PHYSICAL EXAMINATION

• Skin palpation


  • Examine the skin for temperature, texture, elasticity, turgor
• Skin turgor is usually not examined among elderly (those who are over 65 years of age because their skin is normally wrinkled)
• Head and face examination

  • 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 opens and closes the mouth
  • Palpate the maxillary sinuses and the frontal sinuses for tenderness
• Normal head and face findings

  • Normocephalic – round symmetric skull that is 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 with no limitation and tenderness the tragus) has smooth movement as the patient opens his/her mouth, with no limitation and tenderness
  • Facial structures are symmetric (eyebrows, palpebral fissure, nasolabial folds, and sides of the mouth)
  • No tenderness over the maxillary sinuses and frontal sinuses
• Abnormal head and face findings

  • Deformities: microcephaly, macrocephaly, lumps, depressions, and protrusions
  • Temporal arteries look more tortuous, feel hardened and tender
  • Crepitation, limited range of motion or tenderness of the temporomandibular joint
  • Asymmetry of the face may indicate central brain lesion
  • Edema of the face occurs first especially around (periorbital) and the cheeks where subcutaneous tissue relatively loses
• Eye examination

  1. Inspect eyeballs (globes) for protrusion

  2. Inspect palpebral fissure (longitudinal opening between the eyelids) for width and symmetry

  3. Inspect lid margins for scaling, secretions, erythema, position of lashes

  4. Inspect bulbar and palpebral conjunctivae for congestion and color

  5. Inspect sclera for color, iris for color

  6. Inspect pupils for size, shape, symmetry, reaction to light, accommodation

  7. Assess eye movement - extraocular muscles, nystagmus, convergence

  8. Assess visual acuity with Snellen chart

  
• Snellen chart


  Used to measure visual acuity, has lines of letters arranged in decreasing size. Position the patient 20 feet away, test right eye first, then left eye, then both eyes. Ask the patient to read through the chart to the smallest line possible.

  
• Normal Snellen test result is 20/20, which indicates normal vision
• Normal eye findings

  • No protrusion of eyeballs
  • Palpebral fissures appear equal in size, upper lid covers a small portion of iris and cornea, lower lid margin just below junction of cornea and sclera, no ptosis
  • Lid margins are clear, lacrimal duct openings evident, eyelashes evenly distributed and turn outward
  • Bulbar conjunctiva consist of transparent red blood vessels

  
• O.D.

  • 20/30 -2 with glasses
• Normal result of Snellen test

  20/20 (indicates normal vision)
• Numerator


  Indicates the distance of the patient from the chart
• Denominator


  Indicates the distance at which the normal eye can read the letter
• No protrusion of eyeballs

  • Protrusion of eyeballs (exophthalmos) is a manifestation of hyperthyroidism

  
• Palpebral fissures


  • Appear equal in size when the eyes are open
  • Upper lid covers a small portion of the iris and cornea
  • Lower lid margin is just below the junction of the cornea and sclera, there is no ptosis (drooping of eyelids)

  
• Lid margins


  • Are clear, lacrimal duct openings (puncta) are evident at the nasal ends of the upper and lower lids
  • Eyelashes are normally evenly distributed and turn outward
• Bulbar conjunctiva


  • Consist of transparent red blood vessels, which may become dilated and produce the characteristic "bloodshot" eye

  
• Palpebral conjunctivae


  • Are pink and clear (conjunctivitis - inflammation of the conjunctival surfaces)
• Sclera


  • Should be white and clear
• Pupils

  • Normally round, 3 to 5 mm in size (PERRLA - pupils equal, round, reactive to light, accommodation)
  • Pinpoint and dilated pupils indicate neurologic problems
• Extraocular movement

  • Movements of the eyes in conjugated 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 to 15 cm (4-6 inches) from nose
  • Peripheral vision is full in both eyes

  
• If the denominator is increased (20/30 or greater), the patient has myopia (nearsightedness)
• If the denominator is decreased (20/15 or less), the patient has hyperopia (farsightedness)
• If the result is 20/200, the patient is legally blind and not allowed to drive
• Hesitancy, squinting, leaning forward, misreading letters may indicate decreased visual acuity
• Palpation


  • Determine the strength of the upper eyelids by attempting to open closed lids against resistance
  • Palpate eyeballs (globes) through closed lids for tenderness and tension

  
• The examiner should not be able to open the eyelids when the patient is squeezing them shut
• Eyeballs normally are not tender when palpated
• Fundoscopic Examination

  1. Check the transparency of the anterior and posterior chambers

  2. Check the cornea for transparency

  3. Check the lens for transparency

  4. Check the retina for color, pigmentation, hemorrhages, and exudates

  5. Check the optic disc for color, distinction of margins, pigmentation, degree of elevation, cupping

  6. Check the macula for color

  7. Check the blood vessels for diameter, arteriovenous ratio, origin and course, venous arterial crossings
• The red retina reflex can be spotted by the examiner while standing 30 cm (12 inches) from the eye
• The optic disc is circular and has a yellowish pink color, with distinct and regular margins and varying amounts of pigment
• The macula is lighter in color than the rest of the retina because it is free of blood vessels
• Arteries are smaller and lighter in color than veins
• Procedure for using the ophthalmoscope

  1. Hold the instrument in your right hand and use your right eye to examine the patient's right eye, reverse the procedure to examine the left eye

  2. Hold the instrument so your last two fingers are straight, place them against the patient's cheek to steady the instrument

  3. Begin the funduscopic examination standing about 30cm (a foot) from the patient in a darkened room

  4. Turn the dial on the head of the ophthalmoscope to +8 or +10 (black numbers)

  5. Turn on the ophthalmoscope light and place the eyepiece up to your eye

  6. Aim the light at the pupil of the eye to see the red reflex

  7. Slowly move in towards the patient, continuing to look through the eyepiece and keeping the light directed at the pupil

  8. Turn the dial toward zero as you move in to focus on the various chambers of the eye

  9. Once your hand is resting on the patient's cheek, continue to turn the dial until you can focus on the retina, blood vessels and optic disc
• Examination of the skin is correlated with the information gathered in the history and other parts of the physical examination
• Initially (in skin inspection), examine both hands and inspect the nails.
• Capillary refill is an index of peripheral perfusion and cardiac output.
• Check for capillary refill: depress the nail edge to blanch and then release, noting the return of color -- color return is instant, within 1 to 3 seconds.
• Examine the skin for temperature, texture, elasticity, and turgor.
• Capillary refill more than 3 seconds indicated impaired peripheral circulation