2. Head
Skull
Inspection and palpation assess contour, regularity, and
sensitivity.
The temporal arteries should be palpated and auscultated.
In newborns, the bones of the skull are separated from each
other by fibrous tissue, constituting the so-called sutures. The
areas where the sutures meet are called fontanelles ”
The sutures are palpable as rings and the fontanelles as
depressed edges. T
he examination of the fontanelles should be carried out with
the child calm and without effort. Sometimes the bones of the
skull can be found riding one on top of the other, a fact that is
produced by the passage through the birth canal and that
disappears with the days.
3.
4. Facies
The study of the facies allows not only to
recognize the degree of health or illness of the
patient, but also the state of mind and
intelligence.
Expression, color and shape are observed.
The expression is related to muscle tone and
skin coloring. There are variations within
normality, being able to observe fear, anxiety,
concentration, etc.
The color of the facies depends on the hematic
and melanic pigments, the circulatory state of the
skin and the amount of collagen tissue. These
factors can vary according to race, age, sun
5. The shape of the facies depends on the bone
structure and soft tissues, which are closely
related to race, age, family variations, sex,
etc. Very young children may have facial
asymmetry after constant supine sleep on
one side, which disappears as the baby
becomes more active.
Percussion of the parietal bone with the
middle finger of the hand produces a broken
vessel noise. Direct percussion below the
zygomatic bone causes the facial muscles to
contract (Chvostek's sign). This sign can
persist into childhood.
6. Eyes
Examination of the eyes is carried out by
inspection, palpation and auscultation, and
using the ophthalmoscope, flashlight, slit
lamp, etc.
The eye exam begins with inspection of the
eyebrows, location, and presence of hair.
Subsequently, the eyelids are observed in
terms of their shape, symmetry and the
presence of eyelashes. Once the inspection
has been carried out, the patient's left lower
eyelid is lowered with the thumb of the right
hand to observe the bulbar and palpebral
conjunctiva.
7. Eyes
The same maneuver is performed with the left thumb
going down to the lower right eyelid.
To study the conjunctiva of the upper eyelid, it must be
everted (Figure 6-3). For this purpose, and while the
patient looks down, the lower edge of the upper eyelid
is grasped with the right index finger and thumb and,
with the help of a swab, it is drawn upwards.
The conjunctiva and cornea are lubricated by the
lacrimal glands; Tears drain through the tear duct,
whose hole can be seen at the inner end of the upper
edge of the lower eyelid. The lacrimal sac should be
palpated and evaluated for regurgitation of any material
into the eye.
8.
9. Eyes
The color of the iris is variable and depends on genetic
factors. The cornea must be transparent, bright and
clear when illuminated with the flashlight. The sclera is
white.
The vascularity of the conjunctiva varies with the
complexion of the individual. The robust patient will
have more vascularized conjunctiva. Under normal
conditions it is possible to find a small amount of
discharge on the inner part of the lid margin.
The pupils must be transparent; their size, location and
symmetry will be noted. The eyeballs are parallel in
distance vision; the corneas, therefore, must be located
in a symmetrical position.
10. Ears
It is examined by inspection, palpation,
and with special procedures.
It begins with the examination of the
pinna or ear, whose shape and size vary
according to genetic and racial factors.
Usually
It is made up of the helix, antehelix,
tragus, and lobe
The external auditory canal is examined
by rectifying the normal direction of the
canal by pulling the pinna up and back.
11. Ears
Palpation of the preauricular area is carried
out with the index finger, which leans forward,
to palpate the condyle of the
temporomandibular joint, which should not
cause pain. Subsequently, the mastoid region
is palpated, which under normal conditions
should be painless.
In the external third of the ear canal there are
hair follicles, sebaceous glands and earwax.
At the junction of the middle and outer thirds
the duct narrows to form the area called the
isthmus.
12. Ears
The tympanic membrane, which is at the end of
the canal and marks the limits of the middle ear,
is seen with the aid of the otoscope. To do this,
the patient rotates his head to the opposite side,
the pinna is pulled up, back, and slightly out, and
the otoscope is inserted
The eardrum is an oblique membrane, sunken in
its center by the malleolus, the short process of
which protrudes above the hammer.
Characteristically it produces, with illumination, a
reflection known as a cone of light. Its normal
color is pearl gray and the anatomical parts
should be located
13.
14. Nose
Its examination includes inspection of
the nose, palpation and percussion of
the paranasal sinuses,
transillumination of these, and special
tests such as rhinoscopy using the
nasal speculum and the appropriate
otoscope with a wide speculum.
15. Nose
The anatomical characteristics of the
nose, its shape, size, coloration and
symmetry are observed.
The speculum is inserted with the left
hand into the nostril, fixing its position
with the index finger, which rests on the
observed nostril. Both nostrils are
observed with the same hand. The light
source can be the front mirror, a
flashlight or a lamp with directed light.
The more practical otoscope is used with
a short, wide speculum in its lumen.
16. Nose
The upper and lower portions of the nostrils should be
examined, noting: 1) the mucosa (color and brightness),
2) the nasal septum, and 3) the middle and lower
turbinates and the middle meatus
The palpation of the frontal sinuses is carried out
pressing at the level of the internal zone of the
supraorbital areas, and that of the maxillary sinuses
doing the same in the infraorbitrary zone, on the
maxilla.
Transillumination is performed when a pathology is
suspected. In a dark environment, a powerful light
source is placed inside the mouth when the maxillary
sinuses are to be viewed, and in the supraorbital arch
when the objective is to examine the frontal sinuses.
Under normal conditions, a soft reddish light is
observed.
17. Mouth
The physical examination of the mouth is done
by inspection and palpation, along with special
maneuvers that include the use of a rear-view
mirror, a tongue depressor, and a flashlight.
The patient, sitting comfortably with his arms
crossed on the lap, and the doctor, in a sitting or
standing position, with the necessary elements
for the examination, gets to observe the back of
the tongue, the pharynx and the glottis.
The examination of the lips consists of evaluating
their shape, symmetry and mobility. The shape
varies according to family and racial
characteristics. An intense pink color is normal,
subject to variations
18. Mouth
Moisture is also evaluated on the lips. When
opening the mouth, with the tongue blade or the
fingers of the examiner and with the help of a
flashlight, the inner faces of the lips and cheeks
are observed, together with the gums.
Stensen's orifice or parotid exit orifice is found in
the jugal mucosa at the level of the second
molar. The jugal mucosa is moist and pink in
color, and may be pigmented with melanin in
dark-skinned subjects.
At this time the gums will be examined, which
must cover the alveolar process; they are pink in
color and project into the interdental spaces as
interdental papillae.
19. Mouth
The teeth should be examined for their number
and shape by lightly percussion with the tongue
depressor or mirror, which should be painless.
The patient is then asked to raise the tongue to
look at Wharton's duct or the outlet duct of the
submaxillary glands.
You are then asked to open your mouth wider to
examine the bony and soft palate, tonsils, and
pharynx. In the bony palate, the shape and color
will be observed, and the patient will be
instructed to say "A" to verify the normal
elevation of the soft palate. Tonsils are located
between the pillars of the pharynx and can be
variable in size.
20. Mouth
The patient is then asked to protrude
the tongue, evaluating both its ventral
and dorsal surfaces, observing its
shape, size, symmetry and mobility.
The mucosa of the dorsum of the
tongue has fungiform-filiform papillae.
The frenulum with the sublingual
caruncles can be seen on the ventral
side; the lingual venules that should
not be prominent.
21. Mouth
The tongue and floor of the mouth will be
palpated to complete the examination of the
oral cavity.
Palpation should be thorough, gloved, and
will evaluate the sublingual glands and
tongue. The submaxillary glands can be
palpated bimanually,
The parotids are located anterior to the ear
and should not normally be palpable.
With the mouth open, the tongue depressed
by the tongue depressor, and good lighting,
the pharynx can be seen, which may appear
more polished.
22. Neck
The neck is examined by inspection,
palpation, and auscultation. The
sternocleidomastoid, scalene, and trapezius
muscles, the carotid artery, and the venous
pulse should usually be identified, and the
thyroid gland, laryngeal and tracheal
cartilages, can be palpated.
If possible, the patient should be seated,
looking straight ahead, and will be asked to
perform flexion-extension, rotation, lateral
flexion, and neck circumduction movements
to assess cervical mobility.
Under normal conditions, and with the mouth
closed, the patient should be able to touch
the anterior aspect of the thorax with the chin.
23. Neck
Symmetry of the neck and the presence
of carotid and venous beats will be
observed. The venous pulse and carotid
pulse are important to be decsribed
In the neck, the ganglion chains will also
be palpated, where no lymphadenopathy
should be found. This exam should be
done in a certain order so as not to miss
any node groups
24. Neck
preauricular, in front of the tragus;
tonsillar or tonsil, in the submandibular angle;
submaxillary, between the submandibular
angle and the chin;
occipitals; on the back of the skull;
retroauricular, at the level of the mastoid
process;
superficial cervical, following the surface of
the sternocleidomastoid muscle, and deep
below it;
anterior cervical chain, on the anterior border
of the trapezius; and
supraclavicular, between the
sternocleidomastoid and the clavicle.
25.
26. Neck
The trachea and the thyroid and cricoid
cartilages should be identified, verifying that
they are in the midline. Subsequently, the
thyroid gland will be palpated, in which the
shape, size, symmetry, limits, surface,
consistency, sensitivity and mobility with
swallowing will be described;
It is advisable to give the patient a glass of
water and swallow to assess mobility. Often
and under normal conditions, the thyroid
gland is not palpable; the isthmus can be
identified as a transverse band located below
the cricoid cartilage.
27. Neck
To palpate the thyroid gland, the patient will be
seated, with his head slightly extended, and the
examiner facing him.
With the pads of both thumbs below the cricoid
cartilage, the isthmus is sought, and to facilitate
this maneuver, the patient is asked to swallow
water or saliva.
Subsequently, by flexing the head to the palpated
side to flex the sternocleidomastoid muscle, the
thyroid lobe is identified, while the index and
middle fingers compress behind the
sternocleidomastoid muscle.
The thumb of the other hand pushes the trachea
toward the palpated side
To palpate the other lobe, the same maneuvers
are performed in reverse.
28.
29. Neck
The thyroid gland can also be felt from behind of the patient.
The examiner, positioned behind the patient's back, with the
thumbs resting on the back of the neck, identifies the cricoid
cartilage with the balls of the index and greater fingers and
the thyroid isthmus below it.
The patient is asked to swallow and the fingers are moved
slightly to the sides to feel the lobes, again asking him to
swallow.
Then the neck is flexed slightly forward and to the right,
displacing the right thyroid cartilage with the fingers of the left
hand, palpating with the right hand, the thumb is placed
deeply and behind the sternocleidomastoid and the index and
middle fingers in front of him. The patient is asked to swallow.
The thyroid gland should be auscultated to verify the absence
of murmurs. Also, and with the same objective, the carotid
arteries should be auscultated.
