Facial nerve Examination


Facial nerve palsy


  1. General: Loss of facial expressions
  2. Eyelids: on blinking, the affected side closes after the normal eyelid (Bell’s sign – the eyeballs moves vertically upwards when the eye is closed)
  3. Eyes: widened palpebral fissures
  4. Nasolabial folds: flattened on the affected side
  5. Mouth: the affected side droops and moves less when talking


  1. Occipitofrontalis: “ارفع حواجبك
  2. Orbicularis oculi: “زر على عينيك
  3. Orbicularis oris: “ورينى سنانك
  4. Buccinators: “انفخ

Complete examination

  1. Test taste (chorda tempani)
  2. Test hearing (hyperacusis N. to stapedius)
  3. Cause (history – scar)

Parotid Gland Examination


Parotid Gland


Site Parotid region
Shape Parotid shape if diffuse parotid enlargement
Skin and color Scar, fistula
Special signs Relation to chewing food


Relations to the surroundings:


Relation to skin Freely mobile, Tethered or Fixed
Relation to muscles Masseter “جز على سنانك” and Sternomastoid
Relation to nerves Facial nerve examination
Relation to artery Superficial temporal artery pulse
Ear Elevation of ear lobule
Other swellings
Reducibility ?
Solid, fluid or gas
  • Consistence
  • Fluctuation

Open the mouth to assess

  • Ability to open
  • What happen to the lump?
  • Parotid lump usually diminish in size due to tension of parotid facsia
  • Dryness of the mouth
  • Swellings of submandibular glands and its duct (bimanual examination)
  • Parotid duct
  • Deep part of the parotid gland

Continue reading “Parotid Gland Examination”

Thyroid Examination


Thyroid Examination

General examination for thyroid status
  1. Increased sweating
  2. Palmer erythema
  3. Pulse and water hummer pulse (Tachycardia, AF, Any arrhythmia except HB and Sleeping pulse >90 bpm)
  4. Fine tremors (by a sheet of paper on out stretched hands with palms facing downwards)
  5. Thyroid acropachy
  6. Onycholysis
  7. Areas of vitilligo

(stabilize the head)

  1. Lid retraction (front – Dalrymple’s sign)
  2. Lack of forehead wrinkling on looking upwards without moving the head (front – Joffroy’s sign)
  3. Lid lag (front – Von Graefe’s sign)
  4. Defective convergence (front – Moebius’s sign)
  5. Ophthalmoplegia (front)
  6. Exophthalmos (back)
  7. Loss of hair of outer third of eyebrows
Other systemic manifestations
  1. Pretibial myxoedema
  2. Proximal myopathy
  3. Signs of heart failure
  4. Gynecomastia

Thyroid Examination

Local examination



Position Patient: Neck extended

Doctor: In front of the patient

Patient: Slightly flexed

Doctor: Front then behind

Exposure All head till clavicle All head till clavicle
Comment on


  • lump (as any swelling)
  • Scar of previous operation (Healing or Complication)

Relation to surrounding

Sternomastoid Muscle contraction
  • Tilt the patient’s head to the same side
  • Pinch the muscle
  • Ask him to swallow
Skin Ask patient to swallow Ask patient to swallow
Carotid artery
  • Normal site
  • Equal volume
  • Displacement
  • Weak pulse
  • ‘Berry’s sign’
Trachea Move up and down

While standing the patient put fingers on gland and ask him to swallow will feel the gland and the larynx go up

Put fingers to stop descent of the gland while the larynx goes down

Manubrium Is lower edge seen? Is lower edge felt?
Neck L.N.s
Neuro-Vascular Bundle
Percussion Resonant or dull?
Auscultation Upper pole of the gland

To hear systolic bruit if gland is highly vascular as in toxic goiter

Continue reading “Thyroid Examination”

Neck examination


Neck examination

Lymph nodes examination (up-and-down technique)
  1. Palpate from the chin backwards to below the ears (submental – submandibular – parotid glands – pre-auricular)
  2. Move your hand behind the ears (post-auricular) and palpate DOWN the anterior border of sternomastoid to the clavicle (anterior triangle including jugulodigastric)
  3. Move laterally along the clavicle (supraclavicular – infraclavicular) then UP the posterior border of sternomastoid (posterior triangle)
  4. Finish by palpating back of the scalp (occipital nodes)
+ Face and scalp examination (thyroid examination if the swelling in front of the neck)

+ Area above the umbilicus (breast examination in females)

+ ENT examination searching for primary site of infection or neoplasia

+ Abdominal examination (hapatomegaly and splenomegaly) and the rest of lymphoreticular system (other groups of lymph nodes)


image source: http://pedsinreview.aappublications.org/content/34/5/216

Continue reading “Neck examination”

Examination of Oral Cavity

This is a simplified plan to examine the mouth and the tongue..

The Mouth and the tongue


Anterior 2/3
  • Size
  • Shape
  • Papillae
  • No fissures
  • Congenital tie
  • Short ferenulum
  • Ankyloglossia
  • Congenital fissures
  • Geographical tongue

Corda tempani (facial nerve)


Lingual nerve (trigeminal nerve)


Hypoglossal nerve

Paralyzed tongue deviate to the paralyzed side

Posterior 1/3 Not accessible except mirror or under anaesthesia
Lump (as any swelling)
Ulcer (as any ulcer)

Do not forget examination of cervical lymph nodes


Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms Relation to the main complaint

  • Swelling
  • Ulcer
  • Pain
  • Causes of chronic superficial glossitis that predispose malignancy (six Ss)
    • Syphilis, Smoking, Sharp tooth, Spirits, Spices and Sepsis
  • Sequelae of malignancy of the tongue


Local (posterior 2/3)



Lymph nodes enlargement


Lingual artery


Lingual nerve

Pain referred to ear

Recurrent laryngeal nerve

Hoarseness of voice





Aspiration pneumonia





Causes of ulceration of the tongue

(Traumatic, Neoplastic, inflammatory, ischemic, autoimmune,..)

  • Aphthous ulcer
  • Trauma (dental)
  • Non-specific glossitis
  • Chancre
  • Gumma
  • TB
  • Carcinoma
  • Lichen planus
  • Herpetic ulcers
Causes of macroglossia
  • Multiple haemangiomata
  • Multiple lymphangiomata
  • Plexiform neurofibromatosis
  • Amyloid infiltration
  • Infiltrating carcinoma
  • Muscle hypertrophy (cretins)
Causes of swelling of the jaw
  • Infection
    • Alveolar (dental) abscess
    • Acute osteomyelitis
    • Actinomycosis
  • Cysts (odontomes)
    • Dental cyst
    • Dentigerous cyst
    • Other odontogenic cysts and cystic tumors
  • Neoplasm
    • Benign
      • Fibrous dysplasia
      • Giant cell granuloma
      • Odontogenic tumors
    • Locally invasive
      • Adamantinoma
    • Malignant
      • Osteogenic sarcoma
      • Malignant lymphoma (Burkitt’s tumor)
      • Secondary tumors (by direct invasion or blood spread)
  • Epulides
    • Fibrous epulis
    • Granulomatous epulis
    • Myeloid epulis
    • Sarcomatous epulis
    • Carcinomatous epulis
Dental Cyst vs. Dentigerous Cyst

Dental cyst

Dentigerous cyst

Adult Young age
In relation to carious tooth In relation to missing tooth
Maxilla Mandible
Incisors and canines Premolars and molars
Unilocular Tooth inside

Scalp Examination


Scalp examination




  • Number
  • Site
  • Shape
  • Size
  • Surface

Skin and color   Alopecia

  • Special signs

Pulsations Metastasis

Cirsoid aneurysm

Impulse on cough Meningiocele


  • Relations to the surroundings .. Mobility
  • Relation to skin
  • Relation to muscles
  • Relation to bone
  • Other swellings
  • Temperature
  • Tenderness
  • Edge
  • Reducibility
  • Solid, fluid or gas
  • Consistence
  • Fluctuation
Ulcer (as any ulcer)
Differential diagnosis of scalp disorders
  • Traumatic
    • Heamatomas
    • Cephalhaematoma
  • Sebaceous cyst
  • Neoplastic
    • Benign
      • Ivory osteoma
      • Lipoma
      • Haemangioma (capillary, cavernous and arterial)
      • Neurofibroma
    • Malignant
      • Primary
        • Basal cell carcinoma
        • Squamous cell carcinoma
        • Malignant melanoma
        • Leukaemia
        • Myeloma
      • Secondary
        • Breast
        • Bronchus
        • Thyroid
        • Prostate
        • Kidney
  • Infective
    • Cock’s peculiar tumor
    • Tinea capitis
    • Abscess
  • Others
    • Psoriasis
    • Seborrhoeic dermatitis
    • Meningiocele
    • Dermoid cyst

Anatomical Significance

 SCALP Layer Content Surgical importance
S Skin Hair follicles
  • Alopecia
  • Sebaceous Cyst
  • If multiple Turban
C CT Blood vessels
  • Bleeds a lot
  • Good healing
  • Site of heamatomas
nerves Layer of local anesthesia
Fibrous tissue septa Heamatoma will be localized
A Aponeurosis
L Loose areolar tissue Loose
  • Dangerous
  • Spread of infection
  • Mobile Cutaneous swelling
  • Layer of descalping
Emissary veins
P Periosteum

Examination of an ulcer

Points to be emphasised while examining an ulcer in an OSCE station





  • Number
  • Site
  • Shape
  • Size (and Depth)
  • Floor
  • Edge
  • Margin
  • Discharge
  • Temperature
  • Tenderness
  • As inspection
  • Base
    • Extent
    • Induration
    • Tenderness
    • Motility
Draining L.N.s
Neuro-Vascular Bundle

How to take a history from a patient with an ulcer

Differential Diagnosis of an Ulcer

According to the cause



Trauma Sloping edge
inflammation TB undermined edges

associated with pain

Venous various veins i.e. Venous Ulcer Sloping edges
Lymphatic With lymphoedema
Neurologic diabetic neuropathy Neuropathic ulcer

Without pain

Neoplastic SCC


Everted edges

Beaded edges


According the site
Face Leg Foot Tongue
Rodent ulcer



Ulcerated seb. Cyst

Ulcerated M.M.

TB ulcer

Vascular Venous



neuropathic Dyspeptic






Traumatic Vascular Ischemia
Infection TB Traumatic
Neoplastic -1ry as MM or BCC

-Ulcerated deep malignancy

Signs suggestive of malignancy in an ulcer
  • Rapid increase in size
  • Rapid increase in ulceration
  • Bleeding
  • Change in color
  • Halo of pigmentation
  • Satellite nodules
  • Irritation
  • Lymph node enlargement
  • Distant metastasis
Floor of an ulcer
  • Malignant necrotic tissue
  • Granulation tissue
    • Healing
      • Pink
      • Finley granular
      • Bleed in touch
      • Level with skin
    • Non-healing
    • Non specific
      • Pale or yellow
      • Very vascular
    • Specific
      • Like TB caseation