Seminar

General
Physical
Examination Of
Patient
Presented By:
Vishnu V Gopal
Post Graduate Student
Oral And Maxillofacial Surgery
Guided By:
Dr. Keerthi R
Professor
Oral And Maxillofacial Surgery

 Introduction
 Case History
 General Physical Examination
 Vitals
 Inspection
 Palpation
 Percussion
 Auscultation
CONTENTS

INTRODUCTION
As the saying Medicines can cure but a
good doctors inspirational words can
give the strength to fight within.
Attitude of doctor should be based on how you should be
feeling in the patients condition
Behaviour- Always treat the patient with kindness and
respect
Compassion- Should recognize human story associated
with each illness
Dialogue- Acknowledge and respect the patient

A diagnostic procedure should be as follows
Personal Information
Recording the history
Examining the Patient
Establishing a Provisional diagnosis based on
the results and examinations
Conducting necessary Investigation
Formulation of diagnosis based on the results
from investigations
 Making a plan of treatment after assessing the
risk factors
DIAGNOSTIC PROCEDURE

CASE HISTORY
BIO-DATA OF THE PATIENT
NAME: Every body likes to be called by their
name
Patient will feel more comfortable and
help to get the history properly
For Paediatric patients calling by their
name will encourage them
As an identification
To maintain the records

AGE: Can be helpful in many aspects of the treatment
Diagnosis of age related diseases
Treatment planning: Eg Complete absence of the teeth
even at the age of 4-5 years is most frequently associated
with Hereditary Ectodermal Dysplasias
Delayed eruption can be associated with rickets,
cretinism or local factors like fibromatous gingivae,
ankylosed primary teeth etc.
Calculation of dose in children
Young rule: Childs age/Age +12* Adult dose
Clark rule : Childs age at next birth day / 24* adult dose
Dilling rule : Age * Adult dose / 20

 Sex
Some diseases have certain prevalance
Females : Iron deficiency Anaemia, Caries, Disease of Thyroid
Malignant melanoma, Sickle cell anaemia, Juvenile
periodontitis etc
Males : Attrition, Basal cell carcinoma, Carcinoma of the buccal
mucosa,Leukoplakia, Multiple myeloma etc
Dosage in females are low due to lower body weight and
consideration must be given to mensturation, pregnancy and
lactation
Antihypertensive drugs can alter the sexual function in males not in
females
Esthetic consideration of the female patients will be more

Address
Necessary for the future correspondence
To know the geographical prevalence of diseases
Eg: In south asian population the Oral cancer is the most
common one
Mottled enamel and Dental caries will depend on the
Flouride content of the water in that area.
Registration number
For the easy accessibility of the patients data

Occupation
Financial status of the patient
Diseases associated with occupation :
Notching of incisors can be seen in carpenters and tailors who
keeps pin or needle between their teeth.
Hepatitis B the more susceptible person are Doctors, Blood
bank personnel etc.
Varicose veins are commonly found in Bus conductors, Traffic
police etc.
Carcinoma of scrotum is more in Chimney sweepers,workers in
tar and oil companies
Gingival staining is found in people working with lead, bismuth
or cadmium

Notching of incisors
Lead encephalopathy in adults

Religion
Carcinoma of penis and phimosis is less in
muslims and jews as they have custom of
circumcision of penis.
Intussusception is found after a month long fast in
Ramzan.

Chief complaint
Reason for which the patient has come
Should be recorded in patients own words
Chronological Recording of the complaints to be done if
complaints occur simultaneously according to severity it
should be noted
History of illness
Should start from the beginning of the symptoms of the
disease
Mode of onset to be noted
Cause of onset to be asked
Progress of the symptom to be asked ie recurrent,
consistent, agrevating and relieving factors to be asked

Pain
If the symptom is associated with pain
Site of the pain
Intensity of pain
Nature of the pain
Duration of the pain
Effect of functional activities
Concomitant neurologic sign associated with pain
Exacerbating and Relieving factors
Swelling
If the symptom is associated with swelling
Duration of swelling
Mode of onset
Progress of the swelling
Any discharge or fever associated with swelling

Ulcer
Mode of onset
Pain
Discharge from ulcer
Diseases associated with ulcer etc to be taken into
consideration
Past medical history
Patients who have medical problems like diabetes,
hypertension etc being most common
Based on the history we can asses if any consultation from
other speciality is required
Will help in the assessment of diagnosis of oral disease
Eg: HSV infection, use of steroids, HIV etc.
Drug history can be also asked as it help to understand if the
patient is allergic to any particular drug
Previous history of hospitalisation to be asked

Family history
To know about hereditary diseases like haemophilia,
Diabetes, Hypertension, cancer etc.
Personal history
Habits and Addiction
Exercise and diet
Oral hygiene habits
Appetite of the patient
Bowel and Micturition habits
Pressure habits, Mouth breathing, other habits (masochistic
habits)

Habits and addiction
Smoking : can cause lungcancer, Throat cancer, can also
lead to reduced sperm count and infertility, affect the oral
hygeine and periodontal status of the teeth, decreased taste
sensation.
Gutka and other chewable tobaco forms: increase rate of
oral cancer , submucous fibrosis mostly used by south
asian population.
Drinking : excessive alcoholism can lead to liver cirrhosis,
Vit k deficiency,pancreatitis, gastritis etc.

Pressure Habits and others:
Tongue thrusting, thumb sucking, mouth breathing, nail
biting,lip biting, masochistic habits.
Diet and Exercise:
Increase of fluoride in water can cause mottled enamel and
skeletal fluorosis.
Hot and spicy food can lead to submucous fibrosis.
Because of restriction towards certain foods due to
religious reasons can cause malnourishment
Lack of exercise can cause loss of muscle strength ,
causes fatigue.
Lack of physical activity and increased uptake of fat and
consumption of processed food can cause hypertension ,
diabetes etc.

EXAMINATION OF THE PATIENT
Physical examination is defined as a complete assessment
of a patient’s physical and mental status.
A physical assessment is the systematic collection of
objective information that is directly observed or is elicited
through examination techniques
Steps of clinical examination:
Inspection
Palpation:
Bilateral palpation, Bi-digital and Bimanual palpation
Percussion
Auscultation

 HealtH examination
 Health examination is the systematic assessment of
human body which involves the use of one’s senses to
determine the general physical and mental conditions of
the body
 Physical examination stars when we see the patient first
their general appearance, Gait, Body type, and the body
language every thing to be taken in to consideration

 Apparent state of health
 Acute or chronically ill, frail
 Level of consciousness
 Awake, alert, responsive or
lethargic, obtunded,
comatose
 Signs of distress
 Cardiac or respiratory; pain;
anxiety/depression
 Skin color and obvious lesions
Dress, grooming, and personal hygiene
Appropriate to weather
and temperature
Clean, properly buttoned/zipped
Facial expression
Eye contact, appropriate changes in
facial expression
Odors of body and breath
Posture, gait, and motor activity
General Appearance - Description

Hand Shake
Greet the patient in professional manner
Certain information can be obtained from a hand shake

Large fleshy hands Cold and sweaty hands
Dry Coarse hand Deformed hands

Facial Expression
Facial expression and eye to eye contact are indicators of
physiological and psychological wellbeing

Lugubrious expression with bilateral ptosis
Apathy with pale and puffy skin

Poverty of expression
Startled expression

Clothing
Young people wearing old clothes may have problem with
Drug addiction or alcoholism or may be making a personal
statement
Anorectic patients wear baggy clothing to cover weight loss
Complexion
Facial color can depend on oxyhaemoglobin, reduced
haemoglobin
Shallow yellowish brown tinge seen in Chronic renal failure
Bluish tinge can be seen in abnormal haemoglobin, Sulpha
haemoglobin or by drugs such as dapsone
Some drug metabolites can cause abnormal discoloration of skin
Eg: Mecaprine (yellow), Clofazimine (browinish-black),
Amiodarone(bluish-grey), Phenothiazine(slate-grey)

Yellowish pigmentation Bluish pigmentation

Odor of body
• Diabetes can cause Fruity smell of the
body due to keto acidosis
• Obesity can also cause bad odor of the
body.

Built of the Patient
Height
 Measure in stocking feet
 Short or tall
 Build: slender and lanky, muscular, or stocky
 Body symmetry
 Note general body proportions and any deformities
Weight
 Emaciated, slender, plump, obese
 If obese, is fat distributed evenly or concentrated over
trunk, upper torso, or around the hips?
Calculating the body mass index (BMI)

A calculation based on height and weight Used to classify patients as:
Body Mass Index

Vitals
 Pulse
 Blood pressure
 Heart rate and rhythm
 Respiratory rate and rhythm
 Temperature

Blood Pressure
 Avoid smoking or drinking caffeinated beverages
30 minutes prior to measurement
 Ensure that the room is quiet and comfortably
warm
 Patient should be seated quietly in a chair with feet
on the floor for at least 5 minutes
 Patient’s arm should be FREE of clothing
 Palpate the brachial artery
 Position the arm so that the brachial artery is at
heart level
 Rest the arm on a table a little above the patient’s
waist, or support the patient’s arm with your own at
his mid-chest level

• Width: 40% of upper arm circumference
• Length: 80% of upper arm
circumference
Blood Pressure – Cuff Size and Position

Measuring the Blood Pressure
Auscultatory method
Center the inflatable cuff over the brachial artery with the lower
border 2.5 cm above the antecubital crease
Secure the cuff snugly, not tightly, and position the patient’s arm
so that it is slightly flexed at the elbow
With the fingers of your opposite hand, palpate the radial artery
and inflate the cuff until the radial pulse disappears; add 30 mm Hg
to this pressure
Deflate the cuff promptly and completely and wait 15-30 seconds
Palpatory method
Place the bell of the stethoscope lightly over the brachial artery
Inflate the cuff to the sum pressure previously determined and
deflate slowly
The point at which you hear the first two consecutive beats is the
systolic pressure
The disappearance point is the diastolic pressure

Measuring BP on other site :
•Blood pressure measurement in the legs is achieved with an appropriate-
sized cuff, applied at the midthigh, and by listening over the popliteal artery
•the patient should be in a prone position
•. The bladder of the cuff should be about 40% of the circumference of the
thigh, and the length should be about 75% to 80% of this circumference.
•Normally, the systolic blood pressure in the legs is usually 10% to 20%
higher than the brachial artery pressure.
•Blood pressure readings that are lower in the legs as compared with the
upper arms are considered abnormal and should prompt a work-up for
peripheral vascular disease.
•All hypertensive patients should have comparisons of arm and leg blood
pressures as well as volume and timing of the radial and femoral pulses at
least once to rule out coarctation of the aorta.

• it is recommended that patients who have undergone
axillary node dissection avoid having blood pressure
measurements done on the affected side.
• For those who have had bilateral axillary node
dissection, blood pressure measurements should be
obtained in the leg.
• For those patients who have had a mastectomy without
lymph node dissection (ie, prophylactic mastectomy),
blood pressure can be obtained in either arm. These
recommendations should be followed for life.

Auscultatory gap
A silent interval that may be present between the
systolic and diastolic blood pressures; i.e., the sound
disappears for a while, then reappears
Orthostatic blood pressure
Measure blood pressure and heart rate with the
patient supine; wait 3 minutes, then have the patient
stand up; now repeat the measurements
Normal: systolic BP drops slightly or remains
unchanged; diastolic BP rises slightly
Orthostasis: systolic BP drops >20 mm Hg or diastolic
BP drops >10 mm Hg

Normal and Abnormal Blood Pressure
 Normal (adults older than 18 years)
 Systolic: <120 mm Hg
 Diastolic: <80 mm Hg
 If blood pressure is elevated:
 Repeat blood pressure measurement and verify in the
contralateral arm
 Consider “White Coat Hypertension”
o Occurs in 10%–20% of all patients
o Bp should be rechecked after 10 min
o Try to relax the patient and retake BP later in the
visit

Heart rate and rhythm (pulse)
 Radial pulse is commonly used to measure the heart rate
 Use the pads of the index and middle fingers
 If the rate seems normal (50–90 bpm) and the rhythm is
regular, count the rate for 30 seconds and multiple by 2. If
the rate is fast or slow and/or the rhythm is irregular, count
for a full 60 seconds.
 Rhythm of pulse: Regularly irregular in ventricular atopic
and Irregularly irregular in arterial fibrillation.
 Volume of the pulse indicate the pulse pressure (40-
60mm/hg)
 Wide pulse Pressure: Pregnancy, Anemia, Aortic and Mitral
Regurgitation.
 Narrow pulse : Left ventricular failure, Mitral stenosis, Aortic
stenosis

Character of the pulse: Water hammer pulse in Aortic regurgitation
Pulsus paradoxus in Pericardial effusion
Pulsus bifringens in idiopathic hypertrophied
subaortic stenois
Anaerotic pulse in Aortic stenosis
Dicrotic pulse in Typhoid, CCF,
Cardiac tamponade
Delay in the left temporal pulse from right is seen in coarcation of aorta

Respiration
Observe rate, rhythm, depth, and effort of breathing
 Normal rate: ~20 breaths/minute
o Count for 60 seconds
 Observe rhythm: regular, irregular
 Observe depth: shallow, gasping
 Observe effort: normal, labored
 Tachypnea: Hypoxia, Fever, shock, tetany, hysteria
 Snoring noise : Paralysis of soft palate
 Bradypnea: Cerebral compression
 Respiratory wheeze: Bronchitis, Asthma

Temperature
 Average oral
temperature:
37°C or
98.6°F
 Diurnal
variation:
35.8°C
(96.4°F) to
37.3°C (99.1°F
Rectal 0.5°C (1°F) > oral
temperature
Axillary 0.5°C (1°F) < oral
temperature
Tympanic 0.8°C (1.4°F) >
oral temperature

Types of fever:
Continuous fever- above normal throughout the day
One degree rise in 24 hours
Eg: Lobar pneumonia, Typhoid, Endocarditis
Remittent fever- above normal throughout the day but more
than 1 degree rise in 24 hours. Eg: Typhoid
Intermittent fever: temperature only for some hours in a day
Eg: Malaria, Kalaazar, Pyremia, Septicemia etc.
Hyperpyrexia: Tetanus, Septicemia, Malaria, Heat stroke,
Hemorrhage.
Hypothermia: Hypyothyroidism, Hypoglycemia,
Hyperpituitarism, Barbiturate Poisoning etc.

Pallor
Edema
Nail changes/clubbing
Cyanosis
Icterus
Lymph nodes
Skin changes
Useful Pneumonic For Inspection

Causes of clubbing:
 cyanotic congenital heart disease
 Sub acute bacterial endocarditis
 lung carcinoma
 bronchiectasis
 Emphysema
 lung abscess
 lung fibrosis
 Pulmonary Tuberculosis
 cirrhosis
 IBD
 Celiac disease
 Thyrotoxicosis
 Familial

Clubbing
Bulbous enlargement of the distal part of the fingers and toes due
to proliferation of connective tissue
Theories:
1)Platelet derived growth factor theory: This is the most accepted
theory. There is release of PDGF from the platelets in response to
inflammation or hypoxia leading to vasodilation and proliferation of
soft tissues
2)Neurogenic theory: Vagal mediated stimulation causing
vasodilation
3) Humoural theory: GH, PTH, estrogen,PG, bradykinin causes
vasodilation and clubbing
4) Ferritin theory
5) Hypoxic theory
Normal angle between the nail bed and and nail is known as
Lovibond angle and is about 160.
Causes:
Hereditary
Idiopathic
Respiratory: Bronchogenic carcinoma,
bronchiectasis, cystic fibrosis
Cardiac: Cyanotic heart disease, infective endocarditis

GIT causes: Liver cirrhosis,Imflammatory bowel
disease
Hypertrophic osteoarthropathy: Clubbing along
with subperiosteal distal diaphyseal new bone
formation with symmetric arthritis like changes in
shoulders, elbow, knee, ankle seen in lung cancers,
mesothelioma, bronchiectasis, hepatic cirrhosis

Koilinychia
• Spoon shaped nails are seen
• Causes are:
• Anemia
• Malnutrition,
• GIT blood loss
• Worms in intestine
• Malignancy
• Celiac disease

Causes of cyanosis
CENTRAL CYANOSIS
 Abnormal hemoglobin levels
 Congenital heart disease
 Hypoventilation
 Asthma
 Methmoglobinemia
 Valvular heart disease
 COPD
• Pulmonary embolism
• Arterial obstruction
• Heart failure
• Right to left venous
arterial shunts
• High altitudes
• Polycythemia

Periperal cyanosis causes
 Exposure to cold
 Reduced cardiac output
 Arterial or venous obstruction

Cyanosis:
Cyanosis is the bluish discolouration of skin and mucous
membrane.
It results from the increased amount of reduced hemoglobin
the the blood.
Manifests when the reduced hemoglobin is >4g/dL
Cyanosis may be masked in severe anemia
Types:
1) Central cyanosis: Due to the decreased SaO2
Respiratory cause: High altitude, Alveolar hypoventillation,
pulmonary A-V shunts & fistula,
Cardiac causes: Congenital heart diseases
Sites: Skin, lips, tongue

 Other causes: Methemoglobinemia, sulfhemoglobinemia
2) Peripheral cyanosis
Exposure to cold, arterial obstruction, reduced
cardiac output, venous obstruction.
Sites to be examined: tip of the nose, ear lobule, nails

ICTERUS
 Yellowish discolouration of skin,mucous membrane
and sclera.
 Due to increased bilirubin.
 Yellowish discolouration of sclera is due to the high
elastin content in the sclera
Sites to examine icterus
 Upper bulbar conjunctiva, lower surface of tongue
 It denotes the concentration of serum bilirubin of
atleast 3mg/dL

Differential diagnosis of yellowish discolouration of
skin
 Carotenoderma ( increased intake of carrots,
oranges and leafy vegetables): here there is no
yellowish discolouration of sclera
 Quinacrine
 Chronic exposure to phenols
 Long standing anemia
Hypercarotenemia: unequally distributed yellow
pigment of carotine particularly seen in face, palm
and soles not seen in sclera most common in
vegetarians

Exam of the Skin
 Examine the patient in good lighting
 Inspect and palpate skin for the following:
Color
Texture
Turgor
Moisture
Pigmentation
Lesions
Hair distribution
Warmth: use back of hand

Abnormal Findings
 Color
Pallor:
• Iron def. anemia
Yellow:
• Jaundice
• Carotenemia
• Hemolysis
Red:
• Erythroderma
 Pigmentation
Hyper pigmentation
Localized:
• Pregnancy
• BCP ingestion
Generalized:
• Thyrotoxicosis
• Liver disease
• Renal disease
De-pigmentation:
• Vitiligo
• Injury

Abnormal Findings
 Texture
 Soft: (Thyrotoxicosis)
 Tight: (Scleroderma)
 Rough: (Hypothyroidism)
 Moisture
 Dry: (Vitamin A def,
Myxedema)
 Oily: (Acne)
 Turgor
 Decreased: (Dehydration)
 Warmth:
 Generalized warmth:
(Fever, Hyperthyroidism)
 Localized warmth:
(Inflammation)
 Coolness:
(Hypothyroidism, Frostbite,
Hypothermia, Shock, Low
cardiac output)

MOLE WARNING SIGNS
The "ABCD" rule & Melanoma Danger
Signs

Examination
of the
Lymph Nodes

Lymph Node Palpation
 Palpate with pads of
all four fingertips
 Examine both sides
simultaneously
 Use steady gentle
pressure
 The major lymph node
groups are located along
the anterior and posterior
aspects of the neck and on
the underside of the jaw

Exam of Lymph Nodes
 Lymph nodes are part of immune system
 Lymphadenitis
Firm
Tender
Enlarged
Warm
 May remain enlarged after infection
Less than 1 cm
Nontender

Lymph node palpation:
Most of the lymph nodes are best palpated with the examiner standing
behind the patient who is comfortably seated in a dental chair
Palpation of the lymph nodes is ideally done commencing from the most
superior lymph node and then working down to the clavicle region.
Nodes are palpated for consistency, size, tenderness, fixity to the
surrounding structures.
Consistency
Enlarged lymph nodes should be palpated carefully with palmar aspect of
3 fingers.
While rolling the fingers over the lymph node, slight pressure has to be
applied to know the consistency of the node.
Enlarged lymph nodes could be
 Soft (fluctuant) Eg in infections
 Elastic , rubbery , in hodgkins lymphoma
 Firm,
 Stony hard, in malignancy
 Variable, in lymphosarcoma

Matting:
A group of lymph nodes that feels connected and move as a unit
is said to be matted
Nodes that are matted could be
Malignant: Metastatic carcinoma
Lymphomas
Benign : Sarcoidosis
Tuberculosis
Lymphogranuloma venerum
Size:
Nodes are generally considered to be normal if they are up to 1cm in
diameter.
Little information exists to suggest that a specific diagnosis can be based
node on size alone.
But in a study on a series of 213 adults with unexplained
lymphadenopathy showed
 Up to1cm-no cancer
 Up to 2.25 cm- 8% cancer
 >2.25 cm- 38% cancer

Fixity to the surrounding tissues:
The enlarged nodes should be carefully palpated to know if they are fixed
to the skin, deep fascia, muscles etc..
Any primary malignant growth or secondary carcinoma is often fixed to the
surroundings.
First the deep fascia and the underlying muscle, the surrounding
structures and finally the skin is involved.
 Upper deep cervical lymph nodes when involved secondarily from any
carcinoma of its drainage area may involve the hypoglossal nerve and
cause hemiparesis of the tongue which will be deviated towards the side of
the lesion when asked to protrude out.
Dyspnoea & dysphagia can occur due to pressure on trachea or
esophagus by enlarged lymph nodes from Hodgkin’s disease or
secondary carcinoma

Method of palpation:
•Preauricular nodes: Anterior to the tragus of the ear
•Post auricular nodes: Posterior to the ear on mastoid process

Occipital nodes :
at the base or lower border of the skull

Submental nodes:
They are palpated under the chin
The clinician can stand behind the patient to palpate.
The patient is instructed to bend his/her neck slightly forward so that the
muscles and fascia in that regions relax.
Fingers of both hands can be placed just below the chin, under the lower
border of mandible and the lymph nodes should be tried to be cupped with
fingers

Submandibular nodes:
Are palpated at the lower border of the mandible approximately at
the angle of the mandible.
The patient is instructed to passively flex the neck towards the
side that is being examined. This maneuver helps relaxing the
muscles and fascia of neck, thereby allowing easy examination.
The fingers of the palpating fingers should be kept together to
prevent the nodes from slipping in between them.
The palmar aspect of the fingers is pushed on to the soft tissue
below the mandible near the midline, then the clinician should then
move the fingers laterally to draw the nodes outwards and trap
them against the lower border of the mandible.

Superficial cervical nodes:
 situated superficial to upper part of sterno-cleido mastoid along
its anterior border.
Posterior superficial nodes:
Palpated in the posterior triangle of the neck close to the anterior
border of trapezius

Supraclavicular lymph nodes:
Above the clavicle lateral to the attachement of
sternocleidomastoid muscle
Palpated in supraclavicular fossa bilaterally standing behind the
patient
Patient can be instructed to elevate or hunch his shoulder forward

Malignancies
 Firm
 Non-tender
 Matted (i.e. stuck to each other)
 Fixed (i.e. stuck to underlying tissue
 Increase in size over time

Common Causes of
Lymphadenitis
 Pharyngitis or dental infections
 Diffuse upper airway infections
Mononucleosis
 Systemic infections
Tuberculosis
 Inflammatory processes
Sarcoidosis

EDEMA
Pitting edema Non pitting edema

Edema:
Accumulation of fluid in interstitial space.
Types:
 Pitting type: Apply firm pressure on the shin of
tibia or 2cm above the medial malleolus for 20-30 s
and see for pitting.
Causes: Congestive cardiac failure, nephrotic
syndrome, liver cirrhosis, hypoproteinemia
 Non pitting type: Graves disease (non pitting due
to deposition of hyaluronic acid), filariasis
(lymphatic obstruction)

Pitting edema
 Grades of pitting edema
 Grade 0 : (none)
 Grade +1 :( trace , 2 mm)
 Disappear rapidly
 Grade +2 ( moderate , 4 mm)
 10-15 sec
 Grade +3 (deep, 6 mm)
 ≥ 1min
 Grade +4 (very deep, 8 mm)
 2-5min

ASSESS THE EYE
 Inspect external eye structure
 Position and alignment
 Exophthalmoses (Hyperthyroidism, tumors,bleeding behind
eyes, Infection in eye socket)
 Strabismus ( due to the extraocular muscles of the eye)

 Eye brows: Eyebrow loss, also known as superciliary madarosis, can occur
with a variety of medical conditions. ...
 Chemotherapy. Some cancer chemotherapy drugs cause temporary hair loss,
which affects all body hair. ...
 Ectodermal dysplasia
 Hypothyroidism. ...
 Atopic Dermatitis. ...
 Alopecia Areata. ...
 Hansen's Disease.
 Eye lid :
 ectropion(eversion ,lid margin turn out)
 Caused by birth defect,bells palsy,stroke, injury,Scar tissue due to burns,
Rapid and significant weight loss
 entropion(inversion, lid margin turns inwards)
 Caused by Aging, trauma, infection, birth defect or Inflammation
 ptosis( abnormal drooping of lid over pupil
 Caused by congenital (poor development of levator Palpebrae superioris),
tumors , neurological

 Eye lashes : stye :A stye or hordeolum is a small,
painful lump on the inside or outside of the eyelid. It is
actually an abscess filled with pus and is
usually caused by a staphylococcus
bacteria eye infection
 Eye balls
 Conjunctiva and sclera{ Paleness, redness or
purulent discharge ,jaundice}

TEMPOROMANDIBULAR JOINT
• The maximum opening distance between the incisal edges of
upper and lower incisor is measured using scale , Boley gauge
or ruler
• Normal opening – 40 to 55 mm
• Normal opening can also be estimated by patient’s own finger
• Normal : three finger end on end
• Two finger opening reveals reduction in opening but not necessarily
reduction in function
• One finger opening indicates reduced function

Maximum mouth opening should be measured
 without pain
 as wide as possible , with pain
 after opening with clinical assistance
Mouth opening with assistance is accomplished by applying mild to moderate
pressure against the upper and lower incisors with thumb and index finger . passive
stretching is a technique for assessing limitation due to muscle or joint problem
Assisted opening can be compared with active opening (≥40 mm)
This procedure provides the examiner with the quality of resistance at the end of the
movement.
•Restricted mouth opening is considered to be any distance less than 40mm.
•This distance is measured by observing the incisal edge of the mandibular central
incisor travelling away from its position at maximum intercuspation.
•If a person has 5mm vertical overlap of anterior teeth and maximum interincisal
distance is 57mm , the mandible has actually moved 62mm in opening.
•If mouth opening is restricted , it is helpful to test the “end feel”
•End feel describes the characteristics of restriction.
•End feel can be evaluated by placing the fingers between patient’s upper and lower
teeth and applying gentle-but-steady force in an attempt to passively increase the
interincisal distance.

 muscle restriction are associated with soft end feel and results
in increase of >5mm above the active opening (wide opening
with pain)
 joint disorders such as acute non reducing disc displacement
have hard end feel and characteristically limit assisted opening
to <5mm

Lateral movement of TMJ:
Normal lateral range of movement is >7mm
Measurements are made with teeth slightly seperated,measuring the
displacement of lower midline from maxillary midline.
Any condition (tumor, muscle spasm, fracture, ankylosis,
displaced meniscus) that prevents the normal translation
of one condyle will not prevent the contralateral condyle from
sliding forward normally . The result is deviation of the chin
toward the affected side .

 Examine the hands for signs of systemic disease (e .g.,
Heberden's nodes of osteoarthrosis, ulnar deviation of
rheumatoid arthritis), which may also involve the TMJ .
 Laboratory tests (e .g., complete blood count, erythrocyte
sedimentation rate, rheumatoid factor, antinuclear
antibody,serum uric acid) are helpful when a systemic cause for
TMJ disease is suspected.
 In patients with an intracapsular restriction (disc displacement without
restriction) a contralateral eccentric movement will be limited , but an
ipsilateral movement will be normal.
 However with muscle disorders , the elevators (temporalis , masseter ,
medial pterygoid) are responsible for limited mouth opening , because
eccentric movements do not generally lengthen these muscles , nor a
normal range of eccentric movement exists.

• When the mouth is opened the pathway of mandible is observed
for any deviations or deflections.
• If deviation occurs during opening and the jaw returns to the
midline before 30-35mm of total opening , it is likely to be
associated with a disc derrangement disorder.
• If the speed of opening alters the location of the deviation , it is
likely to be a discal movement (ex disc displacement with
reduction)
• If the speed of opening does not alter the interincisal distance of
deviation , and if the location of deviation is the same for
opening and closing , then a structural incompatibility is likely
the diagnosis.
• Muscle disorders that cause deviation of mandibular opening
pathways are commonly large , inconsistent , sweeping
movements are not associated with joint sounds.
• Deviation can also occur due to subluxation at wide open
position.

 This is an intracapsular disorder , but not necessarily a
pathologic condition.
 Deflection of the mandibular opening pathway results when one
condye doesnot translate.this may be caused by an intra
capsular proberm ( disc dislocation without reduction )
 With these problems , mandible will deflect to the ipsilateral side
during late stages of opening.
 Deflection can also result if a unilateral elevator muscle , such
as masseter becomes shortened (myospasm).
 This condition can be seprated from intracapsular disorders by
observing the protrusive and lateral eccentric movements.
 If the problem is intracapsular , mandible will move to the side of
involved joint during protrusion and be restricted during
contralateral movement (ie. Normal movement to the ipsilateral
side)
 If the problem is extracapsular , there will be no deflection
during the protrusive movement and no restriction in lateral
movements.

 When deflection is due to intracapsular source , mandible will
always move towards involved joint.
 If deflection is due to shortened muscle the direction in which
mandible moves will depend on the position of the involved
muscle with respect to the joint.
 If the muscle is lateral to the joint , (ie masseter or temporalis) ,
deflection will be towards the involved muscle.
 If medial to the joint , (ie medial pterygoid) deflection will be
away from the involved muscle (in contralateral direction).

MALOCCLUSION:
•Sometime acute malocclusion occurs.
•An acute malocclusion caused by a muscle disorder will vary
according to the muscle involved.
•If inferior lateral pterygoid is in spasm and shortens , condyle will
be brought slightly forward in the fossa on the involved side.this will
result in disocclusion of ipsilateral posterior teeth and heavy contact
on contralateral canines.
•If the spasms are in elevator muscles , the patient is likely to report
a feeling that “teeth suddenly don’t fit right”
•An acute malocclusion resulting from an antracapsular disorder is
usually very closely related to the event that changed the joint
function.
•If the disc is suddenly displaced , the thicker posterior band may
be superimposed between condyle and fossa and cause a sudden
increase in discal space.This appears clinically as loss of
ipsilateral posterior teeth contact.

 If the disc becomes suddenly dislocated , collapse of
discal space can occur as the condyle compresses the
retrodiscal tissue.
 The patient notes it as sudden change in occlusion
characterized as heavy posterior teeth contact on
ipsilateral side.
 If this condition continues , retrodiscitis may result and
cause tissue inflammation with swelling of retrodiscal
tissue.
 The resulting malocclusion may now change to one
characterized by loss of posterior tooth contact on the
ipsilateral side.

Palpation of pretragus area ; the lateral aspect of TMJ
Palpate directly over the joint while the patient opens and closes
the mandible, and the extent of mandibular condylar movement
can be assessed .
 Normally, condylar movement is easily felt . Have the patient
close slowly, and you will feel the condyle move posteriorly against
your finger

 opening :involves two motions. First, the mandibular condyle
rotates anteriorly on the disk. Second, the condyle and the disk
both glide anteriorly and inferiorly over the articular tubercle of
the temporal bone

 Tenderness elicited by this maneuver is invariably associated
with articular inflammation
 Also , there may be palpable differences in the form of the
condyle comparing right and left. A condyle that do not
translate may not be palpable during mouth opening and
closing. This may be finding associated with an anterior disc
displacement without reduction
 A click that occurs on opening and closing is eleminated by
bringing the mandible into a protrusive position before opening
is most often associated with anterior disc displacement with
reduction.
 PROVOCATION TEST:
 it is designed to elicit the described pain.
 Since pain is often aggravated by jaw use , a positive response
adds support for diagnosing TMD.
 THE STATIC PAIN TEST involves having the mandible slightly
open and remainig in one position while the patient resists
slowly

 Increasing manual force applied by the examiner in a lateral , upward , and
downward direction.
 If the mandible remains in static position , muscles will be subjected to activation
 However ability of this test to discriminate between muscle and joint pain is not
known
JOINT SOUNDS
 There are 2 types of joint sound to look out for:
 Clicks - single explosive noise of short duration.
 Crepitus - continious 'grating' noise
 CLICKS
• A joint click probably represents the sudden distraction of 2 wet surfaces,
symptomatic of some kind of disc displacement. The diagnosis of a joint click, and
therefore treatment, varies on whether the click is :
 left, right or bilateral,
 painful or painless,
 consistent or intermittent.
• The timing of a click is also significant: a click heard later in the opening cycle
may represent a greater degree of disc displacement.
• Clicks may frequently be felt as well as heard, though they are not normally
painful.
• Condylar hypermobility , enlargement of lateral pole of condyle,structural
irregularity of eminence.
• If the click is relatively loud , it is referred to as a “pop”

CREPITUS :
•Crepitus is the continuous noise during movement of the joint,
caused by the articulatory surfaces of the joint being worn. This
occurs most commonly in patients with degenerative joint disease.
•The joint sounds should be listened to with a stethoscope.

TMJ can also be palpated through anterior wall of external auditory
meatus

Examination of other parts
NOSE AND SINUSES

Examination Sequence
 Position the patient so that he is reclining supine comfortable
until the wave form is completely visible (start at 45 degree)
 Rest the patients head on a pillow to ensure that neck musceles
are relaxed
 Look across the neck from the right side of the patient
 Jugular venous pulsation can be seen to confirm abdomino
jugular reflex or occlusion is used
 JVP is the vertical height in centimeters between the top of the
venous pulsation and sternal angle.
 The timing and the form of the pulsation to be noted.
Abdomino jugular reflux:
Gently press over the abdomen for 10 seconds.this increases the
venous return to the right side of the heart temporarily and the
JVP normally rises. This rise can take 15 seconds to decrease
in congestive heart failure.

 Changes of JVP with respiration: JVP falls with
inspiration as the decrease in the intrathoracic pressure
is transmitted to the right atrium.
 Wave form : two distinct peaks per cardiac cycle.
 The “a” wave corresponds to right atrial contraction and
occurs just before the first heart sound. In atrial fibrillation
the “a” wave is lost in the absence of coordinated atrial
contraction.
 The “v” wave is caused by atrial filling during ventricular
systole and the tricuspid valve is closed.
 Third peak rarely seen is “c” wave seen on the closure of
the tricuspid valve.
Occlusion: The JVP is obliterated by gently occluding the
vein at the base of the neck with your finger.
 Can be used to assess JVP
 JVP reflect central venous pressure or right arterial
pressure

INTRAORAL EXAMINATION
Diagnostic set:
Mouth mirror
Probe
Explorer
Tweezer
Position of doctor
Upper left posterior: Stand behind the patient with left hand
around the patient
Upper right posterior: Side of the patient
Lower right posterior: Side of the patient
Lower left posterior: Stand behind the Patient

Lip
 Look for color, texture, vertical or angular fissure
 cleft
 Pigmentations
 Chelitis
Palpation:
 Benign neoplasm is firm and lobulated
 Carcinoma of lip is hard in consistency
 Chancre is rubbery hard
 Mucus retention cyst is found in inner surface of lip

Non healing ulcer on lips Chanchre of lips
SCC of lips
Mucocele of lips
Herpes lesion of lips
Chelitis

Tongue
Inspection:
Volume of the tongue
Papillae of the tongue
Colour of the tongue
Mobility of the tongue
Any crack, swelling, ulcer to be noted
Palpation:
Check the base of tongue for ulcer, induration, selling etc
Check for ankyloglossia

Ankyloglossia
Microglossia Macroglossia
Geographic tongue

Verucous cancer of tongue
SCC OF TONGUE
Syphillis of tongue
Aphthous ulcer

Palate
Inspection
Look for ulcerations
Pigmentations
Fistula
Tori
Hypeplasias etc
Cleft examination
Perforation of the palate
Palpation
Swelling and tenderness to be noted for checking alveolar
abscess.
Soft swelling in mid palate for gumma

Teritiary syphillisPrimary syphillis
Necrotising sialometaplasia SLE
Veerucous carcinoma of palate

Floor of the mouth
Inspection
Ask the patient to touch the palate with tongue to expose the
floor of the mouth
Any swelling, Red and white patches to be noted
Color of the swelling Bluish ranslucent – ranula, Hemangioma-
Red in color
Site of the lesion
•Sublingual dermoid cyst – lies in midline and have submental
extension
•Plunging ranula- Cervical Prolongation to submandibular
region
•Ankyloglossia, red lesion, Pigmented patches etc to be noted

Palpation
Mucous cyst – smooth and mobile
Fluctuation – by pressing on top of the cyst and palpated
by other two fingetrs
Papiloma – solid tumor with irregular surface and mobile
Carcinoma – fixed and indurated

Tonsil and Pharynx
 Size, color and surface abnormalities of the tumor
 Observe faucial pillars for nodules, red and white patches
 Palpate for the discharge, tenderness and restriction of
oropharyngeal airway
Tonsilitis

Salivary Glands
Parotid gland
Position of the gland: below behind and slightly in front of
the ear lobule
Duct: stensons duct on the buccal surface of the cheek
opposite to the crown of upper second molar
Skin over the gland: In case of parotid abscess the skin is
edematous and pitting on pressure
Suppurative parotitis: Gentle pressure over the gland give
purulent saliva
Presence of fistula to be noted
Facial nerve and movement of jaw is affected if the growth
is malignant

Submandibular salivary gland
Swelling with colicky pain at the time of meal suggest
obstruction in submandibular duct
If the obstruction is due to a stone in duct the swelling may
appear at once if patient is asked to suck a lemon or lime juice
Whartons duct seen in the floor of mouth in either side of the
lingual frenum
Palpation
Nodular swelling discrete or matted is suggestive of lymph node
enlargement
Bimanual palpation : patient is made to open the mouth
One finger is placed on the floor of the mouth medial to alveolus and
lateral to tongue and pressed as far as possible
Finger on other hand is pleced on exterior medial to inferior margin of
mandible thus both the superficial and deep lobes of the
submandibular saliverygland can be palpated.

Stenson’s ductWarthons duct
Submandibular gland bimanual palpation
Large sialolith in warthons duct

Examination of the Dental structures
Teeth:
Nomenclature :
 Zigmondy palmer
Universal system
FDI(two digit system)
Inspection:
Look for caries, defective restoration, missing teeth,
supernumerary teeth, Neonatal teeth, size and shape
changes, Mobility, stains and calculus etc.

Taurodontism
microdontia
Screw shaped incisors

Percussion:
Horizontal: Tenderness indicate the periodontal problem
Vertical: tenderness indicate the periapical pathology
Mobility : can be pathologic or adaptive mobility

 Occlusal interferences to be noted
 Presence of periodontal pocket
 Furcation involvement

Pulp vitality testing
Electrical pulp testing
Thermal testing
Anesthetic testing
Test cavity

Gingiva:
Color, texture, consistency shape contour and position of
the gingiva to be noted
Earliest sign of pyorrhea(periodontitis) is deep red line
along the edges of the gum.
Cancrum oris starts with painful, purple, red indurated
papule found on the alveolar margin
Recession of the gingiva to be noted

Pyogenic granuloma
Gingivitis Trench mouth
Linear gingivitis
Nifedipine induced enlargement

Oral odour
 Diabetes can cause fruity smell of mouth
 Excessive smoking
 Indigestion
 Carious teeth, Sinus drainage, Pericoronitis etc.
 Bad oral hygeine. (accumulation of plaque or calculus).
 Drinking of alcohol

Examination of Swelling
Inspection:
situation
Color
Contour
Size
Shape
Surface
Edge
Number
Pulsation
Movement with respiration
Movement on deglutition
Impulse on coughing
Movement with protrusion of the tongue
Skin over the swelling

Palpation:
Temperature
Tenderness
Size, shape and extent
Surface
Edges or borders
Consistency
Fluctuation:
Fluid thrill
Translucency
Impulse on coughing
Reducibility
Compressibility
Pulsatility
Fixity to skin
Relation to surrounding structures

Aspiration:
Straw colored fluid- It contain cholestrol crystals in the wall that
are frequently seen as small shiny particles when the syringe is
transilluminated. Seen in some odontogenic and fissural cyst
thick yellowish white granular fluid- Epidermoid and keratocyst in
which the lamina is filled with keratin
Dermoid cyst – contain dermal appendage and aspirate is the
thickest and fills of yellowish cheesy substance
Sebaceous cyst- contains sebum thick homogenous and yellowish
cheesy substance
Dark amber colored- thyroglossal duct cyst
Lymph fluid- colorless and high in lipid appear cloudy and frothy .
Seen in hygroma and lymphoma
Blue blood- Hemangioma, hematoma and varicosities
Brighter red blood- aneurysyms and arteriovenus fistula
Pus with yellow granule-Actinomycosis
Sticky viscous fluid- in retention cysts

 Percussion:
 Auscultation: exclude the presence of bruit or murmur
 Measurement: to check increase of size of swelling
 Movement: to exclude any impairement
 Examination of the pressure effect:

Ulcer
Inspection:
Size and shape
Number
Position
Edge
Floor
Discharge
Surrounding area

Palpation:
Tenderness
Edge
Base
Depth
Bleeding
Relation with deeper structures

Sinus or Fistula
Inspection:
Number
Position
Opening of the sinus
Discharge
Surrounding skin
Palpation:
Tenderness
Wall of sinus
Mobility
Lump
Examination with a probe: depth of the sinus and direction of
the sinus
Depth of sinus : can be measured by inserting a GP point or a
lacrimal probe.

Intra oral sinus
Extra oral fistula Lacrimal probe in sinus

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