Inspection

INSPECTION (inspectio) of the patient represents a method of investigation used since time immemorial, as the most natural, accessible, and simple, but at the same time very reliable and in many ways irreplaceable. One attentive glance in many cases gives an idea not only of the general somatic and psychic appearance of the subject, but often also determines his general condition and many characteristic phenomena that have great diagnostic significance. Visual impressions to a large extent also predetermine the choice of other methods of investigation. Despite the fact that during I. (inspection) no instruments are mostly used, a systematic application of certain techniques and methodology is still required, as well as the ability to determine the diagnostic significance of visible phenomena. General lighting technique. When using light for medical inspection, the intensity and concentration of illumination, the direction of rays, and the color tone must be taken into account. Light intensity. As a rule, illumination should be at least bright enough to allow reading ordinary print in normal font from several steps away from the light source. At the same time, it should be uniform, diffused. Concentrated light in the form of a bundle of bright rays is mainly needed when examining very small objects and when examining natural cavities with the naked eye or by means of instruments (mirrors, narrow tubes), as well as when it is necessary to see tissues located at a certain depth with complete clarity, for example, during various operations and manipulations. Under other conditions, too bright and concentrated light is not advisable. The direction of light rays also has very great significance. Direct (frontal) lighting much better reveals the entire object as a whole, its constituent parts, details and color shades on the illuminated surface. Side lighting obscures details and color shades, but instead creates contrasts between more and less illuminated (shaded) objects and their parts; thanks to this, it better reveals the outlines of the body, contours and reliefs (profile) and allows one to grasp subtle changes in form not only on the surface, but even under the outer coverings of the body. Thus, side lighting much more clearly reveals the apical impulse of the heart and the pulsation of vessels; with the body in a vertical position and with a thin abdominal wall, it sometimes allows one to see the contours of a filled stomach; with the body lying on its back, one can much better see the peristaltic movements of the stomach and intestines; only with the body lying on its back with the head toward the light can one see during respiratory movements the shadow of the diaphragm moving from top to bottom and back (Litten's phenomenon), and at the same time often also the shadows of moving abdominal organs. Transmitted light, i.e., light passing through tissues, can also be used in inspection. Thus, when examining the auricle of the ear or the fingertips against the light, one can easily notice a more or less intense pink color of them, which makes it possible to conclude about their blood filling and the saturation of blood with hemoglobin. Color tone. Certain types of artificial lighting, such as the flame of a kerosene lamp or gas burner and even electric bulbs, especially with a carbon filament, give light with a predominance of yellow color, which deprives one of the ability to notice the difference between the colors of illuminated objects, for example between blue and green color, as well as between pink and yellow. Therefore, with artificial light, it is usually almost impossible to notice yellow discoloration of the skin and mucous membranes, even with pronounced jaundice, it is much more difficult to notice blueness, pigmentation (from suntan, in bronze disease, etc.) and even decreased filling of the coverings. In the absence of sufficient daylight for I. (inspection), diffused white artificial light from a strong source is used as much as possible; namely: 1) electric bulbs of 100-500 or more candlepower with frosted glass or with clear glass and a lower shade of milk glass in the form of a bowl, or 2) Auer gas or alcohol burners with frosted caps, which give even better light, similar to daylight. For medical I. (inspection), daylight is still the most convenient. For illuminating cavities more accessible to inspection (such as the oral cavity, pharynx, nose, and ear), it is much more advisable to use reflected light, for which a hand or forehead reflector (in the form of a round concave mirror) and usually stronger artificial light sources serve. When using artificial light, daylight is eliminated by dark curtains or dense shutters. The lamp is placed on the table so that the light source is at the level of the cavity being examined, next to the subject being examined but somewhat to the back.

General inspection technique. In addition to appropriate lighting during inspection, it is also necessary to keep in mind the exposure of the subject being examined and his position. Appropriate exposure during inspection of usually covered parts of the body is of course necessary, but simultaneous complete exposure should be avoided as much as possible. It is absolutely necessary: 1) during mass physical examinations to determine the general state of health; 2) when a complete examination of constitutional features is intended, which often depend on endocrine disorders, particularly in the sexual organs; 3) in deformities of the spine, pelvis, and limbs. The position of the subject being examined should be such that the parts of the body being examined are illuminated by full light. During I. (inspection) of the trunk, the subject should be as much as possible in a sitting position, holding the head straight and letting the arms hang freely, and be at 2-3 steps from the examiner, first facing him under direct frontal lighting; then, remaining in the same place, the patient should turn successively with all sides to the light. Thanks to this, all parts of the body can be seen both under direct and side lighting. In a standing position, as a rule, the chest is examined, paying particular attention to its respiratory excursions, the apical impulse of the heart, and the phenomena of pulsation, which in a lying position may decrease or even disappear. The abdomen should also first be examined in a standing position. In a lying position, the undulation of the neck veins is much better seen, only in a lying position the movement of the diaphragm and the respiratory displacement of abdominal organs. In a lying position, the abdominal press relaxes, as a result of which the abdomen sinks in the middle and spreads out to the sides. During general examination, the height and build and the entire somatic constitution of the subject being examined are first revealed, determined by the combination of many stable (static) signs in certain combinations (captured directly). Among these signs, the following deserve special attention: length, width and thickness of the entire skeleton, in particular the skull and limbs; length and volume of the neck, chest and abdomen; development of musculature; thickness and distribution of fat deposits in subcutaneous tissue and in cavities; condition of lymph glands, thyroid gland; sometimes also peculiarities in the structure of external genital organs, development of secondary sexual characteristics, in particular the hairy covering (its properties and distribution), color and properties of skin, nails, teeth and eyes; facial features. During general medical I. (inspection), many more variable but characteristic dynamic signs of the subject are also revealed. These include: facial expression, mimicry, blood filling and color of the face, expression of the eyes, size of pupils, position of the body (posture), character of gait and in general movements, manner of bearing oneself, speaking, dressing, etc. In combination with stable constitutional signs, the individual appearance of the subject being examined, somatic and partly psychic, his age, temperament, intellect and often traits characterizing even his profession are determined. The general somatic pathological type-habitus of patients, determined by the combination of constitutional features and visible changes that have developed under the influence of various pathological conditions, often has even more important practical significance than the constitutional type.

The somatic and mental state of the patient is also largely determined by visible signs, predominantly of a functional nature. These include characteristic facial expressions, general hyperemia or feverish flush, paleness of the face, feverish brightness of the eyes, a fixed gaze, general immobility, disordered movements, twitching, various types of convulsions, uneven breathing, etc. Through various combinations of such signs in conjunction with phenomena perceived by other sense organs, the patient's condition is determined as visible illness, exhaustion, state of excitement, manic, febrile, typhoid, etc. Among the various phenomena observed during the patient's inspection, some, indicating characteristic disorders of different functions and anatomical changes in organs, stand out as significant signs; certain combinations of them constitute specific clinical syndromes, the presence of which often outlines the general picture of the disease. Systematic external inspection. Head. Of particular importance are: a large head in hydrocephalus and a head with an underdeveloped occiput but a prominent vault, overhanging forehead, and protruding chin (caput progeneum), often found in mental retardation or idiocy; the same head shape is often seen with pronounced microcephaly; a square head is characteristic of rickets; unossified fontanelles and softening of the occipital bones (craniotabes) indicate delayed ossification in childhood; scars on the head may explain persistent headaches, dizziness, Meniere's symptom complex, convulsive states. Face. The following changes have diagnostic significance: 1) leonine face with bumpy-nodular thickening of the skin under the eyes and above the eyebrows and an enlarged nose - in leprosy; 2) acromegalic face with enlargement of prominent parts (nose, chin, cheekbones) - in acromegaly and to a lesser degree during puberty and pregnancy; 3) myxedematous face, uniformly puffy (mucous edema) with narrowed eye slits, smoothed contours, and often loss of hair on the outer halves of the eyebrows; 4) puffy face: a) due to general edema in kidney and heart diseases, particularly in alcoholism, b) due to local congestion in frequent coughing and asthma attacks, and c) from compression of lymphatic pathways in large effusions into the pleural (and pericardial) cavity, in mediastinal tumors, enlargement of mediastinal lymphatic glands, and acute hemorrhagic swelling of them in anthrax septicemia; 5) Parkinson's mask (amimetic face) in the outcome of epidemic meningoencephalitis; 6) wax doll face - slightly puffy, sharply pale with a yellowish tint and skin that appears translucent - in malignant anemia; 7) cachectic face, sunken, pale with a grayish tint, with an expression of hidden suffering - a relatively early symptom in cancer, especially of abdominal organs; 8) facies hippocratica, a face deeply sunken with an expression of suffering, sunken eyes, a sharpened nose and chin, and deepened folds, covered with cold sticky sweat - in peritonitis; 9) facies cholerica, a corpse-like face, pale and darkened, with sunken cheeks, sharpened features, sunken, often rolled-back eyes; 10) phthisical face, thin - with bright feverish flush, increased brightness of the eyes, a burning, inspired gaze; 11) typhoid face with suppressed mimicry and a confused, aimless gaze; 12) septic face, somewhat edematous and immobile (smudged), pale, sometimes with a slight yellowish tint and a confused gaze; 13) face expressing sardonic laughter (risus sardonicus) - contraction of facial muscles creating an expression of bitter smile - in tetanus; 14) face with a persistent expression of surprise - in effusion in the region of crossing of the optic nerves; 15) Basedow's face - quickly reddening, often with moist skin, mobile, with widened eye slits, increased brightness of the eyes, and often with exophthalmos, which gives the face an expression of fear; 16) face in meningitis - concentrated, sometimes with a threatening expression, often dilated uneven pupils, strabismus or ptosis; 17) face in chorea with rapidly changing grimaces, frequent blinking, protrusion of the tongue. Also always deserving of attention, having various symptomatic significance, are the faces of the blind, idiot, maniac, melancholic, hypochondriac; faces with an expression of suffering, oppression, confusion, anxiety, concentration, sadness, exhaustion, indifference, excitement, etc. Local changes deserving of attention include: hemiplegia or paresis of facial muscles; a tumor in the region of the ascending branch of the lower jaw - in enlargement of the parotid gland due to epidemic (mumps) or purulent inflammation; a limited tumor in the jaw region - in purulent periodontitis or periostitis; a small limited swelling or edema near the nose or between the eyebrows - in inflammation of the maxillary and frontal sinuses. Eyes. Exophthalmos occurs as a racial or individual characteristic, then in severe myopia, Basedow's disease, and retrobulbar tumors; widened eye slit with non-closing eyelids - in peripheral paralysis of the facial nerve as a result of spasm of the muscle that raises the eyelid and due to scars causing eyelid wrinkling; persistently drooping upper eyelid (ptosis) - one of the important symptoms of meningitis; strabismus; nystagmus is observed in disseminated sclerosis; persistent dilation, constriction, or unevenness of pupils - in lesions of the central nervous system, particularly in cerebrospinal syphilis; in poisonings - dilation under the influence of atropine, cocaine, constriction in morphinism, tobacco poisoning; unilateral dilation of the pupil - from pressure on the cervical branches of the sympathetic nerve, functional - in unilateral pains (pleurisy, pneumonia), in worms; rhythmic contraction of pupils (hippus) - in meningitis, multiple sclerosis, before convulsions, sometimes in neuroses. Bluish coloration of the sclera - as a constitutional feature together with otosclerosis; particularly bright eyes - in phthisical patients and in Basedow's disease. Among transient phenomena, even slight jaundice of the sclera, their injection in some acute infections, hemorrhage in severe coughing (especially whooping cough) and in elevated blood pressure; dryness of the sclera and cornea - a significantly important sign of death. Swelling of the suborbital fat tissue is one of the most obvious manifestations of general edema, particularly of renal origin, but also occurs in frequent coughing attacks, in asthma, and after sleepless nights. A pug nose is characteristic for rhinoscleroma; a red bumpy nose - for acne rosacea; a saddle-shaped depressed nose - for gummatous syphilis, sometimes also under the influence of trauma, which may be important for explaining nasal breathing disorders, dizziness, headaches; a blade-shaped nose - in adenoids. Mouth. During inspection, attention should be paid to: an open mouth - in nasal breathing disorders; size and shape of the mouth: drooping corner of the mouth and smoothed nasolabial fold - in facial nerve paresis; thickness of the lips, hyperemia, paleness, blueness, often depending on blood composition; dry lips under various conditions (elevated temperature, excitement, polyuria); dry lips with brown crusts (fuliginous coating) in severe infections and intoxications; herpes on the lips in some infectious diseases (especially in lobar pneumonia, but not in typhoid fever), more rarely in gastrointestinal disorders; swelling with redness as a sign of local inflammation, signs of hard chancre, anthrax, cancer. Oral mucosa: brown spots (especially on the inner surface of the cheeks) are characteristic in bronze disease; mucous papules - in condylomatous syphilis; Filatov-Koplik spots - in measles; swelling, loosening, and ulceration - in stomatitis due to mercury poisoning and some infections; herpes, aphthae, vesicles of foot-and-mouth disease, thrush. Tongue greatly enlarged in acromegaly; disturbance of its movement is characteristic for unilateral paralysis, twitching and trembling - for typhoid state, persistent and deep disturbance of tongue movements (as well as lips and pharyngeal muscles) - for bulbar paralysis; swelling and loosening with tooth marks on the edges and a whitish coating is observed in alcoholics, smokers, in gastritis and infectious diseases; thick white or grayish coating - in gastrointestinal diseases and febrile state (especially in lobar pneumonia); dry rough or glossy, sometimes cracked (like varnished wood with cracked lacquer) or fuliginous tongue occurs in severe typhoid and spotted fever, pyemia, and uremia; Hunter's tongue with a smooth, red, shiny surface, and sometimes with painful aphthae on the edges - in severe blood disorders (malignant anemia); raspberry tongue - in scarlet fever; fresh wounds and scars - from biting during epileptic and similar seizures. Gums.

The most characteristic findings are those of gingivitis, especially scorbutic and mercurial gingivitis, a dark border along the edge of the gums in lead and bismuth poisoning, and alveolar pyorrhea. Teeth: the absence of many teeth is important, as well as carious teeth and roots, loose and easily extractable teeth in certain constitutional diseases, Hutchinson's teeth characteristic of congenital syphilis, and a fuliginous coating. Hard palate. Worthy of attention: a high arch in congenital syphilis, ulcers and perforation in gummatous syphilis, less commonly in other infections. Soft palate. It is important to see eruptions in exanthematous infections before they appear on the body; spreading coatings from the tonsils (especially in diphtheria and scarlet fever), paralysis of the soft palate (often at the onset of diphtheria); edema of the uvula due to local irritation or general edema. Pharynx. Attention should be paid to the manifestations of catarrhal angina, enlargement of the tonsils, coatings, membranes, inflamed follicles on them, plugs in their depressions (lacunar angina), manifestations of abscess or phlegmonous angina, infiltrates, ulcers and scars (mostly tuberculous and syphilitic). Neck. Worthy of attention is the shape of the neck, the presence of enlarged salivary, submandibular, and cervical lymph nodes; the size and shape of the thyroid gland, a collar-like neck (diffuse edema of the subcutaneous tissue due to impaired lymph outflow from compression of the mediastinum). Among the dynamic phenomena, great importance is attached to the contraction or spasm of the neck muscles (tic, torticollis), respiratory tension of them in difficult breathing (asthma, emphysema, etc.), pulsation of the carotid arteries, swelling, undulation, and pulsation of the jugular veins, pulsation of the aorta in the suprasternal notch. Skin. The examination of the skin is of great importance for assessing the general condition of the patient. I. Color of the skin: 1) its own color tone, physiological and pathological increase or decrease in pigmentation; 2) degree of blood filling (hyperemia, pallor), marbling, local dilation of skin veins, capillary pulse, erythema, hemorrhage into the skin; 3) unusual color due to changes in the color of the blood (cyanosis) and its derivatives; 4) color from impregnation of the skin with pigments circulating in the blood (jaundice); 5) deposits in the skin of particles precipitating from the blood (argyria); 6) characteristic, in particular, professional contamination. II. Condition of the skin: 1) thickness of the skin, thickening of the horny layer, calluses; 2) tension (shiny, flabby, folds); 3) secretion--degree of perspiration, abnormal perspiration (miliaria, hyperhidrosis), excessive secretion of skin sebum (seborrhea), insufficient secretion of it; dryness of the skin, insufficient or excessive scaling; 4) edema of the skin, urticaria; 5) inflammatory processes in the skin (lymphangitis, acne, furunculosis); 6) various rashes in acute and chronic (syphilitic) infections and characteristic scaling after them; 7) drug rashes; 8) various changes in skin diseases and parasitic skin diseases; 9) violation of the integrity of the skin (abrasions, scratches, tears, ulcers, bedsores); 10) local and metastatic skin neoplasms. Hair cover. Worthy of attention: density of hair, their distribution on the face and other places, especially around the genital organs, thickness of hair, gray hair, loss on the head and in other places; parasitic diseases. Nails. Characteristic changes of them in local and general diseases (distichiasis). Subcutaneous tissue. By inspection is determined: 1) thickness of fat deposits and their distribution, local accumulation of fat in the form of nodes (lipoma); 2) general or local edema--smoothing of contours, varying degree of swelling of the tissue depending on the cause and nature of the edema (see Edema) and formation of pits when pressing on the skin, which should be longer in non-sharp edema; 3) mucous edema, especially expressed on the face, and from pressure no pits are formed; 4) elephantiasis, mainly on the legs; 5) emphysema of the skin, of traumatic origin; 6) diffuse swelling with redness of the skin in phlegmon and other processes. Subcutaneous vessels: dilation of veins with revealing their valves due to local compression of deep veins or chronic stasis in the small circle (often on the hands in chronic cough); nodular dilation of veins, mainly on the legs; visible pulsation of arteries, especially on the temples, in the bend of the elbow. Subcutaneous lymph nodes when enlarged can be visible in many places. Muscles. On inspection may be⁴ visible: their development, degree of tension during contractions, aplasia, atrophy, trembling, muscular fasciculation, local and spreading in response to mechanical irritation. Character of movements--smooth, jerky, tense, intentional tremor (multiple sclerosis); involuntary contractions (chorea); automatic movements (paralysis agitans, athetosis); grasping and picking movements (irritation of the meninges); ataxia (tabes); stiffness, rigidity, limitation of movements, paralysis (immobility, dropping of a raised limb); dilation of the nostrils and tension of the respiratory muscles in difficult breathing; visible difficulty in swallowing (angina, dysphagia). Gait (see) may be paralytic, spastic, ataxic, unsteady, etc. Body position may be free and forced--orthopedic, stooped, twisted, immobile (paralysis, ankylosis); in the position of the patient's body one can also see visual strain in the deaf, tension of hearing and groping movements in the blind, etc. Skeleton. The most pronounced visible constitutional changes are associated with disorders of bone development in the period of intrauterine life and childhood due to the perversion of the function of endocrine organs (see above), as well as under the influence of rickets and Barlow's disease. Further, special attention is deserved: curvatures of the spine, mainly due to tuberculous spondylitis, spondylosis, spondylarthritis, various changes in the shape and position of the pelvis, especially in the outcome of tuberculous coxitis. Extremities. By inspection are determined mainly permanent changes due to tuberculosis of bones and joints, underdevelopment of limbs in the outcome of poliomyelitis, ankyloses after acute purulent arthritis; dislocations, contractions in primary chronic polyarthritis, deformation of the subchondral bone in various arthritides, syphilitic osteophytes and exostoses, malignant neoplasms, Pierre-Marie's osteoarthropathy, drumstick fingers, Heberden's nodes, gouty nodules, various mechanical injuries and inflammatory processes. Chest. On inspection are determined the general shape depending on its length, width and depth at the level of the upper and lower aperture, keeping in mind that the size of the lower one also depends on the position and size of the abdominal organs and the contents of the abdominal cavity; the size of the suprasternal angle; various deformities of the chest and violation of its symmetry due to congenital defects and various pathological processes, such as rickets, tuberculosis of the spine and ribs, prolonged pleural effusion, shrinkage of the lungs, trauma, hypertrophy and dilation of the heart (cardiac hump); development of the pectoral muscles, mammary glands, pigmentation of the areolas; depth of the supra- and infraclavicular, and suprascapular fossae, intercostal spaces; position of the scapulae; dilation on the chest and in the epigastric region of subcutaneous veins and formation of venous collaterals due to compression of deep veins (mainly in neoplasms in the mediastinal region). Among the dynamic phenomena for judging the condition of the circulatory organs, special attention is deserved: the location of the apical impulse, its extent and spread, systolic retraction of the apex, visible mobility of the cardiac impulse when changing the position of the body; pulsation in the II and III intercostal spaces on the left (displacement of the heart upward, narrowing of the pulmonary artery and non-closure of the ductus arteriosus Botalli), pulsation in aneurysm of the aorta, epigastric pulsation. For judging the dynamics of respiration on inspection should be determined: type of breathing, general range of respiratory chest expansion (depth), rate (number of breaths per minute), rhythm and tension of respiratory movements; respiratory excursion of both scapulae (synchronicity and magnitude of excursion); respiratory excursion of the diaphragm according to Litten (see above), bulging of intercostal spaces during inspiration in various areas; ectoscopic determinations of respiratory dynamics according to Weiss: respiratory phenomenon in calm and superficial rapid breathing, vocal and olfactory phenomenon. Abdomen. On I. are determined: volume and shape of the abdomen, visible tension, thickness of the fat layer, hernial protrusions; with moderate thickness of the abdominal wall the relief of distended or enlarged organs, a greatly distended urinary bladder may be visible; on the skin of the abdomen--spotted pigmentation in the outcome of burns from fomentations and hot-water bottles, surgical scars, pregnancy scars, dilation of subcutaneous veins and development of collaterals in the epigastric and hypogastric regions due to compression of deep veins and in the region of the navel (in the form of "Medusa's head") in disorders of the portal circulation.

From dynamic phenomena on the abdomen, predominantly in the recumbent position, the following may be visible: pulsation in the region of the abdominal aorta; peristaltic movements of the stomach (especially in pyloric stenosis) and of the intestines (especially in their obstruction). If there is stretching of the median aponeurosis (linea alba) and no obesity, then between the rectus muscles of the abdomen, peristaltic movements and respiratory displacement of organs are directly observable, and when attempting to raise the upper part of the body, protrusion of the abdominal cavity contents (eventration) sometimes occurs, which can be very significant. Inguinal hernias, however, are often concealed when the patient is lying quietly on their back. The external genitalia are subject to inspection in cases of anomalies of general physical development, underdevelopment of secondary sexual characteristics, and various sexual perversions. From a general medical point of view, among the visible changes, special attention deserves: edema of the prepuce in general edema, inguinal-scrotal hernias, orchitis, especially tuberculous; rupture of the perineum, prolapse of the vagina and uterus, condylomata of the genital cleft, syphilis, gonorrhea, neoplasms.

The area of the anus is subject to inspection for determining external changes, such as hemorrhoidal nodes, prolapse of the mucous membrane or of the rectum itself, condylomata, fissures, fistulas, various dermatoses. The entire setting in which the patient is located also requires inspection, as much can characterize his condition and also serve as at least an indirect indication of what has happened to him. This can have particularly great significance not only from a forensic medical standpoint but also from a clinical point of view. In this sense, inspection of clothing, especially both underwear and bed linen, can often provide valuable indications, as traces of various secretions as well as blood, pus, semen, etc., may be discovered; sometimes traces from insects are of significance⁴. No less importance has the direct inspection of the patient's secretions, which may present obvious and very characteristic changes ('unusual constituent parts/')