Examination of the head, neck, bones and muscles
Examination of the head may be important primarily due to the presence of changes in the sense organs. It is possible to change the shape of the head (usually congenital) in the form of microcephaly and macrocephaly. With various diseases, there is a trembling of the head, for example, in parkinsonism, in the elderly. Attention is paid to the mobility of the cervical spine, which can be limited due to inflammatory changes in intervertebral connections, but more often due to osteochondrosis.
Face inspection
Face, facial expression, as already mentioned, often reflect the state of mind of a person, various pain sensations. A painful facial expression is possible in patients with severe pain that is difficult to bear. The face of Hippocrates is gray, with streaked features, sunken eyes, drops of cold sweat on the forehead - observed in patients with a so-called "acute abdomen" (for example, peritonitis, primarily associated with perforation of the stomach ulcer). Significantly changing the face with various endocrine diseases ( Cushing's syndrome, myxedema, acromegaly ), kidney diseases (typical puffiness, especially the eyelids, against the background of pale skin coloration). A peculiar face in patients with dermatomyositis (parorbital edema with hyperemia), scleroderma (a characteristic mask-like face described by IS Turgenev in "Notes of a Hunter"), systemic lupus erythematosus (a symptom of a "butterfly").
Peculiar changes in the face, especially the eyes, are noted in thyrotoxicosis ( exophthalmos, or glaucoma, shifting the eyeball forward). The identification of some eye signs is of diagnostic significance. For example, the dilatation of the pupils (mydriasis) is observed with atropine poisoning, the unevenness of the pupil diameters ( anisocoria ) - with the defeat of the central nervous system, the lower eyelid (ptosis) - in case of impaired muscle function lifting the eyelid. In the region of the eyelids, the appearance of yellowish, slightly elevated spots - xanthom.
It is important to assess the condition of the cornea and conjunctiva, identify signs of severe dryness, sensation of sand in the eyes (xerophthalmia), which is often combined with a violation of the formation of tears and other signs of "dry syndrome" ( Sjogren's syndrome ). In a routine examination of the conjunctiva, one can detect her pallor (pronounced anemia), the presence of a network of capillaries (alcohol abuse), pinpoint hemorrhages (Osler-Lukin spots with subacute infective endocarditis ), granulomatous eruptions ( sarcoidosis ), etc.
Of great importance is a special ophthalmological study necessary to identify a number of important diagnostic features, such as cataracts in diabetes mellitus, uveitis and iridocyclitis in some cases of severe rheumatoid arthritis, the Kaiser-Fleischer ring in hepatocerebral dystrophy ( Wilson-Konovalov's disease ), and various changes in the fundus (retina) - foci of hemorrhages, dystrophy, the state of the optic nerve disk ( edema and indistinctness of the borders of the latter - very characteristic a sign of malignant hypertension ), blood vessels (the degree of spasm of arteries and veins).
Old masters of painting often depicted in their paintings people with those or other deviations in appearance, reflecting congenital or acquired pathology. Despite the heavy damage to the joints, the great master continued to paint successfully until the end of his life, using a brush that was tied by relatives to the artist's hand.
Examination of lips and oral cavity
It allows to reveal a special "bubble" rash on them (herpes labialis). Bubbles the size of a pinhead, often with transparent contents, can also appear at the base of the nose, occasionally on the forehead. Herpetic rash is typical for viral damage, often associated with serious diseases (it is typical of its occurrence in croupous pneumonia, and patients with kidney disease are very prone to herpetic complications).
When examining the oral cavity, it is possible to detect changes in the teeth, their absence, and widespread caries. The tendency to defeat gums and loosening of the teeth are sometimes observed in diabetes mellitus. With further examination, you can note the increased dryness of the mucous membrane ("dry syndrome"), the presence of ulcers ( aphthous stomatitis in fungal infection, beriberi), various rashes (acute infectious diseases). The type of tongue, overlaid, smoothed pattern are important for diagnosis of diseases of the gastrointestinal tract, blood. A significant increase in the tongue (macroglossia) is observed in amyloidosis and may hamper chewing and swallowing, although the latter is most often altered in connection with the damage to the muscles of the pharynx and the upper part of the esophagus (dermatomyositis, scleroderma).
The size of the tonsils, their appearance, the presence of purulent plugs make it possible to draw a conclusion about chronic tonsillitis, a possible exacerbation of focal infection in this area.
Survey of ears, nose and neck
A very accessible examination of the ear buds, whose skin can be cyanotic ( cyanosis with severe congestive heart failure), it is also possible to detect whitish, thin-skinned nodules - tofusi - peculiar masses of melodious consistence consisting of amorphous salts of uric acid, which is a reliable sign of gout.
When examining the nose, attention is drawn to its deformity, including as a result of extensive necrotic processes - in the past with syphilis, now more often with necrotic vasculitis of Wegener, the presence and nature of secretions (sugars with an unpleasant odor in mucosal necrosis, for example, in Wegener's granulomatosis , tumors). Like on the lips, on the wings of the nose may appear herpetic eruptions.
When examining and probing the neck, you can first find an increase in the thyroid gland and lymph nodes. Palpation is determined by their consistency and soreness. In addition, the examination of the neck can reveal full-blown swollen veins (difficult flow of blood to the right atrium with pericarditis ), increased pulsation of the carotid arteries (synchronous with the work of the heart), as well as pulsation of the veins, which is important for assessing the function of the cardiovascular system.
Sometimes, similar to the pulse on the radial arteries, the pulse is determined on the carotid arteries, which, in particular, is used in resuscitation.
Research of bones, muscles and joints
When examining the extremities, changes in the skin, joints, muscles, violation of proportionality in relation to the trunk, deformation, as observed in acromegalia, Marfan syndrome and other, mainly hereditary diseases, can be noted . An increased tendency of bones to spontaneous fractures is found in disorders of calcium metabolism as a result of tumors, with multiple myeloma.
Inspection and palpation of joints is advisable to carry out in a certain sequence, starting with the symmetrical joints of the upper extremities, then the lower extremities, after which the joints of the head, neck, trunk are examined.
The changes of each joint should be described with the indication of the general appearance (the presence of swelling, deformation, defoguration), the presence of hyperemia and hyperthermia of the skin over it, rashes (including nodular character), tenderness in palpation and movements, and movements.
With certain types of arthritis, certain joints are usually affected: thus, with gout, the most frequent and typical is acute inflammation of the joints of the big toe.
Swelling of the joints is manifested due to inflammatory edema in the synovial membrane and soft tissues surrounding the joint, sometimes due to effusion in the joint cavity. In the chronic course of arthritis, gross changes in the synovial membrane and periarticular tissues lead to changes in the shape of the joint (to the so-called joint defogation). Swelling in the joint area can be explained by the defeat of soft periarticular tissues ( periarthritis, bursitis ) without involving the structures of the joint itself.
Under the deformation of the joint, unlike the defoguration, we mean a stable change in its shape due to bony growths, destruction of the articular ends of bones, the development of ankylosis, for example, the nodes of Geberden (isolated lesion of distal interphalangeal joints, pronounced deformities of the wrist in rheumatoid arthritis).
Hyperthermia of the skin over the affected joints accompanies an acute inflammatory process. Along with hyperthermia, there is often a hyperemia of the skin over the affected joint. The bright red coloring of the skin during arthritis of the big toes in patients with gout, which is common with clear contours, can cause erroneous diagnosis of erysipelas or phlegmon of subcutaneous fat: red and crimson, practically painless swelling of the joints of the fingers is characteristic of psoriatic arthritis, hyperpigmentation of the skin over the affected joints appears in the unfavorable course of rheumatoid arthritis.
If we have in mind the musculoskeletal system as a whole, then, in addition to these phenomena, we should mention the signs of a convulsive syndrome : rigidity of the occipital muscles (Kernig symptom), tonic and clonic convulsions in the skeletal muscle region, various hyperkinesis and other signs, mainly in detail considered in the course of neurology, although the cause of their occurrence may be various violations of homeostasis (primarily electrolyte, as well as endogenous intoxications) in diseases of the kidneys, liver, hypoxia. Separately, one should pay attention to pain in the spine, which can be a manifestation of osteoporosis, metastases, tumors, and inflammatory process (for example, pain in the lower parts with Bekhterev's disease ). Especially it is necessary to note fingers in the form of so-called drumsticks, which can be found on both hands and feet. It is possible to whiten fingers with a feeling of numbness due to vasospasm, which is observed with Raynaud's disease.
On the shins, varicose veins are often found , which can be complicated by the formation of ulcers. Swelling is most often found on the legs. Palpation reveals not only soreness in various areas, but also features of pulsation of large (main) vessels: asymmetry and absence of it on one of the arteries (for example, a dorsalis pedis in atherosclerotic occlusion), nodular thickening (a sign of severe vasculitis - nodular periarteritis ). Pay attention to the strength and development of the muscular system. When you feel the muscles, sometimes they find their soreness. It is also important to evaluate the strength of muscles, especially in symmetrical areas. To assess the strength of the muscles it is useful to ask the patient to sit down: difficulty in getting up, as with climbing the stairs, is very characteristic for dermatomyositis. Various disorders of sensitivity, accompanied by pain, as well as muscle strengths occur in the defeat of the peripheral and central nervous system, which is revealed with the help of special techniques. On the palms, there is sometimes a bright red erythema in the area of the elevations of the aching finger and little finger that occurs in chronic liver diseases, systemic vasculitis.
Specifically, attention should be paid to the importance of identifying, even with a general examination, a number of characteristics that are traditionally considered as markers of alcohol abuse. They include a peculiar purple-bluish complexion, especially the nose, injected sclera, a significant increase in parotid salivary glands (giant parotitis ), excessive body weight or, on the contrary, its significant deficiency, Dupuytren's contracture (consolidation of palmar aponeurosis with restriction of extension of fingers), a profuse vascular capillary pattern of the upper body skin. Since the alcohol etiology of a number of internal diseases is very real (chronic hepatitis and cirrhosis, chronic pancreatitis with a syndrome of impaired absorption, chronic glomerulonephritis, myocardial damage with arrhythmias and congestive heart failure, etc.), the detection of these signs of alcohol abuse is important for a more complete understanding illness and treatment prospects.