N295 EXAM 3 - LONG ISLAND UNIVERSITY - LATEST VERSION, RATED A

Document Content and Description Below

N295 Exam #3 ABDOMINAL ASSESSMENT SURFACE LANDMARKS • The abdomen is a large, oval cavity extending from the diaphragm down to the brim of the pelvis • 4 layers of large, flat muscles form ... the ventral abdominal wall o Joined at the midline by a tendinous seam: linea alba o Rectus abdominis forms a strip extending the length of the midline, and its edge of often palpable o Muscles protect and hold the organs in place, and they flex the vertebral column INTERNAL ANATOMY • Viscera: the abdominal cavity, holds all internal organs • Solid viscera: maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries and uterus) o Liver fills most of the right upper quadrant (RUQ) and extends over to the left midclavicular line (MCL) o The lower edge of the liver and the right kidney normally may be palpable • Hollow viscera: stomach, gallbladder, small intestine, colon and bladder o Usually not palpable • Spleen: a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, immediately under the diaphragm; If it becomes enlarged, its lower pole moves downward and toward the midline • Aorta: just to the left of the midline in the upper part of the abdomen; descends behind the peritoneum and at 2cm below the umbilicus it bifurcates into the right and left common iliac arteries opposite the 4th lumbar vertebra o Can palpate the aortic pulsations easily in the upper anterior abdominal wall • Pancreas: a soft, lobulated gland located behind the stomach; stretches obliquely across the posterior abdominal wall to the left upper quadrant • Kidneys: bean-shaped, retroperitoneal, or posterior to the abdominal contents; protected by the posterior ribs and musculature o 12th rib forms an angle with the vertebral column-costovertebral angle o Left kidney lies at the 11th and 12th ribs o Right kidney rests 1-2cm lower than the left kidney • Abdominal wall is divided into 4 quadrants Subjective Data • Appetite, dysphagia, food intolerance, abdominal pain, nausea/vomiting, bowel habits, past abdominal history, medications and nutritional assessment (what questions do you ask for each?) Objective Data • Equipment needed: stethoscope, small centimeter ruler, skin-marking pen, and alcohol wipe • Preparation: emptied bladder, warm room, position the person supine with head on a pillow, the knees bend or on pillow, avoid abdominal tensing, inquire about painful areas, learn to use distraction for muscle relaxation INSPECTION OF THE ABDOMEN CONTOUR • Stand on the person’s right side and look down on the abdomen • Stoop or sit to gaze across the abdomen • Your head should be slightly higher than the abdomen Normal Range of Findings Abnormal Findings • Normally ranges from flat to rounded • Scaphoid abdomen caves in • Protuberant abdomen, abdominal distention SYMMETRY • Shine a light across the abdomen toward you or lengthwise across the person Normal Range of Findings Abnormal Findings • Should be symmetric bilaterally • Bulges, masses • Hernia-protrusion of abdominal viscera through abnormal opening in muscle wall • Sister Mary Joseph nodule is a hard nodule in umbilicus that occurs with metastatic cancer of stomach, large intestine, ovary or pancreas • Ask the person to take a deep breath to further highlight any change or ask the person to perform a sit up without pushing up with hands • Abdomen should stay smooth and symmetric • Note any localized bulging • Hernia or enlarged liver or spleen may show UMBILICUS Normal Range of Findings Abnormal Findings • Normally it is midline and inverted, no sign of discoloration, inflammation or hernia • Common site for piercings; should not be red or crusted • Everted with ascites or underlying mass • Deeply sunken with obesity • Enlarged, everted with umbilical hernia • Bluish periumbilical color occurs (though rarely) with intraperitoneal bleeding (Cullen sign) SKIN Normal Range of Findings Abnormal Findings • Surface is smooth and even, homogenous color; matches ethnic background • Redness with localized inflammation • Jaundice • Skin glistening and taut with ascites • Striae—silvery white, linear, jagged marks about 1-6cm long; occur when elastic fibers in the skin are broken (pregnancy, weight gain); recent striae are pink or blue then turn silvery white • Striae occur with ascites • Striae look purple-blue with Cushing syndrome • Pigmented nevi (moles)—circumscribed brown macular or popular areas—common on abdomen • Unusual color or change in shape of mole • Petechiae • Normally no lesions present • If scar is present, draw its location in the person’s record, indicating the length in cm • A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue • Cutaneous angiomas occur with portal hypertension or liver disease • Lesions, rashes • Underlying adhesions are inflammatory bands that connect opposite sides of serous surfaces after trauma or surgery • Veins usually not seen • Prominent, dilated veins occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction. Veins are more visible with malnutrition as a result of thinned adipose tissue • Good skin turgor reflects healthy nutrition • Gently pinch up a fold of skin then release to note the immediate return of the skin to original position • Poor turgor occurs with dehydration; often accompanies GI disease PULSATION OR MOVEMENT Normal Range of Findings Abnormal Findings • Normally see the pulsations from the aorta beneath the skin in the epigastric area; particularly in thin people • Respiratory movement shows in the abdomen; particularly in males • Marked pulsation of aorta occurs with widened pulse pressure (ex: hypertension, aortic insufficiency, thyrotoxicosis) and aortic aneurysm • Waves of peristalsis sometimes visible in very thin people • Marked visible peristalsis, together w/ distended abdomen, indicates intestinal obstruction HAIR DISTRIBUTION Normal Range of Findings Abnormal Findings • Males: pubic hair is diamond shape • Females: pubic hair inverted triangle shape • Patterns alter with endocrine or hormone abnormalities, chronic liver disease DEMEANOR Normal Range of Findings Abnormal Findings • Relaxed quietly on the examining table, benign facial expression and slow, even respirations • Restlessness and constant turning to find comfort occur with the colicky pain or gastroenteritis or bowel obstruction • Absolute stillness, resisting any movement, occurs with the pain of peritonitis • Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain • Any client who has a board-like ridged-like abdomen suspect a perforated ulcer but treat as an emergency AUSCULTATE BOWEL SOUNDS AND VASCULAR SOUNDS • Percussion and palpation can increase peristalsis false interpretation of bowel sounds • Use diaphragm end piece • Begin in the RLQ at the ileocecal valve area because bowel sounds normally are always present there BOWEL SOUNDS Normal Range of Findings Abnormal Findings • Note character and frequency of bowel sounds • Bowel sounds are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5-30 times per minute • One type of hyperactive bowel sounds is fairly common: hyperperistalsis; “stomach growling” borborygmus • Two patterns of abnormal bowel sounds o Hyperactive sounds: loud, high pitched, rushing, tinkling sounds that signal increased motility o Hypoactive or absent sounds: follow abdominal surgery or with inflammation of the peritoneum VASCULAR SOUNDS Normal Range of Findings Abnormal Findings • Check for bruits • Using firmer pressure, check over the aorta, renal arteries, iliac and femoral arteries (especially in patients with HTN) • Usually no sound is present • 4-20% of healthy people have a bruit originating from the celiac artery; systolic, medium to low in pitch and heart b/n xiphoid process and the umbilicus • Note location, pitch, and timing of a vascular sounds • A systolic bruit is a pulsatile blowing sounds and occurs with stenosis or occlusion of an artery • Venous hum and peritoneal friction rub are rare • Nasogastric tubes: current evidence mandates confirming initial placement by chest x-ray and continuing assessment by measuring the external portion of the tube • Auscultation method can wrongly suggest that the feeding tube is correctly placed in the stomach; serious harm or even fatality can result from administrating tube-feeding material into the lung PERCUSS GENERAL TYMPANY, LIVER SPAN AND SPLENIC DULLNESS • Percuss to assess the relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses • Above liver and spleen dullness • The rest tympanic GENERAL TYMPANY Normal Range of Findings Abnormal Findings • Percuss lightly on all 4 quadrants • Move clockwise • Tympany should predominate because air in the intestines rises to the surface when the person is supine • Dullness occurs over a distended bladder, adipose tissue, fluid or a mass • Hyperresonance is present with gaseous distention LIVER SPAN Normal Range of Findings Abnormal Findings • Measure height of the liver in the right MCL • Begin in the area of lung resonance and percuss down the interspaces until the sound changes to a dull quality • Mark the spot, usually in the 5th intercostal space • Then find abdominal tympany and percuss up in the MCL • Mark where the sound changes from tympany to a dull sound, normally at the right costal margin • Measure the distance b/n the two marks • Normal liver span in the adult ranges from 6-12cm • Height of the liver span correlates with the height of the person • Mean liver span is 10.5cm for males; 7cm for females • Chronic emphysema liver is displaced downward by the hyperinflated lungs • Measurement screens for hepatomegaly and monitors changes in liver size • Scratch test: uses auscultation to detect the lower border of the liver • place the stethoscope over the xiphoid while lightly stroking the skin with on finger up the MCL from the RLQ and parallel to the liver border • Recommended if the abdomen is distended, obese or too tender for palpation or if muscles are rigid or guarded • An enlarged liver span indicates liver enlargement or hepatomegaly • Accurate detection of liver borders is confused by dullness above the 5th intercostal space, which occurs with lung disease (ex: pleural effusion or consolidation). Accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in the colon, which obscures the lower border SPLENIC DULLNESS Normal Range of Findings Abnormal Findings • May be located by percussing from the 9th to 11th intercostal space just behind the left midaxillary line • The area of splenic dullness normally is not wider than 7cm and should not encroach on the normal tympany over the gastric air bubble • A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma and infection • Percuss in the lowest interspace in the left anterior axillary line. Tympany should result. Ask the person to take a deep breath. Normally tympany remains through full inspiration • In the site of the anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign, indicating splenomegaly. This method detects mild-to-moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria or hepatic cirrhosis COSTOVERTEBRAL ANGLE TENDERNESS Normal Range of Findings Abnormal Findings • To assess kidney place one hand over the 12th rib at the costovertebral angle on the back • Thump that hand with the ulnar edge of your other fist • Person normally feels a thud but no pain • Sharp pain occurs with inflammation of the kidney or paranephric area SPECIAL PROCEDURES Normal Range of Findings Abnormal Findings • Fluid wave test: standing on the person’s right side place the ulnar edge of another examiner’s hand or the patient’s own hand firmly on the abdomen in the middle. Place your left hand on the person’s right flank. With your right hand reach across the abdomen and give the left flank of firm strike • If ascites is present, the blow will generate a fluid wave through the abdomen, and you will feel a distinct tap on your left hand • If the abdomen is distended from gas or adipose tissue you will feel no change • Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer • A positive fluid wave test occurs with large amounts of ascitic fluid. Also note edema in the legs. • Shifting dullness test: you will hear a tympanic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid • Then percuss down the side of the abdomen • If fluid is present, the note will change from tympany to dull as you reach its level. Mark this spot. • Turn the person onto the right side; the fluid will gravitate to the dependent side, displacing the lighter bowel upward • Begin percussing the upper side of the abdomen and move downward • The sound changes from tympany to a dull sound as you reach the fluid level; this time the level of dullness is higher upward toward the umbilicus • Shifting level of dullness indicates presence of fluid • This test has less diagnostic value than the fluid wave test. Shifting dullness is positive with a large volume of ascitic fluid; it will not detect less thank 500-1100mL of fluid • Neither tests are completely reliable • Ultrasound study is the definitive tool PALPATE SURFACE AND DEEP AREAS • To judge the size, location and consistency of certain organs and to screen for an abnormal mass or tenderness • Use additional measures to complete muscle relaxation o Bend the person’s knees, keep palpating hand low and parallel to the abdomen, teach patient to breathe slowly, keep voice low and soothing, try “emotive imagery,” for ticklish person keep the person’s hand under your own with your fingers curled over their fingers, alternatively perform palpation just after auscultation palpating as you pretend to auscultate LIGHT AND DEEP PALPATION Normal Range of Findings Abnormal Findings • Begin w/ light palpation w/ first 4 fingers close together, depress the skin about 1cm • Make a gentle rotary motion, sliding the fingers and skin together • Lift the fingers and move clockwise to the next location across the abdomen • Muscle guarding • Rigidity • Large masses • Tenderness • Voluntary guarding occurs when the person is cold, sense or ticklish; it is bilateral and you will feel the muscles relax slightly during exhalation • Involuntary rigidity is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up • Perform deep palpation, moving clockwise • For a very large or obese abdomen use a bimanual technique (place two hands on top of one another, top hand does the pushing and the bottom stays relaxed • Mild tenderness is normally present when palpating the sigmoid colon • Tenderness occurs with local inflammation, inflammation of the peritoneum or underlying organ, and with an enlarged organ whose capsule is stretched • If mass is identified note: location, size, shape, consistency (soft, firm, hard), surface (smooth, nodular), mobility (including movement w/ respirations), pulsatility, tenderness • Next, palpate for specific organs LIVER Normal Range of Findings Abnormal Findings • Place left hand under the person’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents • Place right hand on the RUQ, with fingers parallel to the midline • Push deeply down and under the right costal margin • Ask person to breathe slowly, with every exhalation move your palpating hand up 1 or 2cm • It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes down during inhalation • Feels like a firm, regular ridge • Except with a depressed diaphragm, a liver palpated more than 1-2cm below the right costal margin is enlarged. Record the # of cm it descends and note its consistency (had, nodular) and tenderness • Hooking technique: alternative method of palpating the liver o Stand up at the person’s shoulder and swivel your body to the right so you face the person’s feet o Hook your fingers over the costal margin from above o Ask the person to take a deep breath o Try to feel the liver edge bump your fingertips SPLEEN Normal Range of Findings Abnormal Findings • Normally not palpable and must be enlarged 3x its normal size to be felt • Reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs • Place right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin • Push hand deeply down and under the left costal margin and ask the person to take a deep breath • You should feel nothing firm • The spleen enlarges with mononucleosis, trauma, leukemias and lymphomas, portal hypertension and HIV infection • If you feel an enlarged spleen, refer the person but do not continue to palpate it • An enlarged spleen is friable and can rupture easily w/ over palpation • Describe the # of cm that it extends below the left costal margin • When enlarged, the spleen slides out and bumps your fingertips KIDNEYS Normal Range of Findings Abnormal Findings • Right kidney: place hands together in a “duck-bill” position at the person’s right flank • Press your two hands together firmly and ask the person to take a deep breath • In most people you will feel no change normal • Occasionally you may feel the lower pole of the right kidney as a round, smooth mass that slides b/n your fingers  normal • The left kidney sits 1cm higher than the right kidney and is not palpable normally • Search by reaching left hand across the abdomen and behind the left flank for support • Push right hand deep into the abdomen and ask the person to breathe deeply; you should feel no change w/ the inhalation • Enlarged kidney • Kidney mass AORTA Normal Range of Findings Abnormal Findings • Using opposing thing and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline • Normally it is 2.5-4cm wide in the adult and pulsates in an anterior direction • Widened with aneurysm • Prominent lateral pulsation with aortic aneurysm pushes the examiner’s two fingers apart SPECIAL PROCEDURES Normal Range of Findings Abnormal Findings Rebound Tenderness (Blumberg Sign) • Choose a site away from the painful area • Hold your hand 90 degrees or perpendicular to the abdomen • Push down slowly and deeply • Lift up QUICKLY • A normal, or negative response is no pain on release of pressure • Performed at the end of the examination • Pain on release of pressure confirms rebound tenderness, which is reliable sign of peritoneal inflammation. Peritoneal inflammation accompanies appendicitis • Cough tenderness that is localized to a specific sport also signals peritoneal irritation. Refer the person with suspected appendicitis for CT scanning Inspiratory Arrest (Murphy Sign) • Hold your fingers under the liver border • Ask the person to take a deep breath • A normal response is to complete the deep breath w/o pain • When the test is positive, as the descending liver pushes the inflamed gallbladder into the examining hand, the person feels sharp pain and abruptly stops inspiration midway Iliopsas Muscle Test • Perform when appendicitis is suspected • With the person supine lift the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold the leg up • When the test is negative, the person feels no change • When the iliopsoas muscle is inflamed (which occurs with inflamed or perforated appendix), pain is felt in the RLQ Obturator test • Lift the person’s right leg, flexing at the hip and 90 degrees at the knee • Hold his or her ankle and rotate the leg internally and externally • There should be no pain • Test is less specific • An inflamed appendix irritates the obturator muscle, and this leg movement produces pain McBurney’s Point • Point above anterior superior spine of the ilium • Located on a straight line joining that process and the umbilicus • Pressure of the finger elicits tenderness in acute appendicitis ABNORMAL FINDINGS ABNORMAL DISTENTION Obesity Inspection: Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it) Auscultation: Normal bowel sounds Percussion: Tympany. Scattered dullness over adipose tissue Palpation: Normal. May be hard to feel through thick abdominal wall Air or Gas Inspection: single round curve. Auscultation: Depends on cause of gas (ex: decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction Percussion: Tympany over large area Palpation: May have muscle spasm of abdominal wall Ascites Inspection: single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin; recent weight gain; increase in abdominal pain Auscultation: Normal bowel sounds over intestines. Diminished over ascetic fluid Percussion: Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness Palpation: Taut skin and increased intra-abdominal pressure limit palpation Ovarian Cyst (large) Inspection: Curve in lower half of abdomen, midline. Everted umbilicus Auscultation: Normal bowel sounds over upper abdomen where intestines pushed superiorly Percussion: Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness Palpation: transmits aortic pulsation, whereas ascites does not Pregnancy Inspection: single curve. Umbilicus protruding. Breasts engorged Auscultation: Fetal heart tones. Bowel sounds diminished Percussion: Tympany over intestines. Dull over enlarging uterus Palpation: Fetal parts. Fetal movements Feces Inspection: Localized distention Auscultation: Normal bowl sounds Percussion: Tympany predominates. Scattered dullness over fecal mass Palpation: Plastic-like or ropelike mass with feces in intestines Tumor Inspection: localized distention Auscultation: Normal bowel sounds Percussion: Dull over mass if reaches up to skin surface Palpation: Define borders. Distinguish from enlarged organ or normally palpable structure Intestinal obstruction • Hx of previous abdominal surgery w/ adhesions • Vomiting • Absence of stool or gas passage • Distended abdomen (after 2nd day) • X-ray shows dilated air-filled loops of small bowel with multiple air-fluid levels • Hyperactive bowel sounds in early obstruction; hypoactive or silent in late obstruction • Dehydration and loss of electrolytes • Accumulation of fluid and gas in bowel proximal (above) to obstruction • Colicky pain from strong peristalsis above the obstruction • Fever • Pressure from excess fluid and gas may leaking fluid into peritoneum • Hypovolemic shock (BP, pulse, cool skin if left untreated) SKIN, HAIR AND NAILS ASSESSMENT SKIN • Two layers: epidermis and dermis Epidermis: thin but tough • Basal cell layer: forms new skin cells o Major ingredient is keratin o Melanocytes produce melanin (gives brown tones to the skin and hair)  Amount of melanin produced varies with genetic, hormonal, and environmental influences • Horny cell layer: consists of dead keratinized cells; cells constantly being shed or desquamated, replaced with new cells from below • Epidermis is completely replaced every 4 weeks • Avascular, nourished by blood vessels in the dermis • Skin color is derived from o Mainly from the brown pigment melanin o From the yellow-orange tones of the pigment carotene o From the red-purple tones in the underlying vascular bed Dermis: inner supportive layer consisting mostly of connective tissue or collagen • Has resilient elastic tissue that allows the skin to stretch with body movements • Nerves, sensory receptors, blood vessels and lymphatics lie in the dermis • Hair follicles, sebaceous glands and sweat glands are embedded in the dermis Subcutaneous layer: adipose tissue made up of lobules of fat cells • Stores fat for energy, provides insulation for temperature control, aids in protection by its soft cushioning effect Hair: threads of keratin • Shaft: visible projecting part; root: below surface, embedded in the follicle o Bulb matrix is the expanded area where new cells are produced at a high rate o Hair growth is cyclical with active and resting phases • Two types of hair o Vellus hair: covers most of the body except palms, soles, dorsa of the distal parts of the fingers, the umbilicus, the glans penis and inside the labia) o Terminal hair: the darker, thicker hair that grows on the scalp and eyebrows; after puberty on the axillae, pubic area and face and chest in males Sebaceous glands: produce a protective lipid substance, sebum, which is secreted through the hair follicles • Sebum oils and lubricates the skin and hair • Glands are everywhere except palms and soles • Glands are most abundant in the scalp, forehead, face and chin • Two types o Eccrine glands: coiled tubules that open directly onto the skin surface and produce a dilute saline solutionsweat o Apocrine glands: produce a thick, milky secretion and open into the hair follicles; mainly in axillae, anogenital area, nipples and navel; become active during puberty Nails: hard plates of keratin on the dorsal edges of the fingers and toes • Nail late is clear with fine longitudinal ridges • Pink color from the underlying nail bed of highly vascular epithelial cells • Lunula is the white, opaque, semilunar area at the proximal end of the nail FUNCTION OF THE SKIN • Protection: skin minimizes injury from physical, chemical, thermal and light-wave sources • Prevents penetration: skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body • Perception: skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature and pressure • Temperature regulation: skin allows hear dissipation through sweat glands and heat storage through subcutaneous insulation • Identification: people identify one another by unique combinations of facial characteristics, hair, skin color and even fingerprints • Communication: emotions are expressed in the sign language of the face and body posture • Wound repair: skin allows cell replacement of surface wounds • Absorption and excretion: skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition • Production of vitamin D: the skin is the surface on which UV light converts cholesterol into vitamin D Subjective Data • Past Hx of skin disease (allergies, hives, psoriasis, eczema), change in pigmentation, change in mole (size and color), excessive dryness and moisture, pruritus, excessive bruising, rash or lesion, medications, hair loss, change in nails, environmental or occupational hazards, patient-centered care Objective Data • Preparation: help the person remove clothing and assess the skin as one entity INSPECT AND PALPATE THE SKIN COLOR Normal range of findings Abnormal Findings • Observe the skin tone • Normally it is even, consistent with genetic background (varies from pinkish tan to ruddy dark tan or light to dark brown) • An acquired condition is vitiligo, the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet and body folds and around orifices • Occurs in all people, although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image • Common (benign) pigmented areas occur: • Freckles (ephelides): small, flat macules of brown melanin pigment that occur on sun-exposed skin • Mole (nevus): a clump of melanocytes, tan-to-brown color, flat or raised; have symmetry, small size, smooth borders and single uniform pigmentation • Junctional nevus: macular only and occurs in children and adolescents • Compound nevus: macular and popular • Birthmarks: tan to brown in color • Danger signs: abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE: Asymmetry (not regularly round or oval, two halves of lesion do not look the same) Border irregularity (notching, scalloping, ragged edges, poorly defined margins) Color variation (areas of brown, tan, black, blue, red, white or combination) Diameter greater than 6mm (ex: the size of a pencil eraser), although early melanomas may be Dx at a smaller size Elevation or Evolution Additional symptoms; rapidly changing lesion; a new pigmented lesion; and development of itching, burning or bleeding in a mole. These signs should raise a suspicion of malignant melanoma and warrant referral • The “Ugly Duckling” sign is a new technique to help screen for malignant melanoma; the suspicious lesion stands out as looking different compared with neighboring nevi • Note any color change over the entire body (pallor, erythema, cyanosis and jaundice) • Note if it is transient and expected change or result of pathology • Dark skinned: check under the tongue, buccal mucosa, palpebral conjunctiva and sclera • Pallor is common in acute high stress states like anxiety or fear • Skin also looks pale with vasoconstriction from exposure to cold and from cigarette smoking and edema • Brown-skinned person pallor presents as yellowish-brown color • Black-skinned person pallor presents as ashen or gray • Ashen gray color in dark skin or marked pallor in light skin occurs with anemia, shock and arterial insufficiency • The pallor of shock presents with rapid pulse rate, oliguria, apprehension and restlessness • Chronic iron deficiency anemia may sow “spoon” nails, with a concave shape. Fatigue, exertional dyspnea, rapid pulse, dizziness and impaired mental function accompany most severe anemias Erythema • Intense redness of the skin is from excess blood in the dilated superficial capillaries • This is expected with fever, local inflammation or emotional reactions like blushing • Erythema occurs with polycythemia, venous stasis, carbon monoxide poisoning, and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma) Cyanosis • Bluish mottled color from decreased perfusion • Tissues have high levels of deoxygenated blood • Seen in the lips, nose, cheeks, ears or oral mucous membranes and in artificial fluorescent light • Dark-skinned Mediterranean origin: normal bluish tone on the lips • Cyanosis indicates hypoxemia and occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease Jaundice • Yellowish skin color indicates rising amounts of bilirubin in the blood • Does not normally occur • First noted in the junction of the hard and soft palate of the mouth and in the sclera • Common calluses on palms and soles often look yellowdo not interpret these as jaundice • Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn • Light or clay-colored stools and dark golden urine often accompany jaundice in both light-and dark-skinned people TEMPERATURE Normal Range of Findings Abnormal Findings • Use the backs (dorsa) of the hands to palpate the person and check bilaterally • Skin should be warm and equal bilaterally • Warmth suggests normal circulatory status • Hands and feet may be slightly cooler in a cool environment • Localized coolness is expected with an immobilized extremity • A localized area feels hyperthermic with trauma, infection or sunburn • General hypothermia accompanies shock, cardiac arrest • Localized hypothermia occurs in peripheral arterial insufficiency and Raynaud disease • Hyperthyroidism has an increased metabolic rate, causing warm, moist skin MOISTURE Normal Range of Findings Abnormal Findings • Perspiration appears normally on the face, hands, axillae and skinfolds in response to activity, a warm environment or anxiety • Diaphoresis: profuse perspiration; increased metabolic heart rate occurs in heavy activity or fever • Dehydration: look in oral mucous membranes, normally there is none, mucous membranes look smooth and moist • Diaphoresis occurs with thyrotoxicosis, heart attack, anxiety or pain • With dehydration, mucous membranes are dry, and lips look parched and cracked. With extreme dryness the skin is fissured, resembling cracks in a dry lake bed TEXTURE Normal Range of Findings Abnormal Findings • Normal skin feels smooth and firm with an even surface • Hyperthyroidism—skin feels smoother and softer, like velvet • Hypothyroidism—skin feels rough, dry and flaky THICKNESS Normal Range of Findings Abnormal Findings • Epidermis is uniformly thin over most of the body • Thickened callus areas are normal on palms and soles • Very thin, shiny skin (atrophic) occurs with arterial insufficiency EDEMA Normal Range of Findings Abnormal Findings • Fluid accumulating in the interstitial spaces; not normally present • Check for edema by imprinting thumbs firmly for 3-4 seconds against the ankle malleolus or the tibia • Normally the skin surface stays smooth • If the pressure leaves a dentin the skin. “pitting” edema is presentgrade it on the four-point scale 1+ mild pitting 2+ moderate pitting 3+deep pitting 4+very deep pitting • Edema shows in dependent body parts (feet, ankles, and sacral areas), where the skin looks puffy and tight. It makes the hair follicles more prominent; thus you note a pigskin or orange-peel lookpeau d’orange • Unilateral edema—consider a local or peripheral cause • Bilateral edema or edema that is generalized over the whole body (anasarca)—consider a central problem such as heart failure or kidney failure MOBILITY AND TURGOR Normal Range of Findings Abnormal Findings • Pinch up a large fold of skin on the anterior chest under the clavicle • Mobility is the ease of skin to rise and turgor is the ability to return to place promptly when released; elasticity of the skin • Mobility is decreased with edema • Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or “tents” and stands by itself • Scleroderma, literally “hard skin,” is a chronic connective tissue disorder associated with decreased mobility VASCULARITY OR BRUISING Normal Range of Findings Abnormal Findings • Cherry (senile) angiomas are small (1-5mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 • They normally increase in size and number with aging and are not significant • Multiple bruises at different stages of healing and excessive bruises above knees or elbows raise concern about physical abuse • Any bruising should be consistent with the expected trauma of life • Document the presence of any tattoos on the patient’s chart • Advise the patient that the use of tattoo needles, equipment, and ink of doubtful sterility increased the risk for Hepatitis C • Needle marks from intravenous street drugs may be visible on the antecubital fossae, forearms, or on any available vein LESIONS Normal Range of Findings Abnormal Findings • If present note: 1. Color 2. Elevation: flat, raised, or pedunculated 3. Pattern or shape: the grouping or distinctness of each lesion (ex: annular, grouped, confluent, linear). The pattern may be characteristic of a certain disease 4. Size in cm: use a ruler to measure 5. Location and distribution on body: is it generalized or localized to the area of a specific irritant; around jewelry, watchband, eyes? 6. Any exudate. Note its color and any odor • Lesions are traumatic or pathologic changes in previously normal structures. When a lesion develops on previously unaltered skin, it is primary. However, when a lesion changes over time or changes because of scratching or infection, it is secondary • Palpate lesions • Roll a nodule between the thumb and index finger to assess depth • Gently scrape a scale to see if it comes off • Note the nature of its base or whether it bleeds when the scale comes off • Note surrounding skin temperature • Note the pattern and characteristics of common skin lesions and malignant skin lesions • Use a magnified and light for closer inspection of the lesion • Use of Wood’s light to detect fluorescing lesions • With the room darkened, shine the Wood’s light on the area • Under the Wood’s light, lesions with blue-green fluorescence indicate fungal infection (ex: tinea capitis) INSPECT AND PALPATE THE HAIR COLOR • Hair color comes from melanin production • Graying begins as early as 30s because of reduced melanin production in the follicles • Genetic factors affect the onset of graying TEXTURE Normal Range of Findings Abnormal Findings • Scalp hair may be fine or thick and may look straight, curly or kinky • Should look shiny • Note dull, coarse, or brittle scalp hair • Gray, scaly, well-defined areas with broken hairs accompany tinea capitis, a ringworm infection found mostly in school-age children DISTRIBUTION Normal Range of Findings Abnormal Findings • Fine vellus hair coats the body • Coarser terminal hairs grow at the eyebrows, eyelashes and scalp • During puberty distribution conforms to normal male and female patterns • In Asians body hair may be diminished • Absent or sparse genital hair suggests endocrine abnormalities • Hirsutism—excess body hair. In females this forms a male pattern on the face and chest and indicates endocrine abnormalities LESIONS Normal Range of Findings Abnormal Findings • Separate hair into sections and lift it, observing the scalp • W/ Hx of itching, inspect the hair behind the ears and in the occipital area • All areas should be clean and free of any lesions or pest inhabitants • Many people normally have seborrhea (dandruff), which is indicated by loose white flakes • Head or pubic lice. Distinguish dandruff from nits (eggs) or lice, which are oval and adherent to hair shaft and cause intense itching INSPECT AND PALPATE THE NAILS SHAPE AND CONTOUR Normal Range of Findings Abnormal Findings • Nail surface is normally slightly curved or flat • Posterior and lateral nail folds are smooth and rounded • Nail edges are smooth, rounded and clean (suggesting adequate self-care) • Jagged nails, bitten to the quick or traumatized nail folds suggest nervous picking habits • Chronically dirty nails suggest poor self-care or the chronic staining of some occupations The Profile Sign • View the index finger at its profile and note the angle of the nail base • Should be able 160 degrees • The nail base is firm to palpation • Curved nails are a variation of normal with a convex profile • Clubbing of nails occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases • In early clubbing the angle straightens out to 180 degrees, and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows CONSISTENCY Normal Range of Findings Abnormal Findings • The surface is smooth and regular, not brittle or splitting • Pits, transverse grooves, or lines may indicate a nutrient deficiency or accompany acute illness that disturbs nail growth • Nail thickness is uniform • Nails are thickened and ridged with arterial insufficiency • The nail firmly adheres to the nail bed, and the nail base is firm to palpation • A spongy nail base accompanies clubbing COLOR Normal Range of Findings Abnormal Findings • The translucent nail plate is a window to the even, pink nail bed underneath • Cyanosis or marked pallor • Dark-skinned people may have brown-black pigmented areas or linear bands or streaks along the nail edge • All people normally have white hairline linear markings from trauma or picking at the cuticle called leukonychia • Note any abnormal marking in the nail beds • Brown linear streaks (especially sudden appearance) are abnormal in light-skinned people and may indicate melanoma • Splinter hemorrhages, transverse ridges, or Beau lines Capillary Refill • Depress the nail edge to blanch and the release, noting the return of color • Normally color return is instant or at least within a few seconds in a cold environment • Indicates status of the peripheral circulation • A sluggish color return takes longer than 1-2 seconds • Inspect the toenails • Separate the toes and note the smooth skin in between • Cyanotic nail beds or sluggish color return: consider cardiovascular or respiratory dysfunction • Athlete’s foot scaling PROMOTING HEALTH AND SELF-CARE TEACH SKIN SELF-EXAMINATION • Teach adolescents and adults to examine their skin, using the ABCDE rule • Use a well-lighted room that has a full-length mirror • Helps to have a small handheld mirror • Ask a family member to search skin areas difficult to see • Report any suspicious lesions promptly to a physician or nurse Aging Adult • Senile lentigines are common variations of hyperpigmentation (commonly called liver spots ) o Small, flat, brown macules o Clusters of melanocytes that appear after extensive sun exposure o Appear on the forearms and dorsa of the hands o Not malignant; no treatment required • Keratoses are raised, thickened areas of pigmentation that look crusted, scaly and warty • Seborrheic keratosis looks dark, greasy, and “stuck on” o Develop mostly on the trunk but also on the face and hands and on both unexposed and sun-exposed areas o Do not become cancerous • Actinic (senile or solar) keratosis is less common o Are red-tan scaly plaques that increase over the years to become raised and roughened o May have a silvery-white scale adherent to the plaque o Occur on the sun-exposed surfaces and are directly related to sun exposure o Are premalignant and may develop into squamous cell carcinoma • Dry skin is common in the aging person because of a decline in the number and output of the sweat glands and sebaceous glands o Skin itches and looks flaky and loose • Common variations occurring in the aging adult are acrochordons”skin tags” which are overgrowths of normal skin that form a stalk and are polyp-like o Occur frequently on eyelids, cheeks and neck and axillae and trunk • Sebaceous hyperplasia consists of raised yellow papules with a central depression o More common in mend, occurring over the forehead, nose or cheeks o Have a pebbly look • With aging, skin looks as thin as parchment, subcutaneous fat diminishes o Thinner skin is evident over the dorsa of the hands, forearms, lower legs, dorsa of feet and bony prominences o Skin may feel thicker over the abdomen and chest o Aging skin increases risk for pressure ulcer development • With aging the rate of hair growth decreases and the amount of hair decreases in the axillae and pubic areas o After menopause white women may develop bristly hairs on the chin or upper lip resulting from unopposed androgens o In men coarse terminal hairs develop in the ears, nose and eyebrows, beard is unchanged o Male-pattern balding, or alopecia, is a genetic trait o Scalp hair gradually turns gray because of the decrease in melanocyte function (men and women) • With aging the nail growth rate decreases, and local injuries in the nail matrix may produce longitudinal ridges o Surface may be brittle or peeling and sometimes yellowed o Toenails are also thickened and may grow misshapen o Fungal infections are common in aging, with thickened, crumbling toenails and erythematous scaling between the toes • The skin turgor is decreased and the skin recedes slowly or “tents” and stands by itself ABNORMAL FINDINGS Etiology Light Skin Dark Skin Pallor Anemia—decreased hematocrit Shock—decreased perfusion, vasoconstriction Generalized pallor Brown skin appears yellow-brown, dull; black skin appears ashen gray, dull; skin loses its healthy glow—check areas with least pigmentation such as conjunctivae, mucous membranes Local arterial insufficiency Marked localized pallor (ex: lower extremities, especially when elevated) Ashen gray, dull; cool to palpation Albinism—total absence of pigment melanin throughout the integument Whitish pink Tan, cream, white Vitiligo—patchy depigmentation from destruction of melanocytes Patchy milky-white spots, often symmetric bilaterally Same Cyanosis Increased amount of unoxygenated hemoglobin Central—Chronic heart and lung disease cause arterial desaturation Dusky blue Dark but dull, lifeless; only severe cyanosis is apparent in skin—check conjunctivae, oral mucosa, nail beds Peripheral—exposure to cold, anxiety Nail beds dusky Erythema Hyperemia—increased blood flow through engorged arterioles such as in inflammation, fever, alcohol intake, blushing Red, bright pink Purplish tinge but difficult to see; palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues Polycythemia—increased red blood cells, capillary stasis Ruddy blue in face, oral mucosa, conjunctiva, hands and feet Well concealed by pigment; check for redness in lips Carbon monoxide poisoning Bright cherry red in face and upper torso Cherry-red color in nail beds, lips and oral mucosa Venous stasis—decreased blood flow from area, engorged venules Dusky rubor of dependent extremities; a prelude to necrosis with pressure sore Easily masked; use palpation for warmth or edema Jaundice Increased serum bilirubin, more than 2-3mg/100mL from liver inflammation or hemolytic disease such as after severe burns, some infections Yellow in sclera, hard palate, mucous membranes, then over skin Check sclera for yellow near limbus; do not mistake normal yellowish fatty deposits in the periphery under the eyelids for jaundice; jaundice best noted in junction of hard palate and soft palate and also palms Carotenemia—increased serum carotene from ingestion of large amounts of carotene-rich foods Yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucous membranes Yellow-orange tinge in palms and soles Uremia—renal failure causes retained urochrome pigments in the blood Orange-green or gray overlying pallor or anemia; may also have ecchymoses and purpura Easily masked; rely on laboratory and clinical findings Brown-Tan Addison disease—cortisol deficiency stimulates increased melanin production Bronzed appearance; an “eternal tan,” most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae) Easily masked; rely on laboratory and clinical findings Café au lait spots—caused by increased melanin pigment in basal cell layer Tan to light brown, irregularly shaped, oval patch with well-defined borders LESIONS Linear—a scratch, streak, line or stripe Target—or iris, resembles iris of eye, concentric rings of color in lesions (ex: erythema multiforme) Annular—or circular, begins in center and spreads to periphery (ex: tinea corporis or ringworm, tinea versicolor, pityriasis rosea) Confluent—lesions run together (ex: urticaria [hives]) Discrete—distinct, individual lesions that remain separate (ex: acrochordon or skin tags, acne) Gyrate—twisted, coiled spiral, snakelike Grouped—clusters of lesions (ex: vesicles of contact dermatitis) Zosteriform—linear arrangement along a unilateral nerve route (ex: herpes zoster) Polycyclic—annular lesions grow together (ex: lichen planus, psoriasis) PRIMARY LESIONS Macule Solely a color change, flat and circumscribed, of less than 1 cm. Ex: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever Papule Something you can feel (ex: solid, elevated, circumscribed, less than 1cm diameter) caused by superficial thickening in epidermis. Ex: elevated nevus (mole), lichen planus, molluscum, wart (verruca) Patch Macules that are larger than 1cm. Ex: Mongolian spot, vitiligo, café au lait spot, chloasma, measles rash Plaque Papules coalesce to form surface elevation wider than 1cm. A plateulike, disk-shaped lesion. Ex: psoriasis, lichen planus Nodule Solid, elevated, hard or soft, larger than 1cm. May extend deeper into dermis than papule. Ex: xanthoma, fibroma, intradermal nevi Wheel Superficial, raised, transient, and erythematous; slightly irregular shape from edema (fluid held diffusely in the tissues). Ex: mosquito bite, allergic reaction, dermographism Tumor Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although “tumor” implies “cancer” to most people. Ex: lipoma, hemangioma Uticaria (hives) Wheals coalesce to form extensive reaction, intensely pruritic Vesicle Elevated cavity containing free fluid, up to 1cm; a “blister.” Clear serum flows if wall is ruptured. Ex: herpes simplex, early varicella (chickenpox), herpes zoster *(shingles), contact dermatitis Bulla Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin walled and ruptures easily. Ex: friction blister, pemphigus, burns, contact dermatitis Cyst Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Ex: sebaceous cyst, wen Pustule Turbid fluid (pus) in the cavity. Circumscribed and elevated. Ex: impetigo, acne SECONDARY LESIONS Crust The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus). Ex: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion Scale Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Ex: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, micalike), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin Fissure Linear crack with abrupt edges; extends into dermis; dry or moist. Ex: cheilosis—at corners of mouth caused by excess moisture; athlete’s foot Erosion Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis Ulcer Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Ex: stasis ulcer, pressure sore, chancre Excoriation Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Ex: insect bites, scabies, dermatitis, varicella Scar After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Ex: healed area of surgery or injury, acne Atrophic Scar The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Ex: striae Lichenification Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen) Keloid A benign excess of scar tissue beyond sites of original injury; surgery, acne, ear piercing, tattoos, infections, burns. Looks smooth, rubbery, shiny and “clawlike”; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest and back. May occur months-years after initial trauma. Most common ages are 10-30 years; higher incidence in Blacks, Hispanics and Asians PRESSURE ULCERS Stage I Intact skin appears red but unbroken. Localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure). Dark skin appears darker but does not blanch Stage II Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed Stage III Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone or tendon. Stage IV Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue) HEAD, FACE AND NECK, INCLUDING REGIONAL LYMPHATICS ASSESSMENT THE HEAD • Skull: a rigid bony box that protects the brain and special sense organs, and it includes the bones of the cranium and the face • Cranial bones: frontal, parietal, occipital, temporal • Sutures: meshed immovable joints where cranial bones unite • Coronal suture: crowns the head from hear to ear at the union of the frontal and parietal bones • Sagittal suture: the head lengthwise between the two parietal bones • Lambdoid suture: separates the parietal bones crosswise from the occipital bone • Facial bones: articulate at the sutures • Cranium is supported by the cervical vertebrae C1-C7 • Face has many expressions that reflect mood; formed by facial muscles; mediated by cranial nerve VII (facial nerve) • Two parts of the salivary glands are accessible to examine on the face: parotid and submandibular • Sublingual glands lie in the floor of the mouth • Temporal artery lies superior to the temporalis muscle THE NECK • Delimited by the base of the skull and inferior border of the mandible above and by the manubrium sterni, the clavicle, the first rib, and the first thoracic vertebra below • Major neck muscles are the sternomastoid and the trapezius; innervated by cranial nerve XI • Thyroid gland is an important endocrine gland with a rich blood supply; straddles the trachea in the middle of the neck LYMPHATICS • Head and neck have 60-70 lymph nodes: preauricular (front of the ear), posterior auricular (superficial to the mastoid process), occipital (base of the skull), submental (behind the tip of the mandible), submandibular (1/2way b/n the angle and the tip of the mandible), jugulodigastric (under the angle of the mandible), superficial cervical (overlying the sternomastoid muscle), Deep cervical (deep under the sternomastoid muscle), posterior cervical (in the posterior triangle along the edge of the trapezius muscle), supraclavicular (just above and behind the clavicle, at the sternomastoid muscle) Subjective Data • Headache, Head injury, Dizzinesss, Neck pain, stiff neck, limitation of motion, Lumps or swelling, History of head or neck surgery, Thyroid problems, Self care behaviors Objective Data INSPECT AND PALPATE THE SKULL HEAD Normal Range of Findings Abnormal Findings Size and Shape • Normally feels symmetric and smooth • Note the general size and shape Normocephalic is the term that denotes a round symmetric skull that is appropriately related to body size • Deformities: microcephaly, abnormally small head; macrocephaly, abnormally large head (hydrocephaly, acromegaly) • Note lumps, depressions, or abnormal protrusions Temporal Area • Palpate the temporal artery above zygomatic (cheek) bone between the eye and the top of the ear. • Palpate the temporomandibular joints located anterior to each ear as the person opens the mouth and note normally smooth movement with no limitations or tenderness. • The artery looks tourtuos, feels hardened, and is tender with temporal arteritis • Crepitation, limited range of motion, or tenderness INSPECT THE FACE FACIAL STRUCTURES Normal Range of Findings Abnormal Findings • Note symmetry, features, movement, expression, and condition of the skin • Hostility and aggression • Tense, rigid muscles may indicate anxiety or pain; a flat affect may indicate depression • Note symmetry of eyebrows, palpebral fissures, nasolabial folds and sides of the mouth. • Marker asymmetry w/central brain lesion (stroke) or peripheral cranial nerve VII damage (Bell Palsy) • Note any abnormal facial structures ( coarse facial features, exophalmos, changes in skin color or pigmentation) or any involuntary movements (tics) in the facial muscles. Normally there are none. • Edema in the face is noted first around the eyes (periorbital) and the cheeks, where the subcutaneous tissue is relatively loose • Note grinding of jaws, tics or fasciculations, or excessive blinking THE NECK INSPECT AND PALPATE THE NECK Normal Range of Findings Abnormal Findings Symmetry • Inspect the neck in a neutral and slightly extended position for symmetry and presence of lumps and masses • Head tilt occurs with muscle spasm. Head and neck rigidity occurs with arthritis Range of Motion • Supple-motion is smooth & controlled • Note any limitations • Ask person to touch chin to chest, turn head to the right and left, try to touch each ear to shoulder and extend the head backward • Test muscle strength and the status of cranial nerve XI by trying to resist the person’s movements with your hands as the person shrugs the shoulders and turns the head to each side • Note any pain at any particular movement • Note ratchet or limited movement from cervical arthritis or inflammation of neck muscles. The arthritic neck is rigid; the person turns at the shoulders rather than at the neck • As the person moves the head, note enlargement of the salivary and lymph glands • Normally no enlargement is present • Also note any obvious pulsations • The carotid artery runs medial to the sternomastoid muscle and creates a brisk localized pulsation just below the angle of the jaw • Normally there are no other pulsations while the person is in the sitting position • Thyroid enlargement may be a unilateral lump, or it may be diffuse and look like a doughnut lying across the lower neck LYMPH NODES Normal Range of Findings Abnormal Findings • Using a gentle circular motion of your finger pads, palpate the lymph nodes • Begin with the preauricular lymph nodes in front of the ear • Palpate the 10 groups of lymph nodes in a routine order • If any nodes are palpable note their location, size, shape, delimitation, mobility, consistency, and tenderness • Location o Size/Shape o Usually not palpable o May be less than 1 cm; round • Delimitation o Discrete or Matted o Normal Finding: discrete • Mobility o Side to Side and or Up and Down o Consistency o Soft • Tenderness o Non-tender • The parotid is swollen with mumps • Parotid enlargement has been found with AIDS • If any nodes are palpable note their location, size, shape, delimitation, mobility, consistency, and tenderness • Location o Size/Shape o Usually not palpable o May be less than 1 cm; round • Delimitation o Discrete or Matted o Normal Finding: discrete • Mobility o Side to Side and or Up and Down o Consistency o Soft • Tenderness • Non-tender • Normal nodes feel movable, discrete, soft and nontender • Lymphadenopathy means enlargement of the lymph nodes (>1cm) from infection, allergy, or neoplasm • Acute infection-acute onset, <14 days duration; nodules are bilateral, enlarged, warm, tender, and firm but freely movable • Chronic inflammation (e.g. in tuberculosis the nodules are clumped) • Cancerous nodes are hard, >3 cm, unilateral, nontender, matted, and fixed • Nodes with HIV infection are enlarged, firm, nontender, and mobile. Occipital node enlargement is common with HIV infection. • A single enlarged, nontender, hard, left supraclavicular node may indicate neoplasm in thorax or abdomen (Virchow node) • Painless, rubbery discrete nodes that gradually appear occur with Hodgkin lymphoma, commonly in the cervical region TRACHEA Normal Range of Findings Abnormal Findings • Normally midline • Place your index finger in the sternal notch and palpate for tracheal shift • Space should be symmetric on both sides • Conditions of tracheal shift: The trachea is pushed to the unaffected (or healthy) side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax The trachea is pulled toward the affected (diseased) side with large atelectasis, pleural adhesions, or fibrosis Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm THYROID GLAND Normal Range of Findings Abnormal Findings • Tilt the head back to stretch the skin against the thyroid • Supply the person with a glass of water and first inspect the neck as the person takes a sip and swallows • Thyroid tissue moves with a swallow then falls into its resting position • Look for diffuse enlargement or a nodular lump Posterior Approach • Most common approach • Normal Findings o Thyroid is smooth, nodules o Ask the client to lower chin to neck and turn neck slightly to the right o This will relax the neck muscles o Place your thumbs on the nap of the neck with fingers on either side of the trachea below the cricoid cartilage o Use your left fingers to push the trachea to the right o Use your right fingers to feel deeply in front of Sternomastoid muscle o Ask the person to swallow as you palpate the gland o Reverse the technique as you palpate the left lobe o Anterior Approach • Alternate method more awkward approach • Right thumb displaces and left thumb palpates • Abnormalities: enlarged lobes that are easily palpated before swallowing or are tender to palpation or the presence of nodules or lumps Auscultate the Thyroid • Perform auscultation if you detect enlarged gland during inspection and palpation • Place the bell of the stethoscope over the lateral lobes of the thyroid gland • Ask the person to hold his breath to block out any tracheal breath sounds • A bruit is auscultated over the gland is common in clients with Hyperthyroidism • A bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid (ex: hyperthyroidism) ABNORMAL FINDINGS Tension Migraine Cluster Definition Headache (HA) of muscoskeletal origin; may be mild-to-moderate, less disabling form of migraine HA of genetically transmitted vascular origin; headache plus prodrome, aura, other symptoms HA that is intermittent, excruciating, unilateral, with autonomic signs Location Usually both sides, across frontal, temporal, and/or occipital region of head; forehead, sides, and back of head Commonly one-sided but may occur on both sides Pain is often behind the eyes, the temples, or forehead Always one-sided Often behind or around the eye, temple, forehead, check Character Bandlike tightness, viselike Nonthrobbing, nonpulsatile Throbbing, pulsating Continuous, burning, piercing, excruciating Duration Gradual onset, lasts 30 minutes to days Rapid onset, peaks 1-2hr, lasts 4-72hr, sometimes longer Abrupt onset, peaks in minutes, lasts 45-90 min Quantity and severity Diffuse, dull aching pain Mild-to-moderate pain Moderate-to-severe pain Can occur multiple times a day, in “clusters,” lasting weeks Severe, stabbing pain Timing Situational, in response to overwork, posture =2 per month, last 1-3 days =1 in 10 patients have weekly headaches 1-2/day, each lasting 1/2 -2hr for 1-2 months; then remissions for months or years Aggravating symptoms or triggers Stress, anxiety, depression, poor posture Not worsened by physical activity Hormonal fluctuations (premenstrual) Foods (ex: alcohol, caffeine, MSG, nitrates, chocolate, cheese) Hunger Letdown after stress Sleep deprivation Sensory stimuli (ex: flashing lights or perfumes) Changes in weather Physical activity Exacerbated by alcohol, stress, daytime napping, wind or heat exposure Associated symptoms Fatigue, anxiety, stress Sensation of a band tightening around head, of being gripped like a vice Sometimes photophobia or phonophobia Aura (visual changes such as blind spots or flashes of light, tingling in an arm or leg, vertigo) Prodrome (change in mood, behavior, hunger, cravings, yawning) Nausea, vomiting, photophobia, phonophobia, abdominal pain Person looks sick Family history of migraine Ipsilateral autonomic signs; Nasal congestion of runny nose, watery or reddened eyes, eyelid drooping, miosis Feelings of agitation Relieving factors, efforts to treat Rest, massaging muscles in area, NSAID medication Lie down, darken room, use eyeshade, sleep, take NSAID early, try to avoid opioid Need to move, pace floor THYROID HORMONE DISORDERS Graves Disease (Hyperthyroidism) Myxedema (Hypothyroidism) • Increased production of thyroid hormones causes an increased metabolic rate • This is manifested by goiter and exophthalmos (Bulging eyeballs) • Symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance • Signs include forceful tachycardia; SOB; excessive sweating; fine muscle tremor; thin silky hair; warm, moist skin; infrequent blinking; and a staring appearance • A deficiency of thyroid hormone • Reduces the metabolic rate and when severe causes non-pitting edema and myxedema • Symptoms included fatigue and cold intolerance. • Signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; and dry, coarse hair and eyebrows ABNORMAL FACIES WITH CHRONIC ILLNESS Acromegaly • Abnormal growth of the hands, feet, and face, caused by overproduction of growth hormone • Note the elongated head, massive face, over-growth of nose and lower jaw, heavy eyebrow ridge, and coarse facial features Cushing Syndrome • With excessive secretion of adrenocorticotrophin hormone (ACTH) and chronic steroid use, the person develops a plethoric, rounded, “moonlike” face; prominent jowls; red cheeks, hirsutism on the upper lip, lower cheeks, and chin; and acneiform rash on the chest Bell Palsy (left side) • A lower motor neuron lesion (peripheral), producing rapid onset of cranial nerve VII paralysis of facial muscles • Usually presents with smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and pain behind the ear • Condition is greatly improved if corticosteroids are given within 72 hours of onset Stroke or “Brain Attack” • An upper motor neuron lesion (central) • An acute neurologic deficit caused by blood clot of a cerebral vessel • Ischemic stroke: atherosclerosis • Hemorrhagic stroke: cerebral vessel • The person will still able to wrinkly the forehead and close the eyes Parkinson Syndrome • A deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain • The immobility of features produces a face that is flat and expressionless, “masklike,” with elevated eyebrows, staring gaze, oily skin, and drooling Cachectic Appearance • Dramatic weight loss and muscle atrophy seen in patients with chronic illness • Accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features include sunken eyes; hollow cheeks; and exhausted defeated expression Nephrotic Syndrome • Nephrotic syndrome is a kidney disorder that causes your body to excrete too much protein in your urine. Results in fluid retention, periorbital edema Scleroderma • Connective tissue disease that involves changes in the skin, blood vessels, muscles, and internal organs NOSE, MOUTH AND THROAT ASSESSMENT NOSE • The first segment of the respiratory system • Warms, moistens and filters inhaled air • Nasal mucosa appears redder than oral mucosa because of the rich blood supply present to warm the inhaled air • Nasal cavity is divided medially by the septum • Anterior part of the septum holds a rich vascular network, Kiesselbach plexus, the most common site of nosebleeds • Contains three parallel bony projections—the superior, middle and inferior turbinates • Sinuses drain into the middle meatus, and tears from the nasolacrimal duct drain into the inferior meatus • Cranial nerve Iolfactory nerve • Paranasal sinuses are air-filled pockets within the cranium • Two pairs of sinuses are accessible to examination: frontal sinuses and maxillary sinuses MOUTH • First segment of the digestive system and an airway for the respiratory system • Oral cavity is a short passage bordered by the lips, palate, cheeks and tongue; contain teeth, gums and salivary glands • Arching roof of the mouth is the palate: hard palate (made up of bone) soft palate (arch of muscle that is pinker in color and mobile) • Uvula is the free projection hanging down from the middle of the soft palate • Tongue is a mass of striated muscle arranged in a crosswise pattern so it can change shape and position • Three salivary glands: parotid gland, submandibular gland, and sublingual gland THROAT • Oropharynx is separated from the mouth by a fold of tissue on each side • Tonsils are made up of lymphoid tissue Subjective Data • Nose: Discharge, frequent colds (upper respiratory infections), sinus pain, trauma, epistaxis (nosebleeds), allergies, altered small • Mouth and Throat: sores or lesions, sore throat, bleeding gums, toothache, hoarseness, dysphagia, altered taste, smoking, alcohol consumption, patient-centered care, dental care-pattern, dentures or appliances Objective Data Preparation: otoscope with short, wide-tipped nasal speculum attachment, penlight, two tongue blades, cotton gauze pad (4x4 inches), gloves • Position the person sitting up straight with head at your eye level INSPECT AND PALPATE THE NOSE EXTERNAL NOSE Normal Range of Findings Abnormal Findings • Nose is symmetric, in the midline, and in proportion to the other facial features • Inspect for any deformity, asymmetry, inflammation, or skin lesions • Test the patency of the nostrils by pushing each wing shut with your finger while asking the person to sniff inward through the other naris (cranial nerve I) • Absence of sniff indicates obstruction (ex: common cold, nasal polyps, rhinitis) NASAL CAVITY Normal Range of Findings Abnormal Findings • Insert the otoscope into the nasal vestibule, avoid pressure on the nasal septum • Gently lift up the tip of the nose with your finger before inserting • View each nasal cavity with the person’s head erect and then with the head tilted back • Inspect the nasal mucosa, its normally red in color and smooth moist surface • Note any swelling, discharge, bleeding, or foreign body • Rhinitis—Nasal mucosa is swollen and bright red with URI • Discharge is common with rhinitis and sinusitis, varying from watery and copious to thick, purulent, and green-yellow • With chronic allergy mucosa looks swollen, boggy, pale and gray • Observe the nasal septum for deviation • Also note any perforation or bleeding in the septum • A deviated septum looks like a hump or shelf in one nasal cavity • Perforation is seen as spot of light from a penlight shining in the other naris and occurs with cocaine use • Epistaxis commonly comes from the anterior septum • Inspect the turbinates • Superior turbinate will not be in your view but the middle and inferior turbinates appear the same light red color as the nasal mucosa • Note any swelling but do not try to push the speculum past it • Note any polyps and distinguish them from the normal turbinates • Polyps are smooth, pale gray, avascular, mobile, nontender PALPATE THE SINUS AREAS Normal Range of Findings Abnormal Findings • Palpate the Frontal sinuses by using your thumbs to press up on the brow or below the brow on each side of the nose • Using your thumbs press up on Maxillary sinuses below the check bones • Sinus areas are tender to palpation in people with chronic allergies and acute infection (sinusitis) • Another sign of sinusitis is to check for focal pain when the person bends over Transillumination • Allows the examiner to see if the sinuses are filled with pus or fluid INSPECT THE MOUTH LIPS Normal Range of Findings Abnormal Findings • Inspect the lips for color, moisture, cracking or lesions • Retract the lips and note their inner surface as well • In light-skinned people: circumoral pallor occurs with shock and anemia; cyanosis with hypoxemia and chilling; cherry red lips with carbon monoxide poisoning, acidosis from aspirin poisoning, or ketoacidosis • Cheilitis (perlèche)—Cracking at the corners • Herpes simplex, other lesions TEETH AND GUMS Normal Range of Findings Abnormal Findings • Compare the number of teeth with the number expected for the person’s age • Ask the person to bite; note alignment of upper and lower jaw • Normally the gums look pink or coral with a stippled (dotted) surface • Check for swelling; retraction of gingival margins and spongy, bleeding or discolored gums • Discolored teeth appear brown with excessive fluoride use, yellow with tobacco use • Grinding down of tooth surface; plaque—soft debris; caries—decay • Malocclusion (poor biting relationship), protrusion of upper or lower incisors • Gingival hyperplasia, crevices between teeth and gums, pockets of debris • Gums bleed with slight pressure, indicating gingivitis • Dark line on gingival margins occurs with lead and bismuth poisoning TONGUE Normal Range of Findings Abnormal Findings • Check the tongue for color, surface, characteristics and moisture • Color is pink and even • Dorsal surface is normally roughened from the papillae • A thin white coating by be present • Ask the person to touch the tongue to the roof of the mouth; ventral surface looks smooth and glistening and shows veins • Beefy red, swollen tongue. Smooth glossy areas • Enlarged tongue occurs with mental retardation, hypothyroidism, acromegaly; a small tongue accompanies malnutrition • Dry mouth occurs with dehydration, fever; tongue has deep vertical fissures • Saliva is present • Saliva is decreased when taking anticholinergic and other medications • Excess saliva and drooling occur with gingivostomatitis and neurologic dysfunction • With a glove, hold the tongue with a cotton gauze pad for traction and swing it out and to each side • Inspect for any white patches or lesions; normally non are present • Oral precancerous and cancerous lesions • Inspect carefully the entire U-shaped area under the tongue behind the teeth • Note any white patches, nodules, or ulcerations • Place your other hand under the jaw to stabilize the tissue and to “capture” any abnormality • Note any induration • Any lesion or ulcer persisting for more than 2 weeks must be investigated • An indurated area may be a mass or lymphadenopathy, and it must be investigated BUCCAL MUCOSA Normal Range of Findings Abnormal Findings • Hold the cheek open with a wooden tongue blade • Check for color, nodules, or lesions • It looks pink, smooth and moist • Expected finding is Stensen’s duct, the opening of the parotid salivary gland; looks likes a small dimple opposite the upper second molar • A large patch also may be present along the buccal mucosa • Leukoedema: a benign, milky, bluish-white, opaque area, more common in Blacks and East Indians • Dappled down patches are present with Addison’s disease (chronic adrenal insufficiency) • Orifice of Stensen’s duct looks red with mumps • Koplik spots—early prodromal (early warning) sign of measles • Fordyce granules are small, isolated white or yellow papules on the mucosa of cheek, tongue and lips • Are painless and not significant • Candida infection usually rubs off, leaving a clear or raw denuded surface • The chalky white raised patch of leukoplakia is abnormal PALATE Normal Range of Findings Abnormal Findings • Shine your light up to the roof of the mouth • Anterior hard palate is white with irregular transverse rugae • Posterior soft palate is pinker, smooth and upwardly movable • Normal variation is a nodular bony ridge down the middle of the hard palate, a torus palatinus (arsis after puberty; more common in American Indians, Inuits, and Asians • The hard palate appears yellow with jaundice. In blacks with jaundice it may look yellow, muddy yellow, or green-brown • Oral Kaposi sarcoma is the most common early lesion in people with AIDS • Observe the uvula • Normally looks like a fleshly pendant hanging in the midline • Ask the person to say “ahhh” • Note the soft palate and uvula rise in the midline • Cranial nerve X, vagus nerve • A bifid uvula looks as if it is split in two; more common in American Indians • Any deviation to the side or absent movement indicates nerve damage, which also occurs with poliomyelitis and diphtheria INSPECT THE THROAT Normal Range of Findings Abnormal Findings • With the light observe the oval, rough-surfaced tonsils behind the anterior tonsillar pillar • Color is the same pink as the oral mucosa, their surface is peppered with indentations, or crypts • There should be no exudate on the tonsils • Tonsils are graded in size: 1+ Visible 2+ Halfway between tonsillar pillars and uvula 3+ Touching the uvula 4+ Touching one another • With an acute infection tonsils are bright red and swollen and may have exudate or large white spots • A white membrane covering the tonsils may accompany infectious mononucleosis, leukemia and diphtheria • Normally see 1+ or 2+ tonsils in healthy people • Enlarge view by depressing the tongue with a tongue blade • Scan the posterior wall for color, exudate and lesions • Tonsils are enlarged to 2+, 3+ or 4+ with an acute infection • Touching the posterior wall with the tongue blade elicits the gag reflex • Tests cranial nerves IX and X (glossopharyngeal and vagus) • Test cranial nerve XII (hypoglossal) by asking the person to stick out the tongue • During the examination notice any breath odor, halitosis • With CN XII damage, the tongue deviates toward the paralyzed side • A fine tremor of the tongue occurs with hyperthyroidism; a coarse tremor occurs with cerebral palsy and alcoholism • Diabetic ketoacidosis has a sweet, fruity breath odor; this acetone smell also occurs in children with malnutrition or dehydration. Others are an ammonia breath odor with uremia; a musty odor with liver disease; a foul, fetid odor with dental or respiratory infections; an alcohol odor with alcohol ingestion or chemicals; a mouselike smell of the breath with diphtheria ABNORMAL FINDINGS NOSE ABNORMALITIES Choanal Atresia • Congenital bony septum between the nasal cavity and the pharynx • Not common in the newborn • When bilateral, it is an airway emergency • Note airway obstruction, stridor, and paradoxical cyanosis • When unilateral, the infant may be asymptomatic until the onset of the first respiratory infection Epistaxis • Most common site is Kiesselbach plexus in the anterior septum • Peak incidence is bimodal, <18years and >50years • Causes include nose picking, forceful coughing or sneezing, fracture, foreign body, illicit drug use (cocaine), topical nasal drugs, warfarin, aspirin, or a coagulation disorder • Bleeding from the anterior septum is easily controlled and rarely severe • Posterior hemorrhage is less common but more profuse, harder to manage, and more serious Sinusitis • Inflamed infected sinus areas following URI are most often viral in origin and do not require antibiotics • Consider bacterial infection when signs last >7-10 days • Major signs are mucopurulent drainage, nasal obstruction, facial pain or pressure and loss of sense of smell • May also have fever, chills, malaise • Maxillary sinusitis has dull, throbbing pain in cheek and teeth and pain with palpation and when bending over • Frontal sinusitis has pain above supraorbital ridge Seasonal Allergic Rhinitis (Hay Fever) • Most common type of rhinitis present with rhinorrhea, itching of nose eyes, lacrimation, nasal congestion, and sneezing • Note serious edema and swelling or turbinates to fill the air space • Turbinates are usually pale, and their surface looks smooth and glistening • Common allergens are dust mite, animal dander, mold, pollen • When severe, allergic rhinitis produces disordered sleep, obstructive sleep apnea, sinusitis, and poor work performance Furuncle • A small boil located in the skin or mucous membrane; appears red and swollen and is quite painful • Avoid any manipulation or trauma that may spread the infection Acute Rhinitis • First sign is clear, watery discharge, rhinorrhea, which later becomes purulent • Accompanied by sneezing, nasal itching, stimulation of cough reflex and inflamed mucosa, which causes nasal obstruction • Turbinates are dark red and swollen Foreign Body • Risk for aspiration, removal should be prompt • Watch our for impaction from a small button battery from an electronic device • Once occluding the nostril, the battery can release voltage or chemicals that cause burns, necrosis, or perforation Perforated Septum • A hole in the septum, usually in the cartilaginous part • May be caused by snorting cocaine or methamphetamine, chronic infection, trauma from continual picking of crusts, or nasal surgery • Seen directly or as a spot of light when the penlight is directed into the other naris Nasal Polyps • Smooth, pale gray nodules, which are overgrowths of mucosa, are most commonly caused by chronic allergic rhinitis • May be stalked • Common site is protrusion from the middle meatus • Often multiple • Are mobile and nontender in contrast to turbinates LIP ABNORMALITIES Cleft Lip • Maxillofacial clefts are the most common congenital deformities and are associated with phenytoin, maternal smoking and alcohol use, benzodiazepines and corticosteroids • Early treatment preserves the functions of speech and language formation and deglutition (swallowing) Herpes Simplex I • The cold sores are groups of clear vesicles with a surrounding indurated erythematous base • These evolve into pustules, which rupture, weep and crust; heal in 4-10 days • Most likely site is the lip-skin junctions; infection often recurs in the same site • Caused by the herpes simplex virus (HSV-I), the lesion is highly contagious and is spread by direct contact • Recurrent infections may be precipitated by sunlight, fever, colds and allergy Angular Cheilitis (Stomatitis, Perleche) • Erythema, scaling and shallow and painful fissures at the corners of the mouth occur with excess salivation and candida infection • Often seen in edentulous persons and those with poorly fitting dentures, causing folding in of corner of mouth, which creates a warm, moist environment favoring growth of yeast Carcinoma • Initial lesion is round and indurated • Becomes crusted and ulcerated with an elevated border • Most occur between the outer and middle thirds of the lip • Any lesion that is still unhealed after 2 weeks should be referred Retention “Cyst” (Mucocele) • A round, well-defined translucent nodule that may be very small or up to 1-2cm • It is a pocket of mucus that forms when a duct of a minor salivary gland ruptures • Benign lesion also may occur on the buccal mucosa, on the floor of the mouth, or under the tip of the tongue BUCCAL MUCOSA ABNORMALITIES Aphthous Ulcers • A common “canker sore” is a vesicle at first and then a small round, “punched-out” ulcer with a white base surrounded by a red halo • It is quite painful and lasts for 1-2 weeks • The cause is unknown, although it is associated with stress, fatigue and food allergy Koplik Spots • Small blue-white spots with irregular red halo scattered over mucosa opposite the molars • An early sign, and pathognomonic, or measles Leukoplakia • Chalky white, thick, raised patch with well-defined borders • Lesion is firmly attached and does not scrape off • May occur on the lateral edge of tongue • Caused by chronic irritation and occurs with heavy smoking and alcohol use • Lesions are precancerous • MUST REFER TO SPECIALIST Candidiasis or Monilial Infection • A white, cheesy, curdlike patch on the buccal mucosa and tongue • Scrapes off, leaving a raw, red surface that bleeds easily • Termed thrush in the newborn • It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people Candidiasis in Adult • Overgrowth of Candida occurs with steroid inhaler use, HIV infection, use of broad-spectrum antibiotics or corticosteroids, leukemia, malnutrition or reduced immunity Herpes Simplex I • Infection on the hard palate TONGUE ABNORMALITIES Anklyogossia • A short lingual frenulum, here fixing the tongue tip to the floor of the mouth and gums • This limits the mobility and affects speech if the tongue tip cannot be elevated to the alveolar ridge • A congenital defect Geographic tongue (Migratory Glossitis) • Pattern of normal coating interspersed with bright red, shiny, circular bald areas caused by atrophy of the filiform papillae, with raised pearly borders • Pattern resembles a map and changes with time • Not significant, and its cause is not known Smooth, Glossy Tongue (Atrophic Glossitis) • Surface is slick and shiny • Mucosa thins and looks red from decreased papillae • Accompanied by dryness of tongue and burning • Occurs with vitamin B12 deficiency, folic acid deficiency and iron deficiency anemia • Also note angular cheilitis Black hairy tongue • Not really hair but rather a elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue • Color varies from black-brown to yellow • It occurs after use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus, and with heavy smoking Carcinoma • An ulcer with rolled edges indurated • Occurs particularly at sides, base and under the tongue • Grows insidiously and may go untreated for months • May have associated leukoplakia • Risk for early metastasis is present because of rich lymphatic drainage • Smoking and heavy alcohol use are associated • Incidence of HPV related to oral pharyngeal cancers is also increased Fissured or Scrotal Tongue • Deep furrows divide the papillae into small irregular rows • The condition occurs in 5% of the general population and in Down syndrome • Incidence increases with age Enlarged Tongue (Macroglossia) • Tongue is enlarged and may protrude from the mouth • Condition is not painful but may impair speech development • Occurs with Down Syndrome • Also occurs with cretinism, myxedema and acromegaly • A transient swelling also occurs with local infections OROPHARYNX ABNORMALITIES Bifid Uvula • Uvula looks partly severed and may indicate a submucous cleft palate • Feels like notch at the junction of the hard and soft palates • May affect speech development because if prevents necessary air trapping • Incidence is more common in American Indians Oral Kaposi Sarcoma • Bruiselike, dark red or violet, confluent macule, usually on hard palate • May be on soft palate or gingival margin • Oral lesions may be among the earliest lesions to develop with AIDS Peritonsillar Abscess • Untreated acute pharyngitis may cause suppurative complications, peritonsillar abscess, or suppurative thrombophlebitis • Two major red flags with this pharyngitis are worsening symptoms or neck swelling Acute Tonsilitis and Pharyngitis • Bright red throat; swollen tonsils; white or yellow exudate on tonsils and pharynx; swollen uvula; and enlarged, tender anterior cervical and tonsillar nodes • Accompanied by severe sore throat, painful swallowing, fever >101F of sudden onset • Bacterial infections may have absence of cough • Severe symptoms or sore throat lasting >3-5days, consider streptococcal infection and confirm with rapid antigen testing or throat culture • Treat positive tests with antibiotics • Untreated GAS pharyngitis may produce peritonsillar abscess, lymphadenitis, or acute rheumatic fever Cleft palate • A congenital defect • Failure of fusion of the maxillary processes • Wide variation occurs in the extent of cleft formation, from upper lip only, palate only, uvula only, to cleft of the nostril and the hard and soft palate EYE ASSESSMENT EXTERNAL ANATOMY • Eye is well protected by the bony orbital cavity, surrounded with a cushion of fat • Eyelids are like two rapid window shades that further protect the eye from injury, strong light, and dust • Palpebral fissure is the elliptical open space between the eyelids • Limbus: the border between the cornea and sclera • Canthus is the corner of the eye, the angle where the lids meet • Caruncle is a small, fleshy mass containing sebaceous glands • Tarsal plates are strips of connective tissue that give it shape • Meibomian glands are modified sebaceous glands that secrete an oily lubricating material onto the lids • Conjunctiva is a thin mucous membrane folded like an envelope between the eyelids and the eyeball • Lacrimal apparatus provides constant irrigation to keep the conjunctiva and cornea moist and lubricated o Lacrimal gland in the upper outer corner over the eye, secretes tears o Tears wash across the eye and are drawn up evenly as the lid blinks o Drain into the puncta (on the upper and lower lids at the inner canthus) EXTRAOCULAR MUSCLES • 6 muscles attach the eyeball to its orbit • Extraocular muscles (EOMs) give the eye both straight and rotary movement o Movement stimulated by 3 cranial nerves (abducens nerve VI, trochlear nerve IV, oculomotor nerve III) INTERNAL ANATOMY • Eye is an asymmetric sphere composed of three concentric coats o Sclera-outer fibrous  Tough, protective, white covering  Continuous anteriorly with the smooth, transparent cornea, which covers the iris and pupil  Cornea: thin, transparent and very sensitive to touch • Corneal reflextrigeminal nerve Vfacial nerve VIIblink o Choroid-middle vascular  Has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to delivery blood to the retina  Pupil is round and regular; size is determined by a balance between the parasympathetic and sympathetic chain of autonomic nervous system  Cranial nerve IIIconstriction of pupil  Lens is a biconvex disc located just posterior to the pupil o Retina-inner nervous  Optic disc is the area in which fibers from the retina converge to form the optic nerve  Retinal vessels normally include a paired artery and vein extending to each quadrant, growing progressively smaller in caliber as they reach the periphery  Macula is located on the temporal side of the fundus  Fovea centralis is the area of sharpest and keenest vision VISUAL PATHWAYS AND VISUAL FIELDS • Object reflects lightrefract through transparent mediastrike the retinaimage formed on the retina is upside down and reversedat optic chiasm nasal fibers cross overleft optic tract has fibers from the left ½ of each retina; right optic tract contains fibers only from the rightright side of brain looks at the left side of the world (vice versa) VISUAL REFLEXES • Pupillary light reflex: the normal constriction of the pupils when bright light shines on the retina (oculomotor nerve, III) • Fixation: a reflex direction of the eye toward an object attracting our attention • Accommodation: adaptation of the eye for near vision Subjective Data • Vision difficulty (decreased acuity, blurring, blind spots), pain, strabismus, diplopia, redness, swelling, watering, discharge, Hx of ocular problems, Glaucoma, use of glasses or contact lenses, patient-centered care Objective Data TEST CENTRAL VISUAL ACUITY Normal Range of Findings Abnormal Findings Snellen Eye Chart • Place the Snellen alphabet chart in a well-lit spot at eye level • Position the person on a mark exactly 20 feet from the chart • Use an opaque card to shield on eye at a time during the test • If the person wears glasses or contacts leave them on • Ask the person to read through the chart to the smallest line of letters possible • Note hesitancy, squinting, leaning forward, misreading letters • Record the result using the numeric fraction at the end of the last successful line read • Indicate whether the person missed any letters or if corrective lenses were worn • Normal visual acuity is 20/20 • The top number indicates the distance the person is standing from the chart, the denominator gives the distance at which a normal eye could have read that particular line • If the person is unable to see even the largest letters, shorten the distance to the chart until it is seen and record that distance • If visual acuity is even lower, assess whether the person can count your fingers when they are spread in front of the eyes or distinguish light perception from your penlight • The larger the denominator, the poorer the vision. If vision is poorer than 20/30, refer to an ophthalmologist or optometrist. Impaired vision results from refractive error, opacity in the media (cornea, lens, vitreous) or disorder in the retina or optic pathway Near Vision • Hold the card in good light about 35cm from the eye—the distance equals the pint size on the 20-feet chart • Test each eye separately with the person wearing glasses • A normal result is 14/14 in each eye, read w/o hesitancy and w/o moving the card closer or father away • Presbyopia, the decrease in power of accommodation with aging, is suggested when the person moves the card farther away TEST VISUAL FIELDS Normal Range of Findings Abnormal Findings • Tests for loss of peripheral vision • Position yourself at eye level about 2 feet away • Looking straight at you, the person covers one eye with an opaque card as you cover the opposite eye • You are testing the uncovered eye • Hold wiggling finger as a target midline between you and the person and slowly advance it in from the periphery in several directions • Ask the person to say “now” as the target is first seen (should be just as you see the object) • For the temporal direction, start your finger somewhat behind the person • Estimate the angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen • Normal results are about 50 degrees upward, 90 degrees temporally, 70 degrees inferiorly and 60 degrees nasally • The sensitivity of confrontation testing can be increased by combining the wiggling finger test with a moving red target • Hold a 5mm red-topped pin beyond the boundary of each quadrant between the horizontal and vertical axes • Move it inward and ask the person to state when the pin first appears red • if the person is unable to see the object as the examiner does, the test suggests peripheral field loss. In an older adult this screens for glaucoma. Refer to a specialist for more precise testing. • Acutely diminished visual fields occur with diseases of the retina and with stroke INSPECT EXTRAOCULAR MUSCLE FUNCTION Normal Range of Findings Abnormal Findings Corneal Light Reflex (Hirschberg Test) • Assess the parallel alignment of the eyes axes by shining a light toward the person’s eyes • Direct the person to stare straight ahead as you hold the light about 30 cm away • Note the reflection of the light on the corneas; should be exactly the same spot on each eye • Asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or paralysis. If you see this, perform the cover test Diagnostic Positions Test • Ask the person to hold the head steady and follow the movement of your finger only with the eyes • Hold the target back about 30 cm so the person can focus on it comfortably, move it to each of the 6 positions • Hold it momentarily, then back to center • Progress clockwise • A normal response is parallel tracking of the object with both eyes • Eye movement is not parallel. Failure to follow in a certain direction indicates weakness of an EOM or dysfunction of the cranial nerve innervating it • Note any nystagmus—a fine, oscillating movement best seen around the iris • Mild nystagmus at an extreme lateral gaze is normal • Nystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions • Note that the upper eye lid continues to overlap the superior part of the iris, even during downward movement • You should not see a white rim of sclera between the lid and the iris • Lid lag occurs with hyperthyroidism INSPECT EXTERNAL OCULAR STRUCTURES Normal Range of Findings Abnormal Findings General • Note facial expression • A relaxed expression accompanies adequate vision • Groping with hands • Squinting or craning forward Eyebrows • Look for symmetry between the two eyes • Normally the eyebrows are present bilaterally, move symmetrically as the facial expression changes • Have no scaling or lesions • Unequal or absent movement with nerve damage • Scaling with seborrhea Eyelids and Lashes • Upper lids normally overlap the superior part of the iris and approximate completely with the lower lids closed • Skin is intact w/o redness, swelling, discharge or lesions • Palpebral fissures are horizontal in non-Asians • Asians normally have an upward slant • Lid lab with hyperthyroidism • Incomplete closure creates risk for corneal damage • Ptosis, dropping of upper lid • Periorbital edema, lesions • Ectropion and entropion Eyeballs • Aligned normally in their sockets with no protrusion or sunken appearance • Blacks normally have a slight protrusion of the eyeball beyond the supraorbital ridge • Exophthalmos (protruding eyes) and enophthalmos (sunken eye) Conjunctive and Sclera • Ask the person to look up • Using your thumbs, slide the lower lids down alone the bony orbital rim • Take care not to push against the eyeball • Inspect the exposed area • They eyeball looks moist and glossy • Numerous small blood vessels normally show through the transparent conjunctiva • Conjunctivae are clear and show the normal color of the structure below—pink over the lower lids, white over the sclera • Note any color change, swelling or lesions • The sclera is china white, blacks occasionally have a gray-blue or “muddy” color to the sclera, have yellowish fatty deposits beneath the lids away from the cornea • General reddening • Cyanosis of the lower lids • Pallor near the outer canthus of the lower lid may indicate anemia (the inner canthus normally contains less pigment) • Scleral icterus is an even yellowing of the sclera extending up to the cornea, indicating jaundice • Tenderness, foreign body, discharge or lesions Eversion of the upper Lid • Ask the person to keep both eyes open and look down • Slide the upper lid up along the bony orbit to lift up the eyelashes • Grasp the lashes between your thumb and forefinger and gently pull down and outward • W/ the other hand, place the tip of an applicator stick on the upper lid above the level of the internal tarsal plates • Gently push down with the stick as you lift the lashes • Secure the everted position by holding the lashes against the body orbital rim • Inspect for any color change, swelling, lesion or foreign body • Gently pull the lashes outward as the person looks up to return to normal position Lacrimal Apparatus • Ask the person to look down • With your thumbs, slide the outer part of the upper lid up along the bony orbit to expose under the lid • Inspect for any redness or swelling • Normally the puncta drain the tears into the lacrimal sac • Presence of excessive tearing may indicate blockage of the nasolacrimal duct, check by pressing the index finger against the sac, just inside the lower orbital rim • Pressure slightly everts the lower lid, should be no other response to pressure • Swelling of the lacrimal gland may show a visible bulge in the outer part of the upper lid • Puncta red, swollen, tender to pressure • Watch for any regurgitation of fluid out of the puncta, which confirms duct blockage INSPECT ANTERIOR EYEBALL STRUCTURES Normal Range of Findings Abnormal Findings Cornea and Lens • Shine a light from the side across the cornea and check for smoothness and clarity • There should be no opacities (cloudiness) in the cornea, the anterior chamber, or the lens behind the pupil • Arcus senilis is a normal finding in aging person • A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays Iris and Pupil • Normally appears flat, with a round regular shape and even coloration • Note the size, shape and equality of the pupils • Normally the pupils appear round, regular and of equal size in both eyes (3-5mm) • Anisocoria: 50% of people have pupils of two different sizes • test the pupillary light reflex: darken the room and ask the person to gaze into the distance • normally you will see constriction of the same-side pupil and simultaneous constriction of the outer pupil • test for accommodation by asking the person to focus on a distant object • have the person shift the gaze to a near object (about 7-8cm) from the person’s nose • normal response includes pupillary constriction and convergence of the axes of the eyes • record the normal response to all maneuvers as PERRLA (Pupils Equal Round React to Light and Accommodation) • Unconscious or sedated person cannot accommodate • PERRL can be as far as you can go • Irregular shape • Although they may be normal, all unequal-size pupils call for a consideration of central nervous system injury • Dilated pupils • Dilated and fixed pupils • Constricted pupils • Unequal or no response to light • Absence of constriction or convergence. Asymmetric response INSPECT THE OCULAR FUNDUS Normal Range of Findings Abnormal Findings • Ophthalmoscope allows for inspection of media and ocular fundus • Hold ophthalmoscope right up to your eye, braced firmly against the cheek and brow • Black numbers indicate a positive diopter (focus on objects nearer in space) • Red numbers show a negative diopter (focus on objects farther away) • Darken the room • Remove eyeglasses (both you and person; contact lenses can remain) • Ask the patient to keep looking at light • Hold the ophthalmoscope in the right hand to your right eye to view the person’s right eye • Begin about 25cm away at about 15 degree lateral to the person’s line of vision • Note the red glow filling the person’s pupil • Red reflex caused by the reflection of the ophthalmoscope • Inspect structures: optic disc, retinal vessels, general background, macula • Cataracts appear as opaque black areas against the red reflex Optic Disc • Explore characteristics Color: creamy yellow-orange to pink Shape: Round or oval Margins: Distinct and sharply demarcated, although the nasal edge may be slightly fuzzy Cup-disc ratio: Distinctness varies. When visible, physiologic cup is a brighter yellow-white than rest of the disc. Its width is not more than ½ the disc diameter • Scleral crescent is a gray-white, new-moon shape, occurs when pigment is absent in the choroid layer • Pigment crescent is black, caused by accumulation of pigment in the choroid • Pallor. Hyperemia. • Irregular shape • Blurred margins • Cup extending to the disc border Retinal Vessels • Follow an artery and vein out to the periphery in the 4 quadrants and note: Number: a paired artery and vein pass to each quadrant. Vessels look straighter at the nasal side Color: Arteries are brighter red than veins. They also have the arterial light reflex, with a thin stripe of light down the middle A:V ratio: The ratio comparing the artery-to-vein width is 2:3 or 4:5 Caliber: arteries and veins show a regular decrease in caliber as they extend to the periphery A-V (arteriovenous) crossing: An artery and vein may cross paths. This is not significant if within 2 DD of disc and if not sign of interruption in blood flow is seen. There should be no indenting or displacing of vessel Tortuosity: a mild vessel twisting; when present in both eyes is usually congenital and not significant Pulsations: are present in veins near the disc as their drainage meets the intermittent pressure of arterial systole (often hard to see) • Absence of major vessels • Arteries too constricted • Veins dilated • Focal constriction • Neovascularization (proliferation of new vessels) • Crossings more than 2 DD away from disc • Nicking or pinching of underlying vessel. Vessel engorged peripheral to crossing • Extreme tortuosity or marked asymmetry in two eyes • Absent pulsations General Background of the Fundus • Color normally varies from light red to dark brown-red • Generally corresponding with the person’s skin color • No lesions should obstruct the retinal structures • Abnormal lesions; hemorrhages, exudates, microaneurysms Macula • 1 DD in size and located 2 DD temporal to the disc • Inspect this area • Note that the normal color of the area is somewhat darker than the rest of the fundus; it is even and homogenous • Clumped pigment may occur with aging • Within the macula may note the foveal light reflex  tiny white glistening dot reflecting the ophthalmoscope light • Clumped pigment occurs with trauma or retinal detachment • Hemorrhage or exudate in the macula occurs with senile macular degeneration Aging adult • Central acuity may decrease, particularly after 70 • Peripheral vision may be diminished • In older adults an increased risk of falls and fractures occurs with a distance visual acuity of 20/25 or greater • Eyebrows may show a loss of the outer 1/3-1/2 of hair because of a decrease in hair follicles • Skin around the eyes may show wrinkles or crow’s feet • Upper lid may be so elongated as to rest on the lashes, resulting in a pseudoptosis • Eyes may appear sunken from atrophy of the orbital fat • Ectropion (lower lid dropping away) and entropion (lower lid turning in) • Lacrimal apparatus may decrease tear production, causing the eyes to look dry • Pingueculae: yellowish elevated nodules are caused by a thickening of the bulbar conjunctiva from prolonged exposure to sun, wind and dust; appear at the 3 and 9 o’clock positions • Distinguish pinguecula from the abnormal pterygium, also an opacity on the bulbar conjunctiva, but one that grows over the cornea • Cornea may look cloudy with age; arcus senilis (gray-white arc or circle around the limbus) is commonly seen around the cornea • Xanthelasma are soft, raised yellow plaques occurring on the lids at the inner canthus • Pupils are small in old age; pupillary light reflex may be slowed. Lens loses transparency and looks opaque • Retinal structures generally have less shine, blood vessels look paler, narrower and attenuated, arterioles appear paler and straighter with a narrower light reflex • Normal development on the retinal surface are drusen or benign degenerative hyaline deposits; small, round, yellow dots scattered haphazardly on the retina • Drusen are easily confused with the abnormal finding hard exudates, which occur with a more circular or linear pattern. Also, drusen in the macular area occur with macular degeneration ABNORMAL FINDINGS EXTRAOCULAR MUSCLE DYSFUNCTION Asymmetric Corneal Light Reflex • Strabismus is true disparity of the eye axes • Also termed tropia and likely to cause amblyopia A. Esotropia—inward turning of the eye B. Exotropia—outward turning of the eyes Cover Test C. Uncovered eye—if it jumps to fixate on designated point, it was out of alignment before (ex: when you cover the stronger eye [C1], the weaker eye now tries to fixate [C2]). Phoria—Mild weakness, apparent only with the cover test and less likely to cause amblyopia than a tropia but still possible D. Covered eye—if this is the weaker eye, once macular image is suppressed, it will drift to relaxed position (D1). As eye is uncovered—if it jumps to reestablish fixation (D2), weakness exists. Esophoria—Nasal (inward) drift. Exophoria—Temporal (outward) drift. Diagnostic Positions Test (Paralysis apparent during movement through 6 cardinal positions of gaze) Indicates dysfunction If eye will not turn: in cranial nerve Straight nasal III Up and nasal III Up and temporal III Straight temporal VI Down and temporal III Down and nasal IV EYELID ABNORMALITIES Periorbital Edema • Lids are swollen and puffy • Lid tissues are loosely connected, so excess fluid is easily apparent • Occurs with local infections; crying; and systemic conditions such as congestive heart failure, renal failure, allergy, hypothyroidism (myxedema) Exophthalmos (Protruding eyes) • A forward displacement of the eyeballs and widened palpebral fissures • Note “lid lag,” in which the upper lid rests well about the limbus and white sclera is visible • Acquired bilateral exophthalmos is associated with thyrotoxicosis Enophthalmos (Sunken Eyes) • A look of narrowed palpebral fissures shows with enophthalmos, in which the eyeballs are recessed • Bilateral enophthalmos is caused by loss of fat in the orbits and occurs with dehydration and chronic wasting illnesses Ptosis (Drooping Upper lid) • Occurs from neuromuscular weakness (ex: myasthenia gravis with bilateral fatigue as the day progresses), oculomotor cranial nerve III damage, or sympathetic nerve damage (ex: Horner syndrome) or is congenital • It is a positional defect that gives the person a sleepy appearance and impairs vision Upward Palpebral Slant • Although normal in many children, when combined with epicanthal folds, hypertelorism (large spacing between the eyes), and Brushfield sports (light-colored areas in outer iris), it indicated Down syndrome Ectropion • The lower lid is loose and rolling out, does not approximate to eyeball • Puncta cannot siphon tears effectively; excess tearing results • The eyes feel dry and itchy because the tears do not drain correctly over the corner and toward the medial canthus • Exposed palpebral conjunctiva increases risk for inflammation • Occurs in aging as a result of atrophy of elastic and fibrous tissues but may result from trauma Entropion • The lower lid rolls in because of spasm of lids or scar tissue contracting • Constant rubbing of lashes may irritate cornea • The person feels a “foreign body” sensation LESIONS OF THE EYELIDS Blepharitis (Inflammation of the Eyelids) • Red, scaly, greasy flakes and thickened, crusted lid margins occur with staphylococcal infection or seborrheic dermatitis of the lid edge • Symptoms include burning, itching, tearing, foreign body sensation, and some pain Chalazion • Beady nodule protruding on the lid, chalazion is an infection or retention cyst of a meibomian gland • If chronic, it is a nontender, firm, discrete swelling with freely movable skin overlying the nodule • If acutely inflamed, it is tender, warm, and red and points inside and not on lid margin (in contrast with stye) Hordeolum (stye) • An acute localized staphylococcal infection of the hair follicles at the lid margin • It is painful, red, and swollen—a superficial, elevated pustule at the lid margin • Rubbing the eyes can cause cross-contamination and development of another stye Dacryocystitis (Inflammation of the Lacrimal Sac) • Infection and blockage of sac and duct • Pain, warmth, redness and swelling occur bellow the inner canthus toward the nose • Tearing is present • Pressure on sac yields purulent discharge from puncta • Dacryoadenitis is an infection of the lacrimal gland • Pain, swelling, and redness occur in the outer third of the upper lid • Occurs with mumps, measles and infectious mononucleosis or from trauma Basal Cell Carcinoma • Most often on the lower lid and presents as a small painless nodule with central ulceration and sharp, rolled-out pearly edges • Occurs in older adults; associated with ultraviolet exposure and light skin • Locally invasive, but metastasis is rare PUPIL ABNORMALITIES A. Unequal Pupil Size—Anisocoria Although this exists normally in 5% of the population, consider central nervous system disease B. Monocular Blindness When light is directed to the blind eye, no response occurs in either eye. When light is directed to the normal eye, both pupils constrict (direct and consensual response to light) as long as the oculomotor nerve is intact C. Dilated and Fixed Pupils—Mydraisis Enlarged pupils occur with stimulation of the sympathetic nervous system, reaction to sympathomimetic drugs, use of dilating drops, acute glaucoma, or past or recent trauma. They also herald central nervous system injury, circulatory arrest, or deep anesthesia D. Constricted and Fixed Pupils—Miosis Miosis occurs with the use of pilocarpine drops for glaucoma treatment, the use of narcotics, with iritis, and with brain damage of pons E. Argyll Robertson Pupil There is no reaction to light; pupil does constrict with accommodation. Small and irregular bilaterally. Argyll Robertson pupil occurs with central nervous system syphilis, brain tumor, meningitis, and chronic alcoholism F. Tonic Pupil (Adie’s Pupil) Reaction to light and accommodation is sluggish. Tonic pupil is usually unilateral, a large regular pupil that does react, but sluggishly after long latent time. There is not pathologic significance. G. Horner Syndrome A unilateral, small, regular pupil does react to light and accommodation. Occurs with Horner syndrome, a lesion of the sympathetic nerve. Also note ptosis and absence of sweat (anhidrosis) on same side. H. Cranial Nerve III Damage Unilateral dilated pupil has no reaction to light or accommodation and occurs with oculomotor nerve damage. Ptosis with eye deviating down and laterally may be present. [Show More]

Last updated: 1 year ago

Preview 1 out of 53 pages