Cushing syndrome. A, Facies include a rounded or “moon-shaped” face with thin, erythematous skin.

Cushing syndrome. B, Side view. Shows upper thoracic fat pad (buffalo hump).

Hippocratic facies. Note sunken appearance of the eyes, cheeks, and temporal areas; sharp nose; and dry, rough skin seen in this patient in the terminal stages of throat cancer.

Myxedema facies. Note dull, puffy, yellowed skin; coarse, sparse hair; temporal loss of eyebrows; periorbital edema; and prominent tongue

Hypothyroidism

Hyperthyroid facies. Note fine, moist skin with fine hair, prominent eyes and lid retraction, and staring or startled expression. 

Bell palsy. Left facial palsy (cranial nerve VII). Facies include asymmetry of one side of the face, eyelid not closing completely, drooping lower eyelid and corner of mouth, and loss of nasolabial fold.

Butterfly rash of systemic lupus erythematosus. Note butterfly shaped rash over malar surfaces and bridge of nose. Either a blush with swelling or scaly, red, maculopapular lesions may be present. 

Early acromegaly. Note the coarsening of features with broadening of the nasal alae and prominence of the zygomatic arches.

Pierre-Robin sequence; a triad of micrognathia, glossoptosis, and palatal clefting. Shows a lateral view with severe micrognathia and cleft palate. Note the small retruded mandible.

Down syndrome. Note depressed nasal bridge, epicanthal folds, mongoloid slant of eyes, and low-set ears.

Hurler syndrome. Facies includes enlarged skull with low forehead, corneal clouding, and short neck.

Fetal alcohol syndrome. This is one of the most common causes of acquired intellectual disability. Note the poorly formed philtrum; widespread eyes, with inner epicanthal folds and mild ptosis; hirsute forehead; short nose; and relatively thin upper lip.

Hydrocephalus. A, Coronal view with characteristic enlarged head, thinning of the scalp with dilated scalp veins, and bossing of the skull.

Hydrocephalus. B, Anteroposterior view demonstrating sclera visible above the iris. In this case the infant has paresis of upward gaze. This phenomenon is often termed the “sunsetting sign.”

Treacher-Collins syndrome. Note the maxillary hypoplasia, micrognathia, and auricular deformity. 

Apert syndrome. Note the severe maxillary and midfacial hypoplasia.

Crouzon syndrome. Observe the severe maxillary and midfacial hypoplasia with low-set ears.

Assessment of auricle alignment showing expected position. Imaginary line extends from inner eye canthus to occiput. Vertical imaginary line just anterior to the auricle.

A. Preauricular skin tag.

Expected variations

B. Auricular sinus.

Expected variations

C. Darwin tubercle.

• A thickening along the upper ridge of the helix

• Expected variation

D. Cauliflower ear.

Results from blunt trauma and necrosis of the underlying cartilage

E. Tophi.

• Small, whitish uric acid crystals along with the peripheral margins of the auricles

• May indicate gout

F. Sebaceous cysts.

Elevations in the skin with a punctum indicating a blocked sebaceous gland are common.

To examine the adult's ear with the otoscope, straighten the external auditory canal by pulling the auricle up and back.

A. Healthy tympanic membrane.

B. Tympanic membrane partially obscured by cerumen.

C. Bulging tympanic membrane with loss of bony landmarks.

D. Perforated tympanic membrane.

E. Perforated tympanic membrane that has healed.

F. Tympanostomy tube protruding from the right tympanic membrane.

Otitis media with effusion. 

A. The middle ear filled with serous fluid; note the bulging appearance and distorted light reflex.

B. Acute otitis media. 

Note the red bulging tympanic membrane with obscured bony landmarks and distorted light reflex.

Otitis externa. 

The inflammation in the auditory canal often extends with inflammation of the pinna.

Weber test. 

Touching only the handle, place the base of the tuning fork on the midline of the skull. Avoid touching the vibrating tines.

Rinne test. 

A. Place the tuning fork on the mastoid bone for bone conduction.

Rinne test. 

B. To test for air conduction hold the tuning fork 1 to 2 cm (.5 to 1 inch) from the ear with the tines facing forward.

 Xanthelasma

Ptosis, a drooping of the upper eyelid.

Ptosis indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve.

Ectropion (eyelid turns outward).

Entropion (inversion or inward turning of the eyelid margin). 

Note that this patient has undergone corneal transplantation.

Acute hordeolum of upper eyelid.

Generally caused by a staphylococcal infection. 

Blepharitis (crusting along the eyelashes).

Caused by bacterial infection, seborrhea, psoriasis, a manifestation of rosacea, or an allergic response 

Erythematous eye from a chemical allergy.

Acute purulent conjunctivitis (infectious).

Subconjunctival hemorrhage

Corneal arcus senilis, which is composed of lipids deposited in the periphery of the cornea. It may in time form a complete circle. If present before age 40, arcus senilis may indicate a lipid disorder.

Arcus senilis and pterygium.

Arcus senilis and pterygium. 

Pulling lower eyelid down to inspect the conjunctiva.

Everting upper eyelid. A, Placing applicator above the globe.

Everting upper eyelid. B, Withdrawing the lid from the globe.

Evaluation of peripheral fields of vision. A, Temporal field.

Evaluation of peripheral fields of vision. B, Nasal field.

Corneal sensitivity, controlled by CN V (trigeminal nerve), is tested by touching a wisp of cotton to the cornea.

The expected response is a blink, which indicates intact sensory fibers of CN V and motor fibers of CN VII (facial nerve).

Decreased corneal senssation is often associated with diabetes, herpes simplex and herpes zoster viral infections or is a sequela of trigeminal neuralgia or ocular surgery.

Evaluating eye fixation by the cover-uncover test. A, Patient focuses on near object. 

B, Examiner evaluates movement of covered eye as cover is removed.

Strabismus: crossed eyes, both eyes not looking at the same time

A, Visualization of the red reflex

B, Examination of the optic fundus.

Retinal structures of the left eye.

A, Normal right fundus in a white patient

B, Normal left fundus.

Fundus of a black patient.

Unexpected findings on nasal examination. 

A. Nasal polyp (allergic). 

A rounded, elongated mass projecting into the nasal cavity from boggy mucosa may be a polyp.

B. Deviation of the nasal septum.

A. Angular cheilitis.

Dry, cracked lips (cheilitis) may be caused by dehydration from win chapping, dentures, braces, or excessive lip licking.

Deep fissures at the corners of the mouth (angular cheilitis) may indicate infection, irritation, nutritional deficiencies (iron and B vitamins), or overclosure of the mouth, allowing saliva to macerate the tissue.

B. Actinic cheilitis.

C. Angioedema.

Swelling of the lips may be caused by infection or allergy.

D. Herpes simplex lesions (cold sores).

E. Squamous cell carcinoma of the lip.

Lesions, plaques, vesibles, nodules, and ulcerations may be signs of infections, irritations, or skin cancer.

F. Peutz-Jeghers syndrome. 

Associated with round, oval, or irrecular bluish gray macules on the lips and buccal mucosa.

Findings of the oropharynx. 

A. Tonsillitis and pharyngitis.

B. Acute viral pharyngitis.

C. Postnasal drip.

 A. Torus palatinus.

The hard palate may have a bony protuberance at the midline, called torus palatinus, an expected variant present in 25% to 35% of the population, more commonly seen in women compared with men.

B. Bifid uvula. 

A bifid uvula is often a benigh condition and may be a normal variant in some Native Americans; however, it may indicate a submucous cleft palate.

A bifid uvula has recently been associated with Loeys-Dietz syndrom, a disorder in which aortic root dilation and aortic dissection may occur.

Oral Kaposi sarcoma. 

A, Moderately advanced.

Oral Kaposi sarcoma. 

B, Advanced lesion.

A. Left hypoglossal paralysis. 

The tongue deviates to the weak side. Note atrophy on the tongue's right side.

B. Geographic tongue.

An expected variant.

Has superficial denuded circles or irregular areas exposing the tips of pipillae.

C. Glossitis.

A smooth red tongue with a slick appearance (glossitis) may indicate a vitamin B12 deficiency.

D. Black hairy tongue.

The hairy tongue with yellow-brown to black elongated papillae on the dorsum sometimes follows antibiotic therapy.

E. Ranula (obstructed sublingual salivary gland).

A ranula (mucocele) may be seen on the floor of the mouth when the duct of a sublingual salivary gland is obstructed.

F. Primary gingivostomatitis showing lesions on the tongue.

Lesions on the tongue may be due to an infectious process.

A. Fordyce spots.

Fordyce spots, an expected variant, are ectopic sebaceous glands that appears on the buccal mucosa and lips as numerous small, yellow-white, raised lesions.

B. Patchy coloration of mucous membranes in individual of dark skin color.

Patchy pigmented mucosa is often found in individuals with dark skin. 

C. Aphthous ulcer.

Aphthous ulcers on the buccal mucosa appear as white, round, or oval ulcerative lesions with a red halo.

D. Leukoplakia.

A thickened white patch lesion that cannot be wiped away may be leukoplakia, a premalignant oral lesion most commonly seen in individuals smoking or chewing tobacco.

Leukoedema.

Leukoedema is a diffuse filmy grayish surface with white streaks, wrinkles, or milky alteration.

Leukoedema.

This asymptomatic benign lesion of the buccal mucosa is considered a normal variant. It is found in 90% of black adults and nearly 50% of black adolescents.

Epulis.

Epulis, a localized gingival enlargement or granuloma, is usually an inflammatory rather than neoplastic change. 

A, Plasma cell gingivitis.

Easily bleeding, swollen gums with enlarged crevices between the teeth and gum margins, or pockets containing debris at tooth margins, are associated with gingivitis or periodontal disease.

B, Phenytoin-related hyperplasia of the gingival.