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physical examination

The Head and Neck

Department of Physical Diagnostics


1st Teaching Hospital
Henan Medical University
血液科 刘延方 博士后
A CASE REPORT
A lady, aged twenty, became affected with some symptoms
which were supposed to be hysterical…. After she had been
in this nervous state about three months it was observed
that her pulse had become singularly rapid…. She next
complained of weakness on exertion and began to look pale
and thin…. It was observed that the eyes assumed a
singular appearance, for the eyeballs were apparently
enlarged. In a few months… a tumour, of a horseshoe shape,
appeared on the front of the throat and exactly in the
situation of the thyroid gland.
ROBERT JAMES GRAVES
1796-1853
头部检查
head examination

头颅 skull
头发 头皮
头颅外形和运动
颜面器官
眼 eye
耳 ear
鼻 nose
口腔 mouth
Skull
Contour: ellipse-shaped
Size (Normal):
„ Neonatal: 34cm
„ Adult: > 53cm
Large skull巨颅
(hydrocephalus脑积水):
sunset phenomenon
Microcephaly小颅:
囟门过早闭合
头颅外形——形状异常
Acrocephaly尖颅the
尖颅 coronal and
sagittal suture fuses
prematurely矢状缝与冠状缝过早
闭合
Squared skull方颅rickets
方颅 佝偻病,
佝偻病
congenital syphilis先天性梅毒
Delichochocephalia长颅Marfan综
合征acromegaly
合征
Deforming skull变形颅变形性骨炎
(Paget病)
Movement 头颅运动

Normal: free
Limited运动受限
diseases of cervical vertebrae 颈椎病变
Involuntary movement不随意颤动
Parkinson’s disease震颤麻痹
Nodding movement点头运动:
Aortic insufficiency动脉瓣关闭不全
Organs in the Head

„ Eyes

„ Ears

„ Nose and sinuses

„ Mouth and throat


EYES 眼部检查内容
眼眉 eyebrow
眼睑 eyelids
结膜 conjunctive
巩膜 sclera
角膜 cornea
虹膜 iris
瞳孔 pupil
眼球 eyeball
Eyebrow 眼眉

Hair of the eyebrows:


¾Loss of the lateral third of the
eyebrows:
¾Myxedema 外1/3稀疏或脱落
¾Sheehan’s disease
¾Loss of all hair: leprosy 麻风病
Eyelids

Everting the lid for examination


Eyelids眼睑 Entropion

„ Edema: renal diseases


„ Entropion 睑内翻: trachoma砂眼
Ptosis上睑下垂 Ptosis
Bilateral双侧: myasthenia gravis重症肌无力
Unilateral: oculomotor paralysis动眼神经麻痹
„ Inability to close completely
„ Bilateral: hyperthyroidism甲状腺机能亢进
„ Unilateral: facial paralysis面神经麻痹
Conjunctiva结膜
¾ Palpebral conjunctiva 睑结膜
Pale 苍白: anemia 贫血
Congestion充血: conjunctivitis
Petechiae出血点:
bacterial endocarditis
Granular follicle 颗粒滤泡:
trachoma 砂眼
¾ Bulbar conjunctiva 球结膜
Congestion and swelling 充血水肿
Carbon dioxide retention
Cerebral edema
Sclera巩膜

ƒ Color: white

ƒ Scleral icterus (yellow or


green)黄染: liver diseases
Cornea角膜
¾ Normal: transparent (无色透明)
¾ Abnormal:
¾ Nebula, blaze, ulceration云翳 白斑 溃疡
¾ Angiopoiesis周围血管增生: trachoma砂眼
¾ Keratomalacia 软化:
Vit.A deficiency
Inflammation
¾ Kayer-Fleischer rings 边缘黄棕褐色环:
Wilson’s disease 肝豆状核变性 铜代谢障碍所致
Iris & Pupil 虹膜与瞳孔
„ Contour
™ Normal: round
„ Abnormal:
„ Ellipse椭圆形: glaucoma青光眼, intra-
global tumor眼内肿瘤
„ Irregular: synechiae虹膜粘连(uveitis眼葡萄
膜炎)
Iris & Pupil
„ Size (2~5mm)
Normal: 3~4mm
„ Dilation扩大: glaucoma, atropinization青
光眼 阿托品中毒
„ Contraction缩小: organophosphorus
poisoning, drug reaction, narcotic
taking虹膜炎 中毒 药物反应
„ Platycoria双侧散大: dying濒死状态
Iris & Pupil
Symmetry等大等圆
Anisocoria不等大: Pathology anywhere
from the reception of light through
the optic nerves to the brain stem,
the third cranial nerve, sympathetic,
or parasympathetic pathways
脑疝 一侧动眼神经受压
虹膜与瞳孔——反射

¾ Light reflex 对光反射(和)光刺激后瞳孔缩小


Direct light reflex 直接
Consensual reflex 间接
¾ Accommodation reflex 调节反射
视物由远至近时瞳孔逐渐缩小
¾ Convergence reflex 辐辏反射(眼球运动)
视物由远至近时眼球向内聚合
The Globe
Movement: Controlled by the integrated
function of the cranial nervesⅢ (oculomotor),
Ⅳ (trochlear),Ⅵ (abducens) and the six
extraocular muscles.
Abnormal
Unilateral: cranial nervesⅢ (oculomotor),
and Ⅵ (abducens) disfunction
Tremor: Bilateral, 耳源性小脑疾病
The Globe
Exophthalmos突出
Bilateral: hyperthyroidism
甲状腺机能亢进
Unilateral: Intra-orbital disease
(tumor) 眼眶内病变
Endophthalmos内陷
Bilateral: severe dehydration
严重脱水
Unilateral: Horner’s syndrome
颈交感神经受压
The Globe
Pressure:
Increase(unilateral): glaucoma青光眼
Decrease
Bilateral: severe dehydration严重脱水
Unilateral: Horner’s syndrome
The eyes in Hyperthyroidism
Inability to close completely
眼睑闭合障碍
Exophthalmos 眼球突出
Graefe征
眼球下转时
上睑不能相应下垂
Stellwag征: 瞬目减少
Mobius征: 辐辏运动减弱
Joffroy征: 上视时无额纹
耳部检查内容

耳廓 Pinna
外耳道
external auditory canal
鼓膜 Tympanic membrane
乳突 mastoid process
External Auditory Canal
„ Skin: Swelling, redness, and pain when
the auricle is pulled: inflammation
„ Exudate and discharge:
„ Yellow: inflammation
„ Purulent: tympanitis中耳炎
„ Blood or cerebrospinal fluid: basicranial
fracture 颅底骨折
„ Cerumen: ceruminal impaction耵聍阻塞
„ Ear drum:
External ear
Pinna: Hard white discrete
nodules 痛性小结:
gouty tophus痛风
Redness, swelling, hot, pain:
infection
Tympanic membrane
Change of color
Red or yellow
Perforation: Tympanitis
Mastoid Process
Middle Ear
Mastoid Process
™ Tenderness, skin redness,
swelling, fistula: mastoiditis

Hearing:
The nose

External examination
Internal examination
External examination
„ Shape Frog-shaped
Frog-shaped : polyps
Saddle
Saddle nose鞍鼻 :
destruction of basal nose:
bones 鼻梁塌陷
„ Color
Rhinophyma (Acne Rosacea):
Prominent hypertrophy of the
sebaceous glands of the nose
with over growth of the soft
tissue.
Lupus蝶形红斑: SLE皮肤狼疮
Nostril 鼻腔
™ Obstruction : Rhinitis, Nasal Polyps
™ Discharge( rhinorrhea) 分泌物增多:
™ Rhinitis鼻炎, sinusitis鼻窦炎

™ Epistaxis鼻出血

™ Local causes: Traumatic or spontaneous rupture of

the superficial mucosal vessels in Little’s area. Chronic


sinusitis or malignance. Nose-picking. Cocaine abuse.
™ Generalized causes: Epidemic hemorrhagic fever,

hematopoietic diseases.
™ Nasal septum鼻中隔: deviation, perforation
Movement

Nasal ala flap 鼻翼扇动:


Dyspnea 呼吸困难
Sinus Anatomy: Front View
•frontal sinus=black check
•maxillary sinus=red,
•anterior ethmoid
sinuses=green
•posterior ethmoid
sinuses= purple,
•sphenoid sinus=yellow
Sinus Anatomy: Side View
„ frontal sinus=black
check
„ maxillary sinus=red,
„ anterior ethmoid
sinuses=green
„ posterior ethmoid
sinuses= purple,
„ sphenoid sinus=yellow
Sinuses
Frontal Frontal EthmoidSphenoid
„ Location sinuses sinuses sinusessinuses

Frontal sinuses额窦
Ethmoid sinuses筛窦
Maxillary sinus上颌窦
Sphenoid sinuses

„ Tenderness &
percussion pain EthmoidMaxillary Maxillary
Sinusitis
sinusessinus sinus
The Oral Cavity and Pharynx

LOOK TO THY MOUTH;


DISEASES ENTER HERE.
GEORGE HERBERT 1593-1632
The Oral Cavity
1. Buccal mucosa粘膜
2. lips口唇
3. tongue舌
4. Hard and soft palates
5. teeth牙齿
6. Salivary glands
7. Gingivae 牙龈
8. Pharynx 咽
9. tonsil扁桃体
10. Halitosis 气味
Lips
Color Normal: ruddy
Abnormal: pale, cyanosis发绀,
fissuring and cracking干裂
Cleft lip唇裂: Abnormal development发育异常
Perlèche口角糜烂: lactoflavin deficiency核黄素缺乏
Herpes labialia口唇疱疹: high fever, herpes virus
infection单纯疱疹病毒感染
Pachycheilia口唇肥厚: myxedema, acromegaly
Buccal mucosa

Petechia, purpura, ecchymosis:


hemorrhagic diseases, Vit. C deficiency

Koplic’s spot (Koplik斑) : measles麻疹粘膜斑


Uleration:chronic relapsing aphtha口疮
White pitches白色膜状物: thrush or Candida雪口病
鹅口疮
The Teeth

Teeth
Abnormal
Caries 龋齿
Residual root残根
Artificial teeth义齿
Malocclusion缺齿
Quadrant description

右 左

Gingivae/Gums
„ Swelling and pyorrhea水肿溢脓:
水肿溢脓
Chronic periodontitis慢性牙周炎

„ Haemorrhage出血:
出血
dental calculus牙石,
牙石 hemorrhagic diseases,
Vit C deficiency

„ Pigmentation游离点线状色素沉着:
游离点线状色素沉着
heavy metal intoxications
„ Grey-black蓝灰色:
蓝灰色 lead铅
„ Black-brown黑褐色: bismuth铋, mercury汞, arsenic
Tongue
Size舌体
„ Enlarged肿大
„ Inflammation,
„ Myxedema,
„ Tumor,
„ Acromegaly
„ Shrinked干小
„ Severe dehydration
Appearance of tongue舌象
Geographic Tongue地图舌:黄色斑片 提示核黄素缺乏
Smooth Tongue镜面舌:光滑红色 铁或维生素B12缺乏
Fissured Tongue草莓舌:舌乳头肿胀 长期发热
Black Hairy Tongue黑毛舌:黑黄褐色毛 真菌感染
Extensive Oral Thrush: Oral candidiasis

Three normal tongue variants:


①Geographic Tongue; ②Black Hairy Tongue;
③ Fissured Tongue
Geographic Tongue
normal variant
Smooth Tongue
niacin deficiency
Fissured Tongue
normal variant
Extensive Oral Thrush
previous antibiotic therapy
Black Hairy Tongue
antibiotic therapy
Macroglossia
congenital anomalies
Movements

„ Tremor舌体震颤
hyperthyroidism
„ Deviation伸舌偏斜
hypoglossal nerve palsy
舌下神经麻痹
Pharynx
Pharynx:
Turkey red accompanied by swelling:
Acute pharyngitis Ⅱ Ⅰ
Wine accompanied by follicle:
Chronic pharyngitis
Tonsil
Degree of Tonsil Swelling
Ⅰ°不超过腭咽弓
Ⅱ°超过腭咽弓未达中线 Ⅲ
Ⅲ°达到超过咽后壁中线
Purulent
——化脓性扁桃体炎
口腔气味
烟味
酒味
口臭味———牙龈炎
烂苹果味——酮症酸中毒
尿味————尿毒症
肝臭味———肝坏死
大蒜味———有机磷中毒
Parotid Gland腮腺
Gland swelling腮腺肿大
以耳垂为中心肿胀
——炎症或肿瘤
用压舌板观察
Stensen’s duct颊粘膜导
管口
Discharge increase分泌
物增多
Inflamation
The Neck
颈部检查
cervical vein颈静脉
carotid artery beat
颈动脉搏动
Bronchi 气管
Thyroid甲状腺
Blood vessels颈部血管
„ Distended cervical vein颈静脉怒张
„ Right heart failure,

„ Pericardial effusion,

„ Loeffer’s endocarditis

„ Enhanced carotid artery beat 颈动脉搏动


„ Bronchi 气管
„ Thyroid甲状腺
颈静脉怒张
„ 判断标准
半卧位(30 ̄45°)时
静脉充盈水平超过
锁骨上缘至下颌角下2/3
„ 临床意义
体循环静脉压升高
右心功能不全 心包积液
缩窄性心包炎
上腔静脉综合征
Measuring the Height of the
JVP
Carotid Artery
™ Enhanced carotid artery beat
™ Aortic insufficiency主动脉瓣关闭不全

™ Hypertension 高血压

™ Hyperthyroidism甲状腺功能亢进

™ severe anemia严重贫血

™ Systolic bruit血管杂音
™ Artery narrowing动脉狭窄

™ Carotid artery颈动脉

™ Vertebral artery椎动脉

™ Subclavian artery锁骨下动脉
Trachea
Palpation of the Trachea
Location: normally in the middle
Indicate the location of mediastinum
Clinical significance:
Deviation may caused by mediastinum and/or
thyroid shifting
移向健侧
——胸腔纵隔推移
大量胸腔积液
气胸
移向患侧
——肺胸膜牵拉
肺不张
Thyroid gland
Size, shape 大小 形状
Symmetry 对称性
Nodule 表面有否结节
Tenderness 硬度与压痛
Tremor 震颤
Movement 随吞咽移动
Murmurs 杂音
Method of examination
Inspection 视诊
Palpation 触诊
Palpation
of the thyroid gland
Thyroid gland swelling
™Ⅰ Invisible but palpable
™Ⅱ Visible and palpable
™ⅢExceeding the out
margin of sterno-mastoid
muscle
Abnormality
Enlarged Thyroid gland
„ Markedly : simple goiter
„ W/ thrill, bruit:
„ hyperthyroidism
„ W/ fever, pain:
„ thyroiditis
„ Hard w/ nodule:
„ thyroid carcinoma
Movement of the Neck
„ Limited and accompanied with pain:
soft tissue inflammation
„ Head tilt: muscle spasm
„ Diminished muscle strength:
myasthenia gravis
„ Rigidity: meningeal stimulus sign
预告下次内容

„ 胸廓检查
„ 肺部检查
视触叩诊
A CASE REPORT
A lady, aged twenty, became affected with some symptoms
which were supposed to be hysterical…. After she had been
in this nervous state about three months it was observed
that her pulse had become singularly rapid…. She next
complained of weakness on exertion and began to look pale
and thin…. It was observed that the eyes assumed a
singular appearance, for the eyeballs were apparently
enlarged. In a few months… a tumour, of a horseshoe shape,
appeared on the front of the throat and exactly in the
situation of the thyroid gland.
ROBERT JAMES GRAVES
1796-1853