Normal hair distribution is well appreciated by most examiners and need not be considered here. However, it should be remembered that facial, axillary, and public hair depend on the presence of sex and other hormones and thus is related to both the sex and the age of the patient. Scalp hair should be specifically examined for length, texture, fragility, sheen, and the ease with which hairs can be manually removed from their follicles.
Lymph nodes are distributed throughout the body but for most purposes can be divided into five major groups: cervicofacial-supraclavicular, axillary, epitrochlear, inguinal, and femoral. Other lymph node groups that occasionally become pathologically enlarged are the suboccipital, postauricular, suprasternal, and popliteal. Evaluation of the numerous lymph nodes of the mediastinum, abdomen, plevis, lymph nodes of the mediastinum, abdomen, pelvis, and lower extremities must be done by computed tomography (CT) or lymphangiography.
Lymph nodes are examined by palpation. In general the tips of the first four fingers are sued, and five major qualities of the nodes are noted: location, size in centimeters (using a ruler), degree of tenderness, fixation to underlying tissue, and texture (hard, soft, etc.).
Normal lymph nodes are not palpable. However, mild enlargement (<1 cm) of the inguinal nodes is quite common, and probably results from repeated superficial infections of the fee and legs. These nodes are soft, nontender, and movable, with normal overlying skin. Femoral node enlargement, in contrast, is more likely to be of clinical significance. Similar small, soft, movable nodes are also found in children in the cervicofacial and axillary areas as a result of exposure to upper respiratory pathogens and superficial infections of the upper extremities.
Lymphadenopathy may be either localized or generalized. The former is generally associated with a local infectious process in the anatomic area drained by the nodes in question, or neoplasm. Texture, size, tenderness, and fixation can all weigh in favor of one or the other of these possibilities; hard nodes favor neoplsms, as do greatly enlarged (>3 cm), nontender, and fixed nodes. Small, soft, tender, red, and movable nodes are more often a result of inflammation or some other type of antigenic challenge. Location is also of importance; isolated occipital, postauricular, or epitrochlear lymphadenopathy is unusual in primary lymphoma and more commonly results from locallized inflammation. Posterior or anterior cervical, supraclavicular, mediastinal, or intraabdominal adenopathy is more commonly associated with neoplasia.
The patient’s position or posture may reveal significant information. (for example: arthritis, congestive heart failure, carcinoma of the body or tail of pancreance) thus, the position of the patient at the time of examination may suggest certain disease possibilities.
Body movements are classified as voluntary and involuntary. Involuntary movements are usually abnormal and may occur in either conscious or comatose states.
1. The tics: These are habit spasms and usually involve the muscule of the eyes, face neck. They generally occur in tense or emotional persons.
2. Convulsive movements
Convulsive movements are a series of violent involuntary muscule contractions.
(1) Tonic convulsions are custained contractions.
(2) Clonic ones are characterized by intermittent contraction and relaxation.
(3) Tremors are trembling movements that are result of various causes such as fatigue, alcoholic intoxicaton. Certain drugs, thyroxicosis, parkingsonism, hysteria and nervous.
(4) A flapping tremor can frequently be seen in the presence of hepatic cama. This is best seen in the hands, although it may occur in the feet or tongue, with the arms outstretched on the bed, the wrists dorsiflexed and the fingers spread apart, there occurs episodes of rapid alternating flexion and extension movements at the patient’s wrists and the metacarpophalangeal joints.
Abnormalities of gait are also noted during inspection. Neurologic deficits resulting from cardioembolic strokes or hypertensive cerebrovascular disease may be associated with abnormalities of gait. A parkinsonian gait may indicate Shy-Drager’s syndrome, which may be associated with orthostatic hypotension. Certain metabolic disorders such as hyperthyroidism, hypothyroidism, Cushing’s syndrome, and acromegaly can be suspected during inspection, and these metabllic diseases may be associated with various cardiovascular abnormalities including systemic and pulmonary hypertension and myocardial and pericardial diseases.
The character of a patient’s voice and the manner of his speech may be of considerable diagnostic aid, involvement of larynx by inflammation. TB or malignancy may result in hoarseness. In cerebral vascular accidents, the speech is often thick, and words are enunciated with considerable difficulty. In paralysis of recurrent laryngeal nerve the voice is weak and loss its normal resonating quality. Three different basic speech defects are encounteaed: pphonia, aphasia, and anarthria.
As part of every P. E. the physician should record the patient’s sex, age, weight, height, temperature, pulse and respiratory rate.
1. Overweight or obesity may be either exogenous or endogenous in origin. Edema must be differentiated from obesity, in edema the tissues pit (indent) when pressed with finger. This phenomena is not present in obesity.
2. Underweight. The examiner should evaluate the patient’s present weight in term of his average weight; that is , has patient always been slender or has been lost weight, pepople may lost weight as the result of voluntarily decreased calaric intake or because of various wasting diseases, such as pulmonary TB, malignancy and hyperthyroidism.
“Stature” here refers to height and build.
People’s height is below normal. Gigantism is of two essential types, both of which are caused by hypersecretion of the anterior pituitary growth hormone. This overactivity of anterior lobe gegins before the body epiphyses fuse, there results an individual of abnormally large stature with absent or retarted sexual development.
On the other hand, the anteriar lobe becomes overactive following fuse of epiphyses, acromegaly results.
Chapter 3 Head and Neck
A. Head: HAIR AND SCALP
The character and the color of the hair should be noted.Alopecia,a thinning of the hair or actual baldness,is the result of injury or death of the hair follicles.Although a number of conditions may cause loss of scalp hair,the most common is hereditary alopecia.Hereditary male baldness usually begins with a generalized thnning of the hair associated with recession of the anterior headline,particularly in the area of the temples.Other forms of alopecia are toxic or symptomatic alopecia and alopecia areata.Presently the most common cause of sudden hair loss among hospital patients is the side effect of drugs used for palliation of malignant tumors and leukemia.In hypothyroidism(myxedema) the hair is commonly coarse,dry,and brittle.
The examiner palpates the entire skull using both hands and simultaneously examines symmetrical areas.The examiner parts the hair to observe the scalp,noting any scaliness,deformities,lumps,tenderness,lesions or scars.
The size and shape of the cranium vary considerably from patient to patient.Certain deformities of the skull result from congenital malformations.Microcephaly is a congenitally small skull resulting from failure of the brain to develop normally in size and function.The result ,a skull much smaller than normal,is always accompanied by severe mental retardation.In contrast,oxycephaly or steeple skull ,which results from premature union of the cranial sutures that leads to grotesque malformations of the calvarium ,is not ordinarily accompanied by mental retardation.An abnormally large head(macrocephalus) may occur with several conditions:Hydrocephalus,Osteitis deformans(Paget’s disease of bone),Acromegaly.Vitamin D deficiency (rickets) causes enlargement of the frontal and parietal prominences,producing a somewhat square head.