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Ростовский Государственный Медицинский Университет

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CHAPTER 5 General examination physical signs

Neck stiffness

Distinguish between limited range of neck movement and neck stiffness

throughout range of movement.

- Limited neck range of movement

Some differential diagnoses and typical outline evidence

Chronic

cervical

spondylitis with

osteophytes

Suggested by: no fever or associated symptoms

Confirmed by: limitation in range of neck movement but

no stiffness within free range of movement. Normal

WBC, no fever, no neurological signs, X-ray appearance

of neck

- Neck stiffness throughout range of movement

Bacterial

meningitis

Suggested by: gradual headache over days, photophobia,

vomiting. Fever, high neutrophil count. Petechial rash in

meningococcal meningitis

Confirmed by: lumbar puncture: turbid cerebrospinal

fluid (CSF). iCSF neutrophil count with d glucose.

Bacteria on microscopy. Growth of bacteria on culture

of CSF

Viral meningitis Suggested by: gradual headache over days. Fever, high

lymphocyte count, normal neutrophil count

Confirmed by: lumbar puncture: clear CSF. iCSF

lymphocyte count with normal glucose. No bacteria

on microscopy. No growth of bacteria on CSF culture

Meningismus

due to viral

infection

Suggested by: gradual headache over days. Fever, high

lymphocyte count, normal neutrophil count

Confirmed by: lumbar puncture: clear CSF. Normal CSF

white cell count. No bacteria on microscopy. No growth

of bacteria on CSF culture

Subarachnoid

hemorrhage

Suggested by: sudden onset of headache over seconds.

Variable degree of consciousness. No fever. Normal

white cell count

Confirmed by: CT or magnetic resonance imaging (MRI)

brain scan. Lumbar puncture: blood-stained CSF that

does not clear in successive bottle collection, or

presence of xanthochromia in CSF (12 hours to

2 weeks after hemorrhage)

NECK STIFFNESS1

Acute cervical

spondylitis

Suggested by: gradual neck pain (occasionally a

headache) over hours or days. Immobile neck.

Usually past history of similar episodes. No fever

Confirmed by: above history

Posterior fossa

tumor

Suggested by: headache, papilledema

Confirmed by: CT or MRI scan appearances

Anxiety with

semi-voluntary

resistance

Suggested by: improvement with reassurance or

temporary distraction

Confirmed by: resolution after rest and observation

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

CHAPTER 5 General examination physical signs

Hair loss in a specific area

Examine overall and then gently part hair to examine the scalp. Use a

magnifying glass if hair is abnormal.

Some differential diagnoses and typical outline evidence

Alopecia areata Suggested by: well-circumscribed loss with

exclamation-mark hairs

Confirmed by: above clinical appearance

Alopecia totalis Suggested by: total hair loss on head and body

Confirmed by: above clinical appearance

Polycystic

ovary

syndrome

Suggested by: bitemporal recession and occipital thin-

ning. Hirsutism on trunk. Onset near puberty. Obesity

Confirmed by: i testosterone and dSHBG (sex

hormone-binding globulin). iLH (luteinizing hormone)

ovarian ultrasound

Testosterone-

secreting

ovarian tumor

Suggested by: bitemporal recession and occipital

thinning. Rapid onset over months

Confirmed by: ii testosterone and dLH

, ovarian

ultrasound scan and laparoscopy

DIFFUSE HAIR LOSS1

Diffuse hair loss

Examine trunk, pubic, and limb hair too.

Some differential diagnoses and typical outline evidence

Cytotoxic

drugs

Suggested by: mainly head hair loss. History of recent

cytotoxic drugs

Confirmed by: improvement after stopping cytotoxic

drug

Iron deficiency Suggested by: mainly head hair loss. Koilonychia, pallor

of conjunctive

Confirmed by: dHb, dMCV (mean corpuscular volume),

dMCHC (mean corpuscular hemoglobin concentration),

d ferritin

Severe illness Suggested by: mainly head hair loss. History of recent

severe illness

Confirmed by: improvement with restoration of health

Hypogonadism Suggested by: loss of hair from axilla, pubic area

Confirmed by: testosterone d or estrogen d with FSH i

and iLH in primary gonadal failure; dLH or normal,

dFSH or normal in secondary hypogonadism

Recent

pregnancy

Suggested by: mainly head hair loss. Recent pregnancy

Confirmed by: improvement after delivery

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

CHAPTER 5 General examination physical signs

External ear abnormalities

Inspect the pinna for scars and other abnormalities. Examine the auditory

meatus by first pulling the pinna up and back to straighten the cartilagi-

nous bend. (In infants, the pinna is pulled back and down.) Swab any

discharge, and remove any wax.

Some differential diagnoses and typical outline evidence

Congenital

anomalies

Suggested by: accessory tags, auricles and preauricular

pit, sinus, or fistula and atresia

Confirmed by: above clinical appearances

Infected

preauricular

sinus

Suggested by: looking like infected sebaceous cyst

Confirmed by: deep tract that lies close to the facial

nerve

Chondroderma-

titis nodularis

chronica helicis

Suggested by: painful nodular lesions on the upper

margin of the pinna in men

Confirmed by: excision of skin and underlying cartilage

Pinna

hematoma

resulting in a

“cauliflower” ear

Suggested by: history of blunt trauma

Confirmed by: appearance of bleeding in the

subperichondrial plane that elevates the perichondrium

to form a hematoma

Exostosis

(localized bony

hypertrophy)

may cause

build-up of

wax or debris

or conductive

deafness

Confirmed by: smooth, often multiple (bilateral)

swellings of the bony ear canals

Wax

(cerumen) may

cause conductive

deafness if it

impacts

Suggested by: dark brown, shiny, soft mass

Confirmed by: improvement in hearing after removal

Foreign bodies

in the ear

Suggested by: visible foreign body and inflammation

(in child or learning-disabled patient)

Confirmed by: retrieval of foreign body

PAINFUL EAR1

Painful ear

Consider referred pain from the neck (C3, C4, and C5), throat, and teeth

and examine these as well. Insert the largest comfortable aural speculum

gently.

Some differential diagnoses and typical outline evidence

Otitis externa

(swimmer’s ear)

due to eczema,

psoriasis, trauma,

Pseudomonas,

fungal infection

Suggested by: pain, discharge, and tragal tenderness

Confirmed by: acute inflammation of the skin of the

meatus, culture of swab

Malignant

necrotizing

otitis externa

Suggested by: pain, discharge, and tragal tenderness in a

diabetic, elderly, or immunosuppressed person, facial

palsy

Confirmed by: X-ray showing local bone erosion,

nuclear bone scan, and tagged white cell scan

Furunculosis

(staphylococcal

abscess in hair

follicle) often

diabetic

Suggested by: acutely painful throbbing ear

Confirmed by: appearance of a boil in the meatus

Bullous

myringitis

(associated with

influenza

infection or

Mycoplasma

pneumoniae)

Suggested by: extremely painful hemorrhagic blisters

on the drum and deep meatal skin, and fluid behind

the drum

Confirmed by: above clinical appearance

Barotrauma

(aerotitis)

Suggested by: history of ear pain during descent in an

aircraft or in diving

Confirmed by: relief by decompression (e.g., holding

nose and swallowing)

Temporo-

mandibular

joint

dysfunction

Suggested by: earache, facial pain, and joint clicking or

popping related to malocclusion, teeth-grinding or joint

derangement, and stress

Confirmed by: tenderness exacerbated by lateral

movement of the open jaw, or trigger points in the

pterygoids

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

CHAPTER 5 General examination physical signs

Ear discharge

Examine the eardrum quadrants in turn. Note color, translucency, and

any bulging or retraction of the membrane. Note size, position, and site

(marginal or central) of any perforations. Drum movement during a

Valsalva maneuver also depends on a patient’s Eustachian tube.

Some differential diagnoses and typical outline evidence

Acute otitis

media

(due to

pneumococcus,

hemophilus,

streptococcus,

and staphylo-

coccus,

occasionally

complicated by

mastoiditis)

Suggested by: rapid onset over hours of pain and fever,

irritability, anorexia, or vomiting after viral upper respi-

ratory tract infection

Confirmed by: bulging red drum or profuse purulent

discharge for 48 hours after drum perforates

Otitis media

with effusion

(serous, secre-

tory, or glue ear)

usually in young

children

Suggested by: gradual onset over weeks or months of

deafness and intermittent ear pain

Confirmed by: loss of drum’s light reflex or retraction

relieved by grommets

Chronic

suppurative

otitis media

(may be

associated with

cholesteatoma,

petrositis,

labyrinthitis;

facial palsy;

meningitis;

intracranial

abscess)

Suggested by: purulent discharge, hearing loss, but no

pain

Confirmed by: central drum perforation

Cholesteatoma

(locally destruc-

tive stratified

squamous

epithelium)

Suggested by: foul discharge, deafness, headache, ear

pain, facial paralysis, and vertigo

Confirmed by: continuing mucopurulent discharge,

pearly white soft matter (keratin) in attic or posterior

marginal perforation

EAR DISCHARGE1

Chronic otitis

externa

Suggested by: watery discharge, itching

Confirmed by: erythema and weeping of meatus

Auditory canal

trauma

Suggested by: bloody discharge

Confirmed by: history of trauma, laceration, and

erythema

CSF otorrhea Suggested by: history of head or facial trauma or

surgery

Confirmed by: halo sign on filter paper

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

CHAPTER 5 General examination physical signs

Striking facial appearance

This is best recognized when meeting the patient for the first time, but

there is a wide normal variation.

Some differential diagnoses and typical outline evidence

Parkinson’s

disease

Suggested by: mask-like (akinetic) face ± hand or

head tremor

Confirmed by: response to dopaminergic drugs

Chorea

(Huntington’s

chorea or drug

effect)

Suggested by: choreiform—jerky, purposeless

facial movement or athetosis (writhing facial

movement)

Confirmed by: Family history, or response to withdrawal

of drug or dose reduction (if due to drug effect)

Bilateral upper

motor neuron

lesion

(due to

amyotrophic

lateral sclerosis,

cerebrovascular

disease, myas-

thenia gravis)

Suggested by: paucity of movement of face

Confirmed by: other features of cause and MRI or

CT scan

Thyrotoxicosis Suggested by: anxious looking with lid retraction and lag

Confirmed by: dTSH and iT3 or iT4

or both

Hypothyroidism Suggested by: puffy face, obesity, cold intolerance,

tiredness, constipation, bradycardia

Confirmed by: iTSH, dFT4

Acromegaly Suggested by: large, wide face, embossed forehead,

jutting jaw (prognathism), widely spaced teeth and

large tongue

Confirmed by: insulin-like growth factor (IGF) i. Failure

to suppress growth hormone (GH) to <2 mU/L with

oral GTT. Skull X-ray confirms bony abnormalities.

Hand X-ray shows typical tufts on terminal phalanges.

MRI or CT scan showing enlarged pituitary fossa

STRIKING FACIAL APPEARANCE1

Cushing’s

syndrome

pituitary-driven

Cushing’s

disease, or

autonomous

adrenal

Cushing’s, or

glucocorticoid

therapy

Suggested by: round, florid face (and trunk with purple

striae) with thin arms, legs, and hirsutism. Inability to

rise from squatting position (due to proximal

myopathy)

Confirmed by: midnight cortisol i and/or failure

to suppress on dexamethasone, or drug history of

glucocorticoids

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

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