.   Nervous   System—Check   for   feelings   of anxiety,   apprehension,   tremors,   convulsions, history  of  psychiatric  care,  changes  in  memory, changes  in  judgment,  pain,  paresthesia  (numb- ness),  paralysis,  and  coordination. .  Musculoskeletal  System—Note  the presence  of  muscular  pain,  swelling,  deformity, disability or pain in joints, weakness, atrophy, and cramps. PHYSICAL    EXAMINATION After   getting   as   much   information   as possible  from  questioning,  a  physical  examina- tion must then be performed. In general, use the same system format that was employed in taking the  medical  history.  (NOTE:  As  stated  in  the section  on  history  taking,  depending  upon  the complaint   of   the   patient   and   your   suspicions of  his  or  her  illness,  it  is  not  necessary  to perform  a  complete  physical  examination  in  every case.) . Vital Signs—Take and record temperature, pulse,  respiration,  and  blood  pressure l  Skin—The  human  skin,  which  is  some- times  referred  to  as  the  “mirror”  of  an  indi- vidual’s health because it often reflects diseases of other organs, should be examined visually and also   by   palpation. Observe  for  visible  ab- normalities   such   as   warts,   cysts,   scales,   and vesicles. An important point to remember in the visual examination of the skin is color. Changes in coloration are often tipoffs to various ailments; for  example,  a  bluish  tinge  can  indicate  congestive heart failure, pneumonia, or any other condition in  which  the  oxygen  content  of  the  hemoglobin is  reduced.  Changes  in  skin  coloration  can  also be caused by abnormal deposits of pigmentation, such as increases of bilirubin in the skin and sclera as   found   in   jaundice.   Note   the   temperature, texture,   elasticity,   moisture,   and   presence   or absence of edema. It is important to include the epidermal appendages in the examination of the skin; for example, note the condition of the nail beds (matrix) since abnormalities in the matrix can often  indicate  local  or  systemic  disorders.  Con- dition  of  the  hair  can  also  indicate  local  or systemic  disorders,  such  as  coarse,  dry,  and brittle  hair,  as  found  in  many  cases  of  hypo- thyroidism. .   Head—Look   for   any   abnormal   head movements, such as spasms, tremors, and tilting. Note  the  size  and  shape  of  the  head.  Note  any signs  of  swelling,  discolorations  (especially  in facial  bones),  and  bloody  or  watery  discharge from the nose and ears. Test the sections over the sinuses  by  palpation  and  percussion  to  detect  any signs  of  tenderness.  Check  for  range  of  motion (provided  there  is  no  neck  injury).  Inspect  the eyes for normal extraocular movements, equality of   pupils,   pupillary   reaction   to   light,   and accommodation.  Check  for  position  and  align- ment   of   the   eyes, abnormal   protrusions, recessions, and spacing; note the position of the eyelids to the eyeballs; observe for swelling of the lacrimal apparatus; note any opacities in the lens and cornea and swellings or nodules in the con- junctival and sclera. Examine the oral cavity for signs  of  bleeding  or  inflamed  gums,  coating  or swelling  of  the  tongue,  ulcers,  inflamed  throat, pus,  and  condition  of  teeth. . Neck—When inspecting the neck, look for any   signs   of   asymmetry,   unusual   pulsations, growths,   stiffness   or   limitation   of   movement, enlargement  of  the  thyroid  gland,  and  swollen lymph nodes behind the ears, on the sides of the neck,  and  in  the  supraclavicular  area.  Test swallowing  ability. l Ears, Nose, and Throat—When inspecting the  ears,  include  the  external  ear.  This  area  is sometimes so obvious that it is often overlooked. Examine  the  external  auditory  canal  for  any  signs of  wax  or  trauma.  Note  the  position,  color,  and shape of the tympanic membrane. Look for signs of  blood,  pus,  redness,  or  swelling.  Test  for hearing  loss  by  using  a  tuning  fork,  a  ticking watch, or the human voice. Observe the nose for signs of swelling or trauma. Use a nasal speculum to check for obstructions, redness, and infection. Inspect  the  throat  for  signs  of  blood,  pus,  redness, swelling,    tenderness, and  any  swellings  or growths. Check the condition of the teeth, gums, tongue,  palate,  tonsils,  uvula. .   Respiratory   System—Determine   if   the patient  is  coughing  and  if  the  cough  is  produc- tive or nonproductive. If productive, examine the sputum  for  quantity,  color,  viscosity,  and  odor. Look for skeletal deformities or funnel chest and exaggerated   or   abnormal   posture.   Check   the accessory  respiratory  muscles  in  the  neck  for deformity.  Take  note  of  rate,  depth,  symmetry, and  pattern  of  respirations.  Palpate  the  chest  wall 2-4