.jpg\")
This ass does not appear to be in pain, despite the stress.
Rob,I found this sentence troubling: “My guess is that they are being paid off by the big drug companies to convince us to throw lots of money at their vaccines that cause autism.” Are you implying that these vaccines cause autism? Surely you aren’t, and I’ve misunderstood. Even if you buy the thimerosal/autism link (which I do not), neither the H flu nor the pneumococcus vaccines have thimerosal in them. In my practice lifetime, I have seen H flu meningitis vanish (believe me, you’re lucky never to have treated a case) and pneumococcal sepsis almost vanish. The effect of these vaccines on what used to be common causes of childhood death is staggering. These vaccines are life savers!
Rob,I found this sentence troubling: “My guess is that they are being paid off by the big drug companies to convince us to throw lots of money at their vaccines that cause autism.” Are you implying that these vaccines cause autism? Surely you aren’t, and I’ve misunderstood. Even if you buy the thimerosal/autism link (which I do not), neither the H flu nor the pneumococcus vaccines have thimerosal in them. In my practice lifetime, I have seen H flu meningitis vanish (believe me, you’re lucky never to have treated a case) and pneumococcal sepsis almost vanish. The effect of these vaccines on what used to be common causes of childhood death is staggering. These vaccines are life savers!
That sentence was 100% sarcastic.
That sentence was 100% sarcastic.
Dr Rob – Since you were talking about meningitis…how often do you see meningoencephalitis? Have you ever seen it in your practice?
Dr Rob – Since you were talking about meningitis…how often do you see meningoencephalitis? Have you ever seen it in your practice?
Don’t really make much of a differential between the two. Meningitis with mental status changes is probably meningoencephalitis. There are certain diseases that are usually meningoencephalitis, such as ehrlichiosis and other like diseases.
Don’t really make much of a differential between the two. Meningitis with mental status changes is probably meningoencephalitis. There are certain diseases that are usually meningoencephalitis, such as ehrlichiosis and other like diseases.
Let’s see if I have this right…meningitis = meningitis, but meningitis + seizures/hallucinations/crazy/other = meningoencephalitis?
And if my googling is correct, ehrlichiosis is tick-borne, right?
Let’s see if I have this right…meningitis = meningitis, but meningitis + seizures/hallucinations/crazy/other = meningoencephalitis?
And if my googling is correct, ehrlichiosis is tick-borne, right?
There are very few ways to diagnose encephalitis other than through the symptoms (you don’t stick a needle in the head). So I would say that is right.
Yes, it is Tick borne – similar to Lyme disease (without the rash). Other spirochetal diseases are also prone to give a Meningoencephalitis (even Syphilis).
There are very few ways to diagnose encephalitis other than through the symptoms (you don’t stick a needle in the head). So I would say that is right.
Yes, it is Tick borne – similar to Lyme disease (without the rash). Other spirochetal diseases are also prone to give a Meningoencephalitis (even Syphilis).
when my son was 6, he had fever, high fever (107) and they wanted to do a spinal tap.They kept telling me that they didn’t think it was meningitis, but they needed to rule it out.
Then they’d keep him over night in the hospital, give him fluids and let him go home in the morning when being rehydrated would bring down the fever.
I kept saying, well, give him the fluids, then tomorrow if the fever’s not down, THEN do the spinal tap!
An hour later, they had me convinced they needed to do the spinal tap. However, I could not get the words “yes, you may do the spinal tap on my son” out of my mouth. “I guess so” “do what you have to do” “if that’s what needs to be done” all of those ..but not “yes, you may do a spinal tap on my son”
They needed those words … so after 2 hours of my beating around the bush (???) my pastor finally said “She’s giving you her permission!”
He had to sign the forms as well since I couldn’t verbally say the words they needed to hear LOL
They kept assuring me the tests would come back clean.
They did the tests …they said the fluid looked good. They admitted him …then the doc came in the room white as a ghost.
It was a good thing I’d not talked them out of doing the spinal tap. A very good thing. Their instincts to rule it out were spot on … because they couldn’t rule it out ..he had it!
when my son was 6, he had fever, high fever (107) and they wanted to do a spinal tap.They kept telling me that they didn’t think it was meningitis, but they needed to rule it out.
Then they’d keep him over night in the hospital, give him fluids and let him go home in the morning when being rehydrated would bring down the fever.
I kept saying, well, give him the fluids, then tomorrow if the fever’s not down, THEN do the spinal tap!
An hour later, they had me convinced they needed to do the spinal tap. However, I could not get the words “yes, you may do the spinal tap on my son” out of my mouth. “I guess so” “do what you have to do” “if that’s what needs to be done” all of those ..but not “yes, you may do a spinal tap on my son”
They needed those words … so after 2 hours of my beating around the bush (???) my pastor finally said “She’s giving you her permission!”
He had to sign the forms as well since I couldn’t verbally say the words they needed to hear LOL
They kept assuring me the tests would come back clean.
They did the tests …they said the fluid looked good. They admitted him …then the doc came in the room white as a ghost.
It was a good thing I’d not talked them out of doing the spinal tap. A very good thing. Their instincts to rule it out were spot on … because they couldn’t rule it out ..he had it!