General appearance(facies).Cetain individuals possess a gifted ability to look at another’s face and,almost instinctively,sense a great deal of information.
ThyrotoxicosisOne form of thyrotoxicosis ,caused by Grave’s disease,is also characterized by protrusion of one or both eyes(exophthalmos),and some signs:Graefe sign,Stellwag sign,Mobius sign,Joffroy sign.
Lids.Faults in position include outward rolling of the lids(ectropion) and inrolling (entropion). Systemic disease(for example nephrosis,heart failure,allergy,or thyroid deficiency ) may be suspected in the presence of lid edema, provided purely local inflammation and the slight bulging of lid skin commonly caused by aging are excluded.Ptosis (drooping of the upper lid ) may be an early sign of involvement of the third nerve by any cause.Congenital defects rank high among causes of ptosis.
Conjunctiva The conjunctiva is divided into two portions,palpebral and bullbar.Palpebral conjunctiva lines the posterior lid surface.Bulbar conjunctiva covers the eye up to the limbus.Conjunctiva is normally quite transparent,and the white color of the eye is caused by the underlying white sclera.
Cornea.Good vision requires a perfectly smooth and transparent cornea.Two of the most common abnormalities of the cornea are abrasions and opacities.Corneal sensitivity(fifth nerve) is tested by touching a wisp of cotton to the center of the cornea and noting the brisk lid closure.This lid closure is a normal and important protective reflex.
PupilNormal pupils are perfectly round,equal in size,and constrict visibly to light and during accommodation.The direct reaction to light refers to constriction of the pupil receiving increased illumination.Constriction of the opposite pupil is termed consensual pupil reaction. The reaction to accommodation is best tested by holding one fingertip about 4 inches from the eye being tested.If the pupil reacts to light,it ordinarily may be assumed that reaction to accommodation will be present.Failure to react to light with preservation of convergence is very characteristic of central nervous system syphilis.
Pupils are normally smaller in infancy and old age.Enlargement of the pupil may be caused by ocular injury,acute glaucoma,systemic poisoning by parasympatholytic drugs,and local use of dilating drops.Constriction of the pupil is seen in iris inflammation ,in glaucoma patients treated with pilocarpine,as an effect of morphine,and physiologically in sleep.
Intraocular pressure.By indentation of the eye with the examining fingers,a crude estimate of intraocular pressure may be made.Pressure measurement is important because elevated intraocular pressure,known as glaucoma, causes slow death of nerve fibers and is responsible for 12% of blindness in American.
Inspection of the external ear is so obvious that it is frequently neglected.It should require only a few seconds.Occasionally tophi,which are small white deposits of uric acid crystals caused by gout,are seen along the margins of the auricle.
Next the examiner inspects the external auditory canal and the tympanic membrane. In physical diagnosis the tympanic membrane or eardrum may be regarded as a translucent membrane through which the otologist views normal anatomy and also pathologic processes in the middle ear.
Examination of hearing
A hearing test should be part of every physical examination.A reasonably accurate estimate of hearing can be made by any physican who understands a few basic principles.For testing hearing in the office or at the bedside the only instruments needed are one or two tuning forks,a masking device,and the examiner’s own voice.
There is an anterior plexus of blood vessels in the mucosa of the nasal septum,and the examiner can often see small arteries and veins here.This is the most common site for epistaxis(nosebleed) .
Examination of the paranasal sinuses is done more indirectly than other otolaryngic procedures.The examiner cannot see into any of the sinuses and only rarely can he see a sinus ostium.Information about the condition of the sinuses is gained(1)by inspecting and palpating the overlying soft tissues(maxillary and frontal sinuses)(2)by noting secretions that may drain from the sinuses ,and (3)by transillumination .
The examiner inspects the lips,all surfaces of the tongue,gums,roof of mouth,and the buccal mucosa(the tissue lining the cheeks) by asking the patient to open his mouth and by shining a light into the area to be examined.The examiner may use a tongue depressor to aid inspection.
Lips-The healthy lips are wet and red in color.This is caused by a rich capillary network.
Buccal mucosa-To examine the buccal mucosa it is necessary to shine a light into the patient's mouth.The healthy buccal mucosa is pink and smooth.The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.
Tongue The tongue is examined by both inspection and palpation for its shape ,motion and ulceration.
Teeth and gingiva There are 32 teeth in the full adult dentition.The teeth are inspected for evidence of caries and malocclusion.
Pharynx is devided into three parts:nasol pharynx,oral pharynx and laryngeal pharynx.When the tonsils become enlarged,they may extend considerably beyond the anterior tonsillar pillars,at times even to the midline .At other times white spots on the tonsils may indicate follicular tonsillitis.
Larynx Tumors of the true cords prevent accurate approximation during phonation and therefore cause hoarseness.For that reason malignant tumors arising on the true cords have a very favorable prognosis if the patients sees a physician as soon as he becomes hoarse and if the physician examines the larynx.
MOVEMENTS OF THE HEAD
The head may be tilted to the side as the result of shortening of the sternomastoid muscle.This condition is known as torticollis.Although this is usually a congenital defect,it may be caused by inflammation of the muscles.
A not uncommon observation in elderly people is the constant rhythmic tremor of the head and its attendant degenerative changes in the brain.
Bounding(a slight up-and-down movement) of the head that is synchronous with the pulsation of the heart may be noted in patients with aortic regurgitation as the result of the widened pulse pressure.
Blood vessels Auscultation over the carotid arteries may reveal bruits that indicate stenosis of major arteries in the neck. These changes are usually caused by atherosclerosis and may produce serious brain damage. Most significant is the high-pitched bruit heard over the bifurcation of the carotid artery. It usually indicates a stenosis of the internal carotid artery that is remediable by surgery. The low-pitched murmurs heard over the base of the neck are commonly cause by artherosclerosis of the subclavian artery.
The jugular veins are ordinarily not distended when the patient is in a sitting position, although filling of these veins will be seen as he reclines. When there is distention of these veins in the upright position, it usually indicates congestive heart failure. On the other hand, it may be the result of any obstruction to the return flow of blood from the head and neck into the thorax, such as constrictive pericarditis, tumor of the mediastinum, or obstruction of he superior vena cava.
Thyroid gland.Palpation. Seat the patient in a chair and stand behind him. He must be relaxed and comfortable with his chin lowered and the back of his head resting against your body. Place your fingers anteriorly with their tips over the patient’s thyroid, and the thumbs resting on the patient’s posterior neck. Throughout the examination, repeatedly ask the patient to swallow to facilitate identification and delineation of the gland.The examiner should feel as much of the thyroid gland as possible.The size,configuration,consistency,presence,and number of abnormal nodules should be carefully recorded.
Trachea. First, the trachea is palpated for evidence of deviation. The trachea is probably best palpated just above the suprasternal notch. The trachea may be displaced laterally by an aortic aneurysm, a mediastinal tumor, or a unilateral thyroid enlargement. In similar fashion, a large amount of fluid or air in the pleural space will push the trachea and other mediastinal structures toward the opposite side. If there are pleural adhesions, fibrosis within the lungs, or atelectasis, there may be displacement of the trachea toward the affected side. Second, the trachea is palpated for evidence of trachea tug.