1. Physical examination exemplars: eyes/exemplars: head, face, neck, and regional lymphatics/exemplars: skin, hair, and nails

Anyone have singed hair on their face

needs to be very cautious of their airway

Skin, hair, nails: age related changes (older adults)

• elasticity loss

• thin, dry, wrinkled appearance

• thin and flattened epidermis

• collagen loss associated with shearing, tearing injury risk

• decrease in sweat and sebaceous gland function and number associated with dry skin

• decreased thermoregulation associated with increased risk of heat stroke

• senile purpura

• skin breakdown associated with delayed wound healing

Senile purpura

so-called areas of dark red discoloration, associated with minor trauma

Alopecia

impressive amount of hair loss

Hirsutism

excessive hair

Jaundice

normal finding in a newborn

• abnormal finding in older adults associated with hepatic disease (hepatitis, cirrhosis), typically severe and chronic in nature

• abnormal increased amounts of bilirubin in blood

• noted as change in skin coloration and both eyes

Skin, hair, nails objective data: ABCDEF mnemonic

• Asymmetry

• Border irregularity

• Color variation

• Diameter (6mm+, size of pencil eraser)

• Elevation/evolution

• Funny looking (so-called ‘ugly duckling’ sign), lesion in local area different in appears to local nevi)

Objective data: evaluate temperature (hypothermia)

associated with:

• shock

• peripheral arterial insufficiency

• raynauds syndrome

Objective data: evaluate temperature (hyperthermia)

associated with:

• hyperthyroidism

Inspection and palpation of the skin: evaluate texture, thickness, edema

note: anasarca

Anasarca

bilateral extremity or so-called generalized edema

Skin tenting

may occur where pinched skin stands by itself

Scleroderma

so-called “hard skin” associated with chronic connective tissue ailment and decreased mobility

Inspection and palpation of the skin: evaluate vascularity (bruising)

• cherry angiomas (senile)

• contusion

Cherry angiomas (senile)

bright red dots, slightly raised, smooth, small in size and a normal finding in adults 30+ years old

Contusion

term for bruise

Skin, hair, nails objective data: primary lesions

• macule

• papule

• patch

• plaque

• nodule

• wheal

Primary lesions: macule

flat, circumscribed, less than 1cm and strictly a color change

ex: freckle, petechiae

Primary lesions: papule

lesion that can be felt due to epidermis superficial thickening

ex: wart (verruca)

Primary lesions: patch

macules with size (1cm+)

ex: vitiligo

Primary lesions: plaque

papule with a surface elevation greater than 1cm in width

ex: psoriasis

Primary lesions: nodule

greater than 1cm in size, solid and elevated; can extend deeper than a papule into the dermis

ex: xanthoma

Primary lesions: wheal

dark skin

somewhat irregular shape associated with edema, superficial, transient, erythematous, and raised

ex: mosquito bite

Skin, hair, nails objective data: evaluate lesions

• tumor

• urticaria (hives)

• vesicle

• bulla

• cyst

• pustule

Evaluate lesions: tumor

a few centimeters or greater in diameter, may be soft or firm, can be benign or malignant

Evaluate lesions: urticaria (hives)

light skin

extensive pruritic reaction of several wheals in a collection coming together

Evaluate lesions: vesicle

cavity of so-called free fluid, elevated and up to 1cm in size, ‘blister’

Evaluate lesions: bulla

cavity of free fluid that is larger than 1cm and can rupture with ease

ex: burn, contact dermatitis

Evaluate lesions: cyst

fluid filled cavity enclosed by a capsule within the dermis or subcutaneous tissue

Evaluate lesions: pustule

cavity containing pus (turbid fluid) that is elevated and circumscribed

ex: acne

Objective data: secondary lesions

evolution of primary lesion over a period of time with a resultant change

• crust, scale, fissure, erosion

• ulcer

• excoriation

• scar

• keloid

• pressure ulcer

Secondary lesions: ulcer

depression, irregular in shape, potential bleeding and can leave scar upon healing

ex: pressure injury stasis ulcer

Secondary lesions: excoriation

superficial abrasion that is self inflicted, described as scratches from impressive amount of itching

ex: insect bite

Secondary lesions: scar

repaired skin lesion with loss of normal tissue and replacement using collagen (connective tissue); so-called permanent fibrotic change

ex: surgical site (healing or healed)

Secondary lesions: keloid

excess scar tissue outside of original injury site, benign in nature

• described as smooth, claw-like, shiny, rubbery in nature and firm

Pressure ulcer

associated with lack of perfusion, oxygenation and interruption of vasculature of body tissue, commonly found over a bony landmark

Staging of ulcer progression: stage 1

non-blanchable erythema

• skin intact

• redness

• no blanch ability of skin

Staging of ulcer progression: stage 2

partial-thickness skin loss

• epidermis loss

• exposed dermis layer

• no visible fat/deep tissue

Staging of ulcer progression: stage 3

full-thickness skin loss

• injury to tissue extends within subcutaneous tissue layer

• fat and granulation tissue exposed

• no visible muscle, tendon or bone structures

Staging of ulcer progression: stage 4

full-thickness skin/tissue loss

• all skin layer involvement

• supporting tissue involvement

• visualization of bone, muscle, tendon

• potential for tunneling

• can include

  • slough

  • eschar

Slough

wound bed so-called stringy matter

Eschar

necrotic tissue

Staging of ulcer progression: stage 5

unstageable

• deep tissue injury

Profile sign

nail clubbing associated with congenital heart disease, pulmonary pathology and lung cancer

Lentigines (seniles)

called ‘liver spots’

• seen in older adults

• not considered malignant and no need for treatment

Keratoses

areas of pigmentation that are thick and raised and may appear crusty, scaly or so-called warty

• seborrheic keratosis

Keratoses: seborrheic keratosis

have a so-called ‘stuck on’ appearance and are not associated with cancer

Actinic keratosis

• plaques that are scaly and red-tan with raised and roughened edges

• associated with sun exposure

• premalignant

• potential to develop into squamous cell carcinoma

Skin tags

also called acrochordons

• so-called normal skin overgrowth that are characterized as polyp-like

Vertigo

spinning sensation of the head

Normocephalic

so-called normal anatomical description including round skull with symmetry that is sized in proportion to overall body habitus

Tympanic membrane

what you look at when looking inside someones ear

Normal finding in tympanic membrane

pearly gray

Inspection and palpation of thyroid gland: myxedema

severe form of hypothyroidism

Inspection and palpation of thyroid gland: graves disease

leads to hyperthyroidism

Cachetic appearance

Ears: tympanic membrane

Eyes pupillary light reflex: direct light reflex

pupil constriction of respective eye

Eyes pupillary light reflex: consensual light reflex

light shined on one eye, yet opposite eye has simultaneous pupil constriction

Eyes pupillary light reflex: fixation

eye is attracted reflexively moves toward an object drawing a person’s attention

Eyes pupillary light reflex: accommodation

eye adaptation in setting of near vision

Scotoma

blind spot noted in setting of glaucoma or other pathology

Strabismus/diplopia

two images of one object

• deviation of two eye parallel axes

Eyes: confrontation test

screen for peripheral vision loss

Eyes objective data: evaluate via inspection; extra-ocular muscle function

• hirschberg test

• diagnostic positions test

Eyes: hirschberg test

corneal light reflex

• shine light into one eye approximately 12 inches away from eye, note light reflection in same spot of each of the two corneas

Eyes: diagnostic positions test

• 6 cardinal positions of gaze

• normal response: both eyes track object in parallel

Nystagmus

fine oscillating movement around iris

PERRLA

pupils equal, round, reactive to light, and accomodating

Eyes: periorbital edema

Eyes: exophthalmos

eye protrusion

• associated with pathology of thyrotoxicosis

Eyes: mydriasis

associated with trauma, acute glaucoma, CNS injury, deep anesthesia

Eyes: miosis

associated with narcotic use and glaucoma treatment via pilocarpine drops