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Examination of the head, neck, bones and muscles
Last reviewed: 05.07.2025
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Examination of the head may be important primarily due to changes in the sense organs. Changes in the shape of the head (usually congenital) in the form of microcephaly and macrocephaly are possible. Head tremors are observed in various diseases, for example, in Parkinsonism, in the elderly. Attention is paid to the mobility of the cervical spine, which may be limited due to inflammatory changes in the intervertebral joints, but more often due to osteochondrosis.
Facial examination
The face and facial expression, as already mentioned, often reflect a person's mental state and various painful sensations. A suffering facial expression is possible in patients with severe, unbearable pain. The Hippocratic face - gray, with sharpened features, sunken eyes, drops of cold sweat on the forehead - is observed in patients with the so-called "acute abdomen" (for example, peritonitis, primarily associated with perforation of a gastric ulcer). The face changes significantly in various endocrine diseases ( Cushing's syndrome, myxedema, acromegaly ), kidney diseases (typical swelling, especially of the eyelids, against the background of pale skin color). A peculiar face is seen in patients with dermatomyositis (periorbital edema with hyperemia), scleroderma (the characteristic mask-like face is described by I.S. Turgenev in "Notes of a Hunter"), systemic lupus erythematosus (the "butterfly" symptom).
Peculiar changes in the face, especially the eyes, are observed in thyrotoxicosis ( exophthalmos, or exophthalmos; forward displacement of the eyeball). The detection of certain eye signs is of diagnostic value. For example, dilation of the pupils (mydriasis) is observed in atropine poisoning, uneven pupil diameters ( anisocoria ) - in damage to the central nervous system, drooping of the upper eyelid (ptosis) - in dysfunction of the muscle that lifts the eyelid. In the eyelid area, yellowish, slightly elevated spots - xanthomas - may appear.
It is important to assess the condition of the cornea and conjunctiva, to identify signs of severe dryness, a feeling of sand in the eyes (xerophthalmia), which is often combined with a violation of the process of tear formation and other signs of "dry syndrome" ( Sjogren's syndrome ). During a routine examination of the conjunctiva, one can detect its pallor (severe anemia), the presence of a network of capillaries (alcohol abuse), punctate hemorrhages (Osler-Lukin spots in subacute infective endocarditis ), granulomatous rashes ( sarcoidosis ), etc.
Of great importance is a special ophthalmological examination, necessary for the detection of a number of important diagnostic signs, such as cataract of the lens in diabetes mellitus, uveitis and iridocyclitis in some variants of severe rheumatoid arthritis, Kayser-Fleischer ring in hepatocerebral dystrophy ( Wilson-Konovalov disease ), as well as various changes in the fundus (retina) - foci of hemorrhage, dystrophy, the state of the optic nerve disc ( edema and blurring of the boundaries of the latter - a very characteristic sign of malignant arterial hypertension ), blood vessels (the degree of spasm of the arteries and varicose veins).
Old masters of painting often depicted people with one or another deviation in appearance, reflecting congenital or acquired pathology. Despite severe damage to the joints, the great master continued to successfully paint until the end of his life, using a brush that was tied to the artist's hand by relatives.
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Examination of the lips and oral cavity
Allows to identify a special "blister" rash on them (herpes labialis). Blisters 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 characteristic of a viral lesion, often accompanying serious diseases (its occurrence is quite typical with lobar pneumonia; patients with kidney disease are very prone to herpetic complications).
When examining the oral cavity, one can detect changes in the teeth, their absence, widespread caries. Tendency to gum disease and loosening of teeth are sometimes observed in diabetes mellitus. Upon further examination, one can note increased dryness of the mucous membrane ("dry syndrome"), the presence of ulcers ( aphthous stomatitis with fungal infection, vitamin deficiency), various rashes (acute infectious diseases). The appearance of the tongue, its coating, and smoothness of the pattern are important for diagnosing diseases of the gastrointestinal tract and blood. A significant increase in the tongue (macroglossia) is observed in amyloidosis and can make chewing and swallowing difficult, although the latter is more often changed due to damage to the muscles of the pharynx and the upper part of the esophagus (dermatomyositis, scleroderma).
The size of the tonsils, their appearance, and the presence of purulent plugs allow us to conclude that it is chronic tonsillitis, a possible exacerbation of a focal infection in this area.
Examination of the ears, nose and neck
It is quite possible to examine the auricles, the skin of which may be bluish ( cyanosis in severe congestive heart failure), and one can also detect whitish nodules covered with thin skin - tophi - peculiar accumulations of masses of chalky consistency, consisting of amorphous salts of uric acid, which is a reliable sign of gout.
When examining the nose, attention is paid to its deformation, including as a result of extensive necrotic processes - in the past with syphilis, now more often with Wegener's necrotizing vasculitis, the presence and nature of discharge (blood-stained with an unpleasant odor with necrosis of the mucous membrane, for example with Wegener's granulomatosis, tumors). As on the lips, herpetic eruptions may appear on the wings of the nose.
When examining and palpating the neck, one can detect, first of all, an enlarged thyroid gland and lymph nodes. Their consistency and soreness are determined by palpation. In addition, when examining the neck, one can detect full-blooded swollen veins (obstructed blood outflow into the right atrium in 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 on the carotid arteries is determined, which is used, in particular, when carrying out resuscitation measures.
Examination of bones, muscles and joints
When examining the extremities, changes in the skin, joints, muscles, disturbances in proportion to the body, deformations, as observed in acromegaly, Marfan syndrome and other, mainly hereditary diseases, may be noted. Increased susceptibility of bones to spontaneous fractures occurs in disorders of calcium metabolism as a result of tumors, in multiple myeloma.
It is advisable to examine and palpate the joints in a certain sequence, starting with the symmetrical joints of the upper limbs, then the lower limbs, after which the joints of the head, neck, and torso are examined.
Changes in each joint should be described with an indication of the general appearance (presence of swelling, deformation, defiguration), the presence of hyperemia and hyperthermia of the skin above it, rashes (including nodular ones), pain during palpation and movement, and range of motion.
In some types of arthritis, certain joints are usually affected: for example, in gout, the most common and typical is acute inflammation of the joints of the big toe.
Swelling of the joints is caused by inflammatory edema in the synovial membrane and soft tissues surrounding the joint, sometimes due to effusion in the joint cavity. In chronic arthritis, gross changes in the synovial membrane and periarticular tissues lead to changes in the shape of the joint (the so-called joint defiguration). Swelling in the joint area can also be explained by damage to the soft periarticular tissues ( periarthritis, bursitis ) without involving the structures of the joint itself.
In contrast to defiguration, joint deformation is understood as a persistent change in its shape due to bone growths, destruction of the articular ends of bones, and the development of ankylosis, for example, Heberden's nodes (isolated lesions of the distal interphalangeal joints, severe deformities of the hand in rheumatoid arthritis).
Hyperthermia of the skin over the affected joints accompanies the acute inflammatory process. Along with hyperthermia, hyperemia of the skin over the affected joint is often noted. Widespread, clearly outlined, bright red coloration of the skin in arthritis of the big toes in patients with gout may be the cause of an erroneous diagnosis of erysipelas or phlegmon of the subcutaneous fat: crimson-red, virtually painless swelling of the finger joints is characteristic of psoriatic arthritis, hyperpigmentation of the skin over the affected joints appears with an unfavorable course of rheumatoid arthritis.
If we mean the musculoskeletal system as a whole, then, in addition to the above phenomena, we should name the signs of convulsive syndrome: rigidity of the occipital muscles (Kernig's symptom), tonic and clonic convulsions in the skeletal muscles, various types of hyperkinesis and other signs, mainly discussed in detail in the course on neurology, although their cause may also be various homeostasis disorders (primarily electrolyte, as well as endogenous intoxications) in kidney diseases, liver, and hypoxia. Separately, attention should be paid to pain in the spine, which may be a manifestation of osteoporosis, metastases, tumors, as well as an inflammatory process (for example, pain in the lower sections in Bechterew's disease ). Particularly noteworthy are the fingers in the form of so-called drumsticks, which can be found on both the hands and feet. Fingers may turn white with a feeling of numbness due to vascular spasm, which is observed in Raynaud's disease.
Varicose veins are often found on the shins, which can be complicated by the formation of ulcers. Edema is also most often found on the shins. Palpation reveals not only pain in various areas, but also features of the pulsation of large (main) vessels: asymmetry and its absence over one of the arteries (for example, a. dorsalis pedis in atherosclerotic occlusion), the presence of nodular thickenings (a sign of severe vasculitis - nodular periarteritis). Pay attention to the strength and development of the muscular system. When palpating the muscles, their pain is sometimes noted. It is also important to assess muscle strength, especially in symmetrical areas. To assess muscle strength, it is useful to ask the patient to sit down: difficulty in getting up, as well as in climbing stairs, is very characteristic of dermatomyositis. Various disturbances of sensitivity accompanied by pain, as well as muscle strength, are encountered in lesions of the peripheral and central nervous system, which is revealed using special techniques. On the palms, bright red erythema is sometimes visible in the area of the elevations of the sore finger and little finger, which is encountered in chronic liver diseases, systemic vasculitis.
Special attention should be paid to the importance of identifying, already during a general examination, a number of signs that are traditionally considered markers of alcohol abuse. These include a peculiar purple-blue color of the face, especially the nose, injected sclera, a significant increase in the parotid salivary glands (giant mumps ), excess body weight or, conversely, its significant deficiency, Dupuytren's contracture (thickening of the palmar aponeurosis with limited extension of the fingers), abundant vascular-capillary pattern of the skin of the upper body. Since the alcoholic etiology of a number of internal diseases is quite real (chronic hepatitis and cirrhosis of the liver, chronic pancreatitis with malabsorption syndrome, chronic glomerulonephritis, myocardial damage with arrhythmia and congestive heart failure, etc.), detection of these signs of alcohol abuse is important for a more complete understanding of the disease and the prospects for treatment.