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Skin

Examination of the skin is correlated

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

Poor skin turgor-inability of a pinched up large

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

Head and Face


Inspection and palpation
Inspect and palpate scalp for masses, hair,

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

Head and Face


Inspection and palpation(normal findings)


Normocephalic-round symmetric skull that is

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)

Head and Face

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

Pupils-for size, shape, symmetry, reaction to

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

Inspection(Snellens eye chart)


Normal findings: 20/20 - Numerator indicates distance of the pt from the

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

- Lid margins: are clear, lacrimal duct openings

(puncta) are evident at the nasal ends of the upper and lower lids
-

Eye lashes: evenly distributed and turn outwards

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

- Red retinal reflex: check the transparency of the

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

- Retina: check for color, pigmentation,

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

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