OnExam

Head

  • Position
  • Skull
    • Size
    • Shape
      • Congenital deformity
      • Deformity due to trauma
    • Symmetry
    • Tenderness
  • Hair
    • Quantity
    • Distribution
    • Texture
    • Colour
    • Alopecia
    • Lice/Nits
    • Hirsutism
  • Skin
    • Rashes
    • Lesions
    • Scars
    • Trauma
    • Jaundice
    • Pallor
    • Turgor

Face

  • Asymmetry
  • Masses
    • Parotid swelling
  • Myxedema
  • Congenital abnormalities
  • Characteristic Facies
    • Mask facies (Parkinson’s)
    • Moon facies (Cushing's Syndrome)
    • Flat affect (depression)
    • Ticks
    • Myxedema

Eyes

Note: The basic eye exam is considered here. For further details, see the Ophthalmology Physical Exam and the Nervous Physical Exam

  • Position and Alignment
    • In front of patient survey the eyes for position and alignment. If one or both eyes protrude assess for exopthalmos
  • Structural
    • Eyebrows
      • Inspect hair and skin, noting quality, distribution, underlying skin quality
    • Lids
      • Ptosis
      • Lid lag
        • Having the pt. slowly move from upward to downward gaze, the examiner should observe if the eyelid lags behind the globe on downward gaze
      • Cellulitis
      • Myxedema
      • Periorbital edema
      • Nephritic edema
      • Lacrimal swelling
      • Excess tearing or dryness
      • Upper lid retraction
        • Most common sign of thyroid-associated orbitopathy
        • Note presence of proptosis, optic nerve involvement or restriction of extraocular muscles
        • Mechanisms for upper lid retraction include: proptosis, sympathetic hyperactivity of Muller muscle during hyperthyroidism; upgaze restriction; fibrosis of levator muscle and contralateral ptosis
      • Entropion/ectropion
    • Conjunctiva and sclera: injection, foreign body
      • Have patient look upwards and downwards as you displace the opposing lid in the opposing direction. I.e. look up and physician displaces lower lid downwards
    • Iris for coloboma
    • Cornea for ulcers, abrasions
    • Pupils
      • Size and symmetry of pupils
        • Decreases with age: 7 mm at 10 yrs, 6 mm at 30, and 4 mm at 80 yrs
        • Simple/benign anisocoria:pupillary inequality of < 0.5 mm present in 20% of population
      • Pupils reactive to light and accomodation
    • Red reflex
    • Symmetrical corneal light reflection (assessment of conjugate gaze)
    • Lens for opacity, cataracts
  • Visual Acuity: Use Snellen eye chart for each eye (see cranial nerve test in nervous system section)
  • Visual field testing through confrontation (see cranial nerve test in nervous system section)
    1. Examiner’s head positioned directly in front of patient
    2. Patient covers one eye and gazes into examiner’s opposite eye with uncovered eye
    3. Examiner tests four quadrants by getting patient to state number of fingers held up halfway between patient and examiner
    4. Repeat for other eye
  • Extraocular movements (see cranial nerve test in nervous system section)
    • Positional nystagmus in predicting BPPV: sensitivity: 78%, specificity: 50%
  • Ptosis
  • Lid lag
  • Fundoscopic examination with ophthalmoscope
    • Optic disc
      • Colour
      • Contour and sharpness of disc edges
      • Disc to cup ratio
      • Papilledema (increased intracranial pressure)
    • Vasculature
      • Colour
      • Size
      • Light reflex
      • Venous pulsations
      • Arteriovenous malformations
    • Fovea and surrounding macula (dry atrophic vs. wet exudative, drusen)
    • Retina
      • Colour
      • Cotton wool spots
      • Tears
      • Microhemorrhages

Ears

  • Inspection
    • Pinnae
    • Scars
      • Trauma ("Cauliflower ear" from subchondral hematoma)
    • Inflammation
    • Lesions
      • Herpes Zoster lesion accompanied by facial nerve neuropathy in Ramsay Hunt syndrome
      • Skin tumors (squamous cell carcinoma, basal cell carcinoma)
    • Otorrhea: color, consistency, clarity, odour
    • Tenderness
    • Congenital abnormalities: pre-auricular sinus, aural atresia
  • Palpation
    • "Tug Test": the auricle and tragus are tender on palpation and with movement in acute otitis externa
    • Tenderness on palpation of the mastoid process may be present in acute otitis media
  • Otoscopy
    • Use of otoscope:
      1. Gently elevate pinna upwards and backwards for adults, downwards and backwards for children to straighten external auditory meatus
      2. Use largest speculum that can be easily inserted into canal
      3. Hold otoscope as you would a pen, bracing extended pinky finger on patient’s temple for stability
      4. Gently insert otoscope into meatus while looking through instrument
      5. Impaired view usually due to wrong size speculum or incorrect angulation
      6. Mobility of drum can be assessed via pneumatic otoscopy if available
    • External auditory canal
      • Cerumen: occlusion/impaction
      • Otorrhea: mastoid cavity, otitis externa
      • Cholesteatoma
      • Keratosis obturans
      • Foreign body
      • Inflammation
      • Exostoses (surfer’s ear)
    • Tympanic membrane (TM)
      • Landmarks
        • Pars tensa posteroinferiorly
        • Pars flaccida anterosuperiorly
        • Cone of light anteroinferiorly
        • Malleus: umbo (center), long process (extending superiorly), lateral process (anterosuperior)
        • Incus: long process (extending posterosuperiorly)
        • Light reflex in anteroinferior quadrant
      • Bulging (97.1% probability of otitis media)
      • Injected (if distinctly red, 84.8% probability of otitis media)
      • Fluid-line, bubbles (serous otitis)
      • Retraction (70% probability of otitis media)
  • Hearing
    • Auditory acuity (see cranial nerve test in nervous system section)
    • Whispered voice test
      • Normal test virtually excludes significant hearing loss
      • Abnormal whispered voice test 90-99% sensitive and 80-87% specific for significant hearing loss
    • Rinne Test
    • Weber Test

Nose

  • External
    • Skin
    • Trauma
    • Inspect and palpate nasal bones and cartilages for asymmetry and abnormalities
  • Nasal Cavity
    • Tilt head back and apply light pressure to the tip of the nose to open the nostrils; use Thudichum nasal speculum if available; hold handle parallel to floor to open nasal vestibule anteroposteriorly
    • Patency of choanae, Cottle’s Test of Nasal Patency
    • Polyps or lesions
    • Turbinate: colour, size and signs of inflammation (frequently asymmetrical on exam)
    • Rhinorrhea
    • Septum: deviation, perforation, trauma, Kiesselbach’s plexus (Little's area) for blood vessel engorgement or signs of recent epistaxis
  • Sinuses
    • Temperature (acute sinusitis: sensitivity: 16%; specificity: 83%)
    • Tenderness to palpation (acute sinusitis: sensitivity: 48%; specificity: 65%)
    • Transillumination (acute sinusitis: sensitivity: 73%; specificity: 54%)
  • Sinusitis
    • Symptoms most sensitive for detecting sinusitis: nasal discharge (72%), cough (70%), sneezing (70%). These symptoms are not highly specific

Oropharynx

  • Assess for strep throat with the Strep Throat Score
  • Inspect

  • Lips
    • Observe color, noting any lumps, ulcers, cracks or changes
  • Oral Mucosa
    • Color
    • Ulcers
    • White patches
    • Nodules
    • Look specifically for herpetic lesions, apthous ulcers, angular stomatitis, thrush and oral lichen planus
  • Gums and Teeth
    • Examine gingival margins and interdental papillae for inflammation or retraction
    • Inspect for missing, discolored, misshapen or abnormally positioned teeth
  • Roof of Mouth
    • Inspect for color and architecture of hard palate
    • Torus palatinus: a benign midline bony protursion of the hard palate
  • Tongue
    • Symmetry and midline protrusion
    • Atrophy and fasiculation (brainstem or hypoglossal nerve lesion)
    • Erythroplakia or leukoplakia (Tongue cancer)
    • Unilateral hypoglossal nerve weakness causes a deviation of the tongue in the ipsilateral direction
  • Pharynx
    • Inspect for equal palatal elevation
    • Uvular position (deviation in peritonsillar abcess, CN X paralysis)
    • Inspect soft palate, anterior and posterior pillars, tonsils and pharynx
      • Look for inflammation, swelling, exudate, ulceration, or tonsillar enlargement
  • Tonsils
    • Hypertrophy
    • Exudates or crypts
    • Erythmea
    • Abscesses
    • Uvular position (deviated by peritonsillar abcess or CN X paralysis)
    • Swelling
  • Structural abnormalities
    • Cleft palate
    • Torus palatinus (benign)

    Palpate

  • Tongue and Floor of Mouth
    • Ask patient to protrude tongue, inspecting for symmetry, deviation, fasiculations
    • Inspect for glossitis seen in B12 deficiency
    • Note: 30% of patients with oral carcinoma are asymptomatic. Carcinoma occurs most commonly on one side of the tongue or at its base
  • Salivary glands
    • Palpate the sublingual, submandibular and/or the parotid glands if signs of inflammation for heat, tenderness and/or swelling
  • Temperomandibular joints
  • Motor Examination

  • Gag Reflex (CN IV/V)
  • Equal palatal elevation (CN V)
  • Central tongue protursion (CN XII)

Vasculature

  • Examine the jugular venous pressure.
  • Palpate for carotid (rate, rhythm and amplitude)
  • Auscultate carotid for bruits

Neck

  • Inspection
    • Symmetry of muscles
    • Scarring
    • Tracheal position
    • Masses/Swelling
    • Webbing and skin folds
    • Identify landmarks for major vessels
      • Distention of the jugular vein
  • Range of motion of cervical spine (with c-spine cleared)
    • Anterior and posterior flexion
    • Rotation
    • Lateral flexion
  • Meningeal irritation
    • Nuchal rigidity: neck stiffness (sensitivity 90%, specificity 80%)
    • Brudzinski’s sign: flex patient’s neck; patient involuntarily flexes hips and knee (60% sensitivity)
    • Kernig’s sign: flex patient’s hip and knee to 90°, painful with subsequent extension of knee (60% sensitivity)
  • Thyroid
    • Inspection (from front): use tangential lighting
      • Have the patient tilt their head back
      • Locate the thyroid just below the cricoid cartilage
      • Ask patient to swallow and observe thyroid movement noting contour and symmetry
      • Midline lump (goiter), scars, raised JVP indicating obstruction from mass effect
      • Ask patient to speak and cough
        • Hoarseness and weeak cough in vocal cold palsy due to infiltration of the recurrent laryngeal nerve
    • Palpation (from behind)
      • Palpate thyroid and cricoid cartilages and the cricothyroid membrane
      • Swallow test: ask patient to sip and swallow water
        • Palpate both lobes of the thyroid
        • Normal thyroid is non-palpable
        • Enlarged thyroid may rise under your fingers
        • Size, tenderness, mobility, consistency of thyroid
        • If palpable mass, ascertain if solitary or multiple nodules, localize to either lobe or isthmus
      • Thyroglossal duct cyst: suspected if a palpable central mass rises with tongue protrusion
    • Auscultation for systolic bruit

Lymph Nodes

  • Ask patient to drop chin slightly to relax anterior neck muscles
  • Use the pads of three fingers to palpate
  • Note:
    • Size
    • Shape
    • Delimitation
    • Consistency
    • Mobility
    • Tenderness
  • “Up-and-down” palpation technique
    • Palpate along jaw from chin to ears
      • Submental node
      • Submandibular nodes
      • Parotid gland
      • Pre-auricular nodes
      • Post-auricular nodes
    • Palpate down anterior border of sternocleidomastoid muscles (SCM) beginning at mandibular angle
      • Anterior triangular nodes
      • Tonsillar nodes
    • Palpate laterally above and beneath the clavicle
      • Supraclavicular nodes
      • Infraclavicular nodes
    • Palpate the posterior border of SCMs
      • Posterior triangular nodes
    • Palpate base of the skull posteriorly
      • Occipital nodes
  • Special Note:
    • Consistency of palpated nodes
      • Soft, insignificant
      • Rubbery, may be indicative of lymphoma
      • Hard, may be malignant and/or granulomatous infection
    • Supraclavicular Nodal Abnormalities
      • These nodes are localized close to where major lymphatics empty into the systemic venous circulation. Therefore, they're flow consists of lymph drained from many of the bodies significant organ systems
      • Lymphadenopathy of the supraclavicular lymph nodes may be indicative of deeper more insidious illness
        • Of patient's undergoing supraclavicular lymph node biopsies, 46-69% have malignant disease, largely metatstatic carcinomas

References

  1. Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
  2. Ramachandran M, Gladman MA. Clinical Cases and OSCEs in Surgery. 2nd ed. Edinburgh. Churchill Livingstone Elsevier.
  3. McGee S. Evidence based physical diagnosis, 3rd ed. Philadelphia, PA: Elsevier; 2012.
  4. Acute Otitis Media Suspected. Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated August 1, 2006. Accessed March 6, 2011.
  5. Warner G, Thirlwall A, Patel S, Martinez-Devesa P, Corbridge R. Otolaryngology and head and neck surgery. Oxford: Oxford University Press; 2009. 354.
  6. Sutter AD, Hickner J. Sinusitis (adult, acute). Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated November 13, 2010. Accessed February 24, 2011.
  7. Thomas, K. E., Hasbun, R., Jekel, J., & Quagliarello, V.J. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clinical Infectious Diseases, 2002 (35):46-52.
  8. Seidel HM, Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Mosby’s Guide to Physical Examination, 7th ed. St. Louis, MO: Mosby Elsevier; 2011:238-262
  9. Hall J et al, ed. Essentials of Clinical Examination Handbook 7th ed. New York, NY: TMSP, Thieme; 2013.
  10. Standford 25: An initiative to revive the culture of bedside medicine. Standford School of Medicine.
  11. William J. & Simel D. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. 1993; 270(10): 1242-1246.