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Dr Sham A. Cader
Method Of Exam
•Inspect the head for size
•Feel for the skull for integrity and evenness
•Evaluate the hair for texture and hair loss.
•Inspect and palpate the scalp.
•The head is symmetrical. Size varies with age and
body stature.
•Male pattern hair loss is common.
•Minor undulations are normal for the skull.
Author: A. Chandrasekhar
Consultant: M. Massa
• Skin exam is not separate from the rest of
the physical examination examine the
patient in good lighting.
• Inspect and palpate skin for the following:
• Color: Contrast with color of mucous
• Texture
• Turgor: Lift a fold of skin and note the ease with
which it moves (mobility) and the speed with
which it returns into place
• Moisture
• Pigmentation
• Lesions
• Hair distribution
• Warmth: Feel with back of your hand
• SUDDEN LOSS of VISION: Potential Causes
• AMAUROSIS FUGAX: Temporary, monocular, ischemic
Painless Caused buy ipsilateral Carotid stenosis or
embolization of the retinal artery.
• RETINAL DETACHMENT: Flashing lights, floating
halos, and blurry vision before the blindness is indicative
of retinal detachment.
• UVEITIS: Inflammation of uveal tract -- iris, ciliary body,
and choroid. Always painful.Associated with multiple
diseases: connective tissue diseases, histoplasmosis,
sarcoidosis, tuberculosis
• CATARACTS: Opacities of the lens, occurring with age.
• GLAUCOMA: Increased intraocular pressure. It is the most common
reason for loss of vision over age 50.
• MACULAR DEGENERATION: Secondary to Diabetes, and
expected to cause visual blindness.
• Diabetic Retinopathy.
• OPTIC NERVE COMPRESSION: Caused by an intracranial
neoplasm, or pituitary adenoma.
• OPTIC NEUROPATHY (Optic Neuritis): Multiple Sclerosis, and
drugs such as Ethambutol, Methanol, can all cause optic neuritis and
gradual blindness.
• PRESBYOPIA: Gradual loss of ability of Accommodation for nearvision, occurring with age.
• CORTICAL BLINDNESS: Infarct of the Occipital Lobe can lead to
cortical blindness. Patient will have binocular blindness, but will retain
the pupillary light reflex which is unaffected
• DIPLOPIA: Double vision.
• Monocular Diplopia: Should suggest corneal or lens problem.
• Binocular Diplopia: Indicative of cranial nerve palsy or ocular muscle
problems, or a brainstem problem.
• Myasthenia Gravis (MG): Diplopia without pain is often the
presenting complaint in MG
• The cornea is innervated by the Ophthalmic Nerve, CN
• Possible causes of eye pain
• CNS problems affecting CN V1: Meningitis, cavernous
sinus thrombosis, aneurysms, migraine
• Adjacent structures: sinus problems
• Eye problems / inflammations: Conjunctivitis, stye,
• Photophobia: Eye pain upon exposure to light,
indicative of
• SCOTOMATA: Specific islands or spots of impaired
vision; an impaired visual field.
• PTOSIS: Droopy eyelids; failure of lids to open
fully. Caused by failure of levator palpebrae,
innervated by CN III, or failure of Tarsal Muscle,
innervated by sympathetics. Some causes:
Horner's Syndrome, Myasthenia Gravis,
• LID LAG: Evidence of white sclera between the
iris and upper lid margin. This is normally not
found. It is a sign of Grave's Disease
• STYE: Small abscess caused by infection of
sebaceous glands of Zeis.
• CHALAZION: Acute inflammation of the
meibomian gland
• SCLERITIS: Inflammation of the sclera, visible as brown
/ red infiltrates in sclera on gross examination. Found in
autoimmune and collagen vascular diseases, such as SLE,
• BLUE SCLERA: Pathognomonic of Osteogenesis
Imperfecta. Results from very thin sclera in which the
choroid shows through.
• BROWN SCLERA: Found in disorder Alkaptonuria
(metabolic disorder)
• YELLOW SCLERA: Found in Jaundice. It should raise
the question of liver disease or hemolytic anemia
• Eyes jutting out past eyelids. A sign of
Grave's disease, acromegaly, and cavernous
sinus thrombosis
SICCA: Found in Sjögren's Syndrome, resulting
from autoantibodies against salivary glands
resulting in no salivary secretion.
• Classic triad of symptoms with Sjögren's
• Keratitis Sicca (dry eyes)
• Xerostomia (dry mouth)
• Rheumatoid Arthritis
of congenital syphilis.
• Hutchinson's Triad:
Triad of interstitial
keratitis, deafness, and
notched teeth is
classical evidence for
congenital syphilis
• ARCUS SENILIS: Gray band of opacity around the
• KAYSER-FLEISCHER RINGS: Copper in Descemet's
• Circular bands of brownish pigment on lateral and medial
margins of cornea.
• Found in Wilson's Disease
• PINGUECULAE: Small, yellowish elevations of the
conjunctivae, which appear brown in Gaucher's disease. It
is caused by hyaline degeneration of conjunctival tissue.
• ANISOCORIA: Unequal pupils, caused by miosis or
mydriasis of one pupil
• MARCUS GUNN PUPIL: A pupil that
dilates (rather than constricts) as light
swings toward it.
• It indicates either severe macular disease or
optic nerve disease in the affected eye.
• Absent Direct Reflex: Indicates a problem
with the afferent branch (Trigeminal V1) of
the reflex.
• Absent Consensual Reflex: Indicates a
problem with the efferent branch (CN III,
Edinger-Westphal Nucleus) of the affected
• CONVERGENCE: Ability of eyes to focus
inward and accommodate for near vision.
• Impaired convergence is seen with Grave's
Indicates a form of CNS Syphilis, Tabes
• Weak or absent direct pupillary reflex.
• Normal response to accommodation.
• Failure of pupillary dilation with painful
stimulation or after atropine
• ADIE'S PUPIL: Similar to Argyll
Robertson Pupil.
• Weak or absent direct pupillary reflex.
• Impaired or absent accommodation.
• Eye appears larger than the other eye on
• MYDRIASIS: Abnormal dilation of pupil,
can occur in Diabetes.
• MIOSIS: Abnormal constriction of pupil,
seen in Horner's syndrome.
sympathetics from the Superior Cervical
Plexus. Ptosis, Miosis, Anhydrosis.
• NYSTAGMUS: Nystagmus is normal when
looking in the periphery for extended times.
All other nystagmus is abnormal.
• Causes: Labyrinthitis, MS, WernickeKorsakoff, Meniere's Disease
• TINNITUS: Ringing in ear.
• Objective Vertigo: The earth is moving
around you.
• Subjective Vertigo: You are moving in
• EPISTAXIS: Bloody nose.
• Transient Epistaxis: May occur with forceful
nose-blowing, sneezing, nose-picking, facial
• Recurrent Epistaxis: Differential diagnosis =
hypertension, coagulopathies, renal failure,
cirrhosis, hereditary hemorrhagic
• RHINOPHYMA: Severe acne rosacea found in
association with skin hypertrophy and congestion
of subcutaneous tissue, around the nose.
• Inspect lips: angle of mouth for color and
• Teeth: Inspect the number condition of the teeth
• Observe the gums for color swelling and
• Inspect the roof of mouth for color architecture
of hard palate
Proceed with the exam by using a wooden tongue blade
and penlight
Parotid gland
• Inspect the pre- and infra-auricular region,
observing for symmetry.
• Palpate the parotid gland
Lacrimal gland
• Have the patient close their eyes and observe the
upper and outer aspect of the upper lid.
• The lid is normally smooth and symmetrical.
• Gently retract the upper lid and have the patient
gaze to the opposite side.
• The lacrimal gland is located under the lid near the
outer angle.
Submandibular gland
• Observe the submandibular region.
• Tilt the patient's head forward and gently
roll your fingers over the inner surface of
the mandible
• SOAR THROAT: Infection
mononucleosis, strep-throat (streptococcal
• HOARSENESS: Larynigitis, Laryngeal
cancer, hypothyroidism, smoking ------>
broncho-genic carcinoma
• Hypoguesia: Impaired ability to taste. Seen in
URI's, glossitis, stomatitis.
• Dysguesia: Unpleasant taste. Differential
• Medications: metronidazole, Vitamin and mineral
deficiencies: zinc depletion ,Chyronic
hypercalcemia, hyperparathyroidism.
• Viral hepatitis
• MACROGLOSSIA: Large tongue can occur with
amyloidosis and acromegaly.
• GLOSSITIS: Inflammation on sides, base, and
underside of tongue.
• Vitamin and mineral deficincies
• Medications: metronidazole, phenytoin
• Infections: candidiasis
• Pernicious Anemia
• Cytotoxic drugs, radiotherapy
Thyroid Gland
Thyroid Gland
• Inspect the neck for fullness over the thyroid
• While standing behind the patient, affix the
trachea on one side, gently tilt the head and roll
the thyroid gland over the tracheal rings.
• Repeat this procedure on the opposite side.
• Ask the patient to swallow water, extend the neck
gently and observe the mobility of the thyroid
gland while swallowing.
• Palpate the thyroid gland while swallowing,
separately examining each lateral lobe and
the isthmus
• Some prefer to examine the thyroid from
the front.
• Evaluate Thyroid gland for consistency,
tenderness, size and approximate weight
• The Thyroid gland is palpable and rises
along with thyroid and cricoid cartilage
during swallowing, in persons with a
slender neck.
• It is soft and approximately weighs no
more than 20 grams.
• It is often not palpable with aging
• Goiter refers to any enlargement of the thyroid gland.
Because of the gland's location at the front of the neck, this
condition becomes visually apparent
• Diffuse goiter refers to a uniformly enlarged thyroid. It is
associated with disease processes (for example,
Hashimoto's and Grave' diseases) and is endemic to areas
in the world where the diet is iodine deficient. In such
areas, goiter can become quite large, appearing as a huge,
bizarre growth hanging down from below the chin. Diffuse
goiter is a consequence of stimulation of the thyroid to
hypertrophy and hyperplasia
• The cause of lumpy or nodular goiter is not
well understood. Nodules raise concerns
about thyroid cancer (see below), and those
that are hot or autonomously functioning
are of concern because they may eventually
cause hyperthyroidism
• Hypothyroidism refers to clinical status when
thyroid hormone concentrations are below the
euthyroid (eu- meaning normal) range. Symptoms
may include goiter (enlarged thyroid), fatigue cold
intolerance, weight gain, constipation, dry skin,
puffy face, depression, and loss of hair. Severe
manifestations may include hypothermia, seizures,
stupor, and coma.
Primary Hypothyroidism
• In primary hypothyroidism, the disorder is at the
site of the thyroid gland itself. Primary
hypothyroidism may be acquired or congenital
• The most common cause of acquired
hypothyroidism is Hashimoto's thyroiditis.
• Other causes of acquired hypothyroidism include
thyroid ablation, antithyroid drugs administration,
and iodine deficiency
Secondary and tertiary hypothyroidism
• Secondary and tertiary hypothyroidism are rare
diseases. In secondary hypothyroidism, a pituitary
lesion impairs production of TSH
• In tertiary hypothyroidism, a lesion in the
hypothalamus causes inadequate production of
TRH. In the absence of adequate TRH stimulation,
pituitary production of TSH is inhibited which, in
turn, inhibits production of thyroid hormones by
the thyroid.
• Hyperthyroidism refers to clinical status in
which thyroid hormone concentrations are
above the euthyroid (eu meaning normal)
range. Symptoms may include goiter,
nervousness and irritability, heat
intolerance, cardiac arrhythmias, tremors,
exophthalmos (bulging eyes), and mental
• The most common cause of
hyperthyroidism is Graves' disease
• Graves' disease afflicts approximately 1
million patients in the United States
• The disease is caused by autoantibodies
directed against TSH receptors on the
surface of thyroid cells
toxic nodular goiter
• In toxic nodular goiter, another
hyperthyroid condition, discrete portions of
the thyroid (nodules), for reasons that are
not well understood, are no longer under
normal feedback control and secrete excess
amounts of thyroid hormone. This condition
occurs more frequently in elderly patients
and, in contrast to Graves' disease, is not
accompanied by ophthalmopathy
Lymph Nodes: Cervical
• For palpation o
fpreauricular nodes,
roll your finger in
front of the ear,
against the maxilla
Sub occipital lymph nodes
• are palpable
immediately behind
the ear.
Posterior cervical
• Posterior cervical nodes are behind
sternomastoid and in front of Trapezius.
Sub maxillaryand Submental
• Roll your fingers
against inner surface
of Mandible with
patient's head gently
tilted towards one side
Deep cervical lymph nodes
• should be palpated,
one side at a time.
Gently bend the
patient's head forward
and roll your fingers
over the deeper
muscles along the
carotid arteries.
Scalene nodes
• roll your fingers gently behind the clavicles.
Instruct the patient to cough or to bear down
like they are having a bowel movement.
Occasionally an enlarged lymph node may
pop up
External Ear
• Inspect and feel the external ears.
• Examine skin over External Ear
• Note the size, color, position of ear lobes,
contour and texture of the cartilage and
soft tissue.
• Note tenderness on movement of ear lobes
• The cartilage is firm in
texture and movable.
Be aware of changes
secondary to ear
piercing effects based
on culture and ethnic
• With eyes closed, the patient should be instructed
to acknowledge hearing the gentle rubbing of the
examiner's fingers approximately 3-4 inches away
from his right and left ear.
• A watch, which the examiner can hear at a specific
distance from his ear, is placed next to the patient's
ear. Ask him to note when the watch sound
disappears. Note that the examiner has to have
normal hearing to do this exam (in at least one
Herpes Zoster