Head and Face
The first thing a doctor pays attention to is the shape and size of the skull. Changes such as macrocephaly (enlargement) or microcephaly (reduction) are most often hereditary or congenital. It is important to assess facial expression, which can reflect the patient's emotional state or the presence of a pain syndrome.
Involuntary movements should also be noted:
- Tremor: a typical sign of parkinsonism, which is more common in elderly individuals.
- de Musset's sign: rhythmic head nodding synchronous with the cardiac cycle. This is a prominent marker of aortic valve regurgitation.
Eye Examination
The condition of the eyes is an indicator of many somatic and neurological diseases.
Assessment of pupils and eyelids:
- Mydriasis (pupillary dilation) is observed in atropine poisoning, coma, and clinical death.
- Anisocoria (pupillary inequality) indicates a unilateral CNS lesion, including post-traumatic cases.
- Ptosis (drooping of the upper eyelid) indicates paralysis of the corresponding muscles or nerves.
- The eyelids may reveal xanthomas and xanthelasmas — yellowish elevations signaling lipid metabolism disorders.
Conjunctiva and cornea:
- Pale conjunctiva indicates anemia.
- Dilated capillaries are often found in chronic alcoholism.
- Lukin-Libman spots (petechial hemorrhages) are a sign of subacute infective endocarditis.
- Granulomas indicate sarcoidosis.
- Arcus senilis (arcus senilis) — peripheral corneal opacity, a marker of systemic atherosclerosis in the elderly.
- Xerophthalmia («dry eye» syndrome) with a gritty sensation in the eyes is characteristic of Sjögren's syndrome.
Special ophthalmological signs: In-depth examination may reveal cataracts (diabetes), Kayser-Fleischer rings on the cornea (hepatolenticular degeneration), and uveitis (rheumatoid arthritis). Fundoscopy allows detection of papilledema and vascular changes, which are typical for severe arterial hypertension.
Ear and Nose Examination
Inspection of the auricles helps identify metabolic and circulatory disorders. A bluish skin color (cyanosis) of the ear indicates severe congestive heart failure. The presence of tophi — whitish nodules containing uric acid crystals — is a reliable sign of gout.
When examining the nose, attention is paid to deformities, rashes, and discharge:
- Herpetic vesicles may appear on the nasal alae.
- Tissue necrosis and foul-smelling bloody-serous discharge are found in Wegener's granulomatosis, syphilis, and tumors.
- Frequent epistaxis requires ruling out arterial hypertension, blood clotting disorders, trauma, and neoplasms.
Neck Inspection and Palpation
Neck examination includes assessing its mobility, the condition of organs, lymph nodes, and vessels. Movement restriction is most often associated with osteoclasia or inflammation of the intervertebral joints.
What needs to be assessed:
- Organs and lymph nodes: palpation determines the size of the thyroid gland (detection of goiter), as well as the consistency and tenderness of lymph nodes.
- Venous system: jugular venous distension signals impaired blood outflow to the right atrium (right ventricular failure, constrictive pericarditis, hydropericardium). The venous pulse is also assessed.
- Arteries: pronounced pulsation of the carotid arteries («Corrigan's pulse») is a classic sign of aortic regurgitation. It is precisely on the carotid arteries that pulse presence is checked during resuscitation when it cannot be palpated at the wrist.
Briefly: answers to topical questions
What pathological skull shapes can be detected during inspection, aside from macrocephaly and microcephaly?
Aside from macrocephaly and microcephaly, inspection can reveal pathological skull shapes associated with various syndromes:
- Oxycephaly (turribrachycephaly) with an overhanging forehead — a sign of Apert syndrome (acrocephalosyndactyly).
- Craniosynostosis — characteristic of Crouzon syndrome (craniofacial dysostosis).
What signs of oculomotor nerve damage are revealed during a physical eye examination?
Damage to the oculomotor nerve (III pair) reveals the following signs:
- Drooping of the upper eyelid (ptosis).
- Divergent strabismus (strabismus divergens), with the eyeball deviated outward and downward.
- Mild exophthalmos.
- Pupil dilation (mydriasis).
- Restriction or complete inability of eyeball movements upward, inward, and partially downward.
- Loss of pupillary light and convergence reflexes, accommodation paralysis.
- Double vision (diplopia) upon passive elevation of the eyelid.
What meningeal signs are checked during the neck examination?
During the neck examination to detect meningeal syndrome, the following are checked:
- Nuchal rigidity (or neck muscle rigidity).
- Upper Brudzinski sign — involuntary flexion of the lower extremities upon passive flexion of the patient's head toward the chest.
What characteristics of cervical lymph nodes must be assessed during palpation?
During palpation of cervical lymph nodes, the following 7 parameters must be assessed:
- Number (single, multiple/clusters).
- Shape.
- Size (strictly in millimeters).
- Consistency (soft, firm, elastic).
- Tenderness (upon palpation).
- Mobility (displaceability).
- Adhesion (to surrounding tissues, skin, or to each other forming conglomerates).
The condition of the skin over the lymph nodes is also assessed.
To remember how Musset's sign and the "carotid dance" relate to aortic regurgitation, imagine a large volume of blood being forcefully ejected into the aorta and neck vessels with every systole, causing them to pulsate and make the head "bob".
Class and exam questions
What does Musset's sign indicate?
This is a rhythmic head bobbing that coincides with the pulse. It indicates aortic valve regurgitation.
What is arcus senilis?
This is a persistent ring-like or arc-shaped corneal opacity at its periphery. It indicates impaired lipid metabolism and systemic atherosclerosis.
In which conditions is jugular venous distention observed?
It occurs when blood return to the right atrium is impaired. Main causes: right ventricular failure, constrictive pericarditis, and significant hydropericardium.
What else to study on this topic
- Thyroid Palpation Technique
- Examination of the Lips and Oral Cavity (Chapter 7)
- Assessment of Venous Pulse Prominence
- Funduscopic Changes in Somatic Diseases
- Breast Examination
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Other topics in the section "Examination of the skin, lymph nodes, and individual body parts"
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