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with the information gathered in the history and other parts of the physical examination Examine the skin as you proceed to each body system Initially, examine both hands and inspect the nails
Skin
Inspection Observe for: skin color, pigmentations, lesions(distribution, type, configuration, size), jaundice, cyanosis, scar, superficial vascularity, moisture, edema, color of mucous membrane, hair distribution, nails Check for capillary refill-depress nail edge to blanch and then release, noting the return of color- color return is instant, within 1-3secs. It is an index of peripheral perfusion and cardiac output
Skin
Palpation
Examine the skin for temp., texture,
elasticity, turgor. Note: skin turgor is usually not examined among elderly(those who are over 65yrs of age because their skin is normally wrinkled
Skin
Palpation(normal findings)
normal varies. Depending on the race or ethnic
background, complexion, sun exposure, pigmented tendencies(freckles) Capillary refill more than 3 seconds indicates impaired peripheral circulation The skin is normally warm, slightly moist and smooth, and returns quickly to its original shape when packed up between 2 fingers and released(good skin turgor) There is characteristic hair distribution over the body association with gender and normal physiologic function. Nails are present and smooth
Skin
Palpation(abnormal findings)
Vitiligo-is the complete absence of
melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds and around orifices Seborrhea-oily skin; dandruff Xerosis-dry skin Pruritus-itchiness Alopecia-hair loss
Skin
Palpation(abnormal findings) Pallor-paleness of skin, mucous membrane Erythema-redness of skin Cyanosis-bluish discoloration of the skin due to inadequate oxygen Jaundice-yellowish discoloration of the skin, junction of the hard and soft palate, sclera Diaphoresis-profuse sweating Edema-accumulation of fluid in the intracellular spaces, char. By swelling
Skin
Palpation(abnormal findings)
Anasarca-generalized edema,whole body
fold of skin to return to place promptly when released, may due to DHN Skin lesion-blue-green flourescence with use of Woods light indicates fungal infection(tinea capitis-scalp ringworm) Dull, coarse/brittle scalp hair Hirsutism-excess body hair in females- may indicate endocrine problem Koilonychia- spoon shaped/concave nails-IDA Onycholysis-fungal infection of fingernails
Skin
Palpation(abnormal findings) Pigmented lesion with the ff. char.(danger sign)-ABCDE(may indicate skin cancer) - assymetry(two halves of the lesion do not look the same - Border irregularity(notching, scalloping, ragged edges, or poorly defined margins) - Color variation(areas of brown, tan, black, blue, red, white or combination) - Diameter greater than 6mm - Elevation and enlargement
color and texture and cranium Inspect face: symmetry, expression Palpate the temporal artery, then the temporo-mandibular joint as the patient open and closes the mouth Palpate the maxillary sinuses and the frontal sinuses for tenderness
appropriately related to body size. Scalp is normally smooth, no tenderness to palpation Temporal artery is palpable between the eye and top of the ear Temporomandibular joint(below the temporal artery and anterior to the tragus) has smooth movement as the pt opens the mouth with no limitation and tenderness The facial structure are symmetric(eyebrows, palpebral fissures, nasolabial folds and sides of the mouth No tenderness over the maxillary sinuses(on each side of the face) and frontal sinuses(above the eyebrows)
Inspection and palpation(abnormal findings) Deformeties: microcephaly(abnormally small head), macrocephaly(abnormaly large head), lumps, depressions and protrusions Temporal artery looks more tortuous, feels hardened and tender temporal arteritis Crepitation, limited range of motion or tenderness of the temporomandibular joint Assymetry of the face may indicate central branin lesion Edema of the face occurs first especially around the eyes(periorbital) and the cheeks where sucutaneous tissue is relatively loose
eyes
Inspection
Eyeballs(globes) for protrusion Palpebral fissures(longitudinal openings
between the eyelids)-for width and symmetry Lid margins-scalling, secretions, erythema, position of lashes Bulbar and palpebral conjunctivae- congestion and color - Bulbar conjunctiva- membranous covering the sclera, contains blood vessels
- Palpebral conjunctiva-membranous covering
of the inside of the upper and lower lids, contains blood vessels
eyes
Inspection
Sclera and iris- for color
light and accommodation(ability of the lens to adjust to objects at varying distances) Eye movement- extra ocular muscles(six cardinal positions-cranial nerve III, IV, VI), nystagmus, convergence - Nystagmus: rapid, lateral, horizontal or rotary movement of the eye - Convergence: ability of the eye to turn in and focus on very close object
eyes
Inspection
Visual acuity- check with Snellen chart(with
and without glasses) The Snellens eye chart - Snellen alphabet chart is used to measure visual acuity, has lines and letters arranged in decreasing size - Position the pt 20ft. Away from the chart - Ask the pt to cover 1 eye with opaque card. Test right eye first, then left - If the pt wears eye glasses or contact lenses, leave them on. Remove only reading glasses because they will blur distance vision
eyes
Inspection
The Snellens eye chart - Ask the pt to read through the chart to the
smallest line possible - Note: use a snellen picture chart for people who cannot read letters - Record the result using numeric fraction at the end of the successful line read. Indicate if some letters were missed or if corrective lenses were worn. Example: OD 20/30-2 with glasses.
eyes
chart - Denominator indicates the distance at which the normal eye can read the letter Abnormal findings: if denominator is increased(20/30 or greater), the pt has myopia - If the denominator is decreased(20/15 or less), the pt has hyperopia - If the result is 20/200, the pt is legally blind and not allowed to drive - Note: hesitancy, squinting, leaning forward, misreading letters may indicate decrease visual acuity
eyes
Inspection
Normal findings: - There is no protrusion of eye
balls(exophthalmos in pt with hyperthyroidism) - Palpebral fissure- appear equal in size when the eyes are open
-
Upper lid: covers a small portion of the iris and the sclera Lower lid: margin is just below the junction of the cornea and sclera. There is no ptosis
(puncta) are evident at the nasal ends of the upper and lower lids
-
eyes
Inspection
Normal findings:
- Bulbar conjunctiva(cover of the sclera): consist
of transparent red blood vessels, (which may become dilated and produce the characteristics of blood shot eye - Palpebral conjunctiva: pink and clear(conjunctivitis- inflammation of the conjunctival surfaces)
- Sclera: white and clear
eyes
Inspection
Normal findings:
- Pupils: normally constrict with increasing light
and accommodation. Pupils are normally round, 3-5mm in size(PERRLA-pupils equal, round, reactive to light, accommodation). (pin point and dilated pupils indicate neurologic prodlems)
eyes
Inspection
Normal findings:
- Extraocular movement- movement of the eyes
in conjugate fashion. Eyes normally move in conjugate fashion, except when converging on an object that is moving closer Nystagmus- may be seen normally as a result of eye fatigue Convergence- fails when double vision occurs, usually 10-15cm from nose. Peripheral vision is full in both eyes
eyes
Palpation
Determine the strength of the upper eyelids
by attempting to open-close lids against resistance Palpate eyeballs(globes) through close lids for tenderness and tension Normal findings: - The examiner should not be able to open the eyelids when the patient is squeezing them shut - Eyeballs are normally not tender when palpated
eyes
Fundoscopic examination-darken the room
Use of ophthalmoscope to inspect ocular fundus
anterior and posterior chambers. It can be spotted by the examiner while standing 30cm from the eyes. It is the red glow filling the persons pupils - Cornea: check for transparency. Should be transparent - Lens: check for transparency. Should be transparent, retina can be seen
eyes
Fundoscopic examination-darken the room
Use of ophthalmoscope to inspect ocular fundus
hemorrhages and exudates. Color varies; no hemorrhages and exudates - Optic disc: check for color, distinction of margins, pigmentation, degree of elevation, cupping
It is circular, and has yellowish pink color The margins are normally distinct and regular with varying amount of