Assessment of Skin, Eyes, Ears, Nose

SKIN

The skin is the largest organ of the body. It is a physical barrier that
protects the underlying tissues and organs from microorganisms, physical
trauma, ultraviolet radiation and dehydration. It plays a vital role in
temperature maintenance, fluid and electrolyte balance, absorption,
excretion, sensation, immunity, and vitamin D synthesis.

Layers of the skin

Epidermis – is the outer layer of the skin
Dermis – inner layer of the skin
Sebaceous Gland – attached to hair follicles and therefore, are present
most of the body, excluding the soles and palms.

SKIN ASSESSMENT
 Skin assessment can be performed throughout the physical
examination. As each body system is examined, assessment of the
skin can be incorporated into findings (Jarvis, 2012).
 Examination of the skin is correlated with the information gathered in
the history and other parts of the physical examination
 Examine the skin as you proceed through each body system
 Assessment of the skin involves the entire skin area, including the
mucous membranes, scalp, hair, and nails. The skin is a reflection of
a person’s overall health, and alterations commonly correspond to
disease in other organ systems.

Inspection
Observe for: skin color, pigmentation lesions (distribution, type,
configuration, and size), jaundice, cyanosis, scars, superficial vascularity,
moisture, edema, color of mucous membranes, hair distributions, nails.
Check for capillary refill – depress the nail edge to blanch and then
release, noting the return of color – color is instant, within 1-3 seconds.
Capillary refill is an index of peripheral perfusion and cardiac output.

Palpation
Examine the skin for temperature, texture, elasticity, and turgor. Skin
turgor is usually not examined among elderly.

Normal Findings
 “Normal” varies. Depending on race or ethnic background,
complexion, sun exposure, pigmentation tendencies (freckles).
 Capillary refill more than 3 seconds indicates peripheral circulation.
 The skin is normally warm, slightly moist and smooth, and returns
quickly to its original shape when picked up between 2 fingers and
released (good skin turgor)
  There is characteristics hair distribution over the body associated with
gender and normal physiologic functions. Nails are present and
smooth.

Abnormal findings
 Vitiligo. Is the complete absence of melanin pigment in patchy areas
of white or light skin on the face, neck, hands, feet, body folds and
around orifices.

https://www.ghp-news.com/wp-content/uploads/2020/08/winnie-harlow.jpg

 Pigmented Lesions with the following characteristics (Danger signs):

ABCDE (signs that may indicate skin cancer)
Asymmetry (two halves of the lesion do not look the same)
Border irregularity (notching, scalloping, ragged edges, or poorly
defined margins)
Color Variation (areas of brown, tan, black, red, white or combination)
Diameter greater than 6mm
Elevation and enlargement

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https://media.springernature.com/original/springer-static/image/chp%3A10.1007%2F978-3-319-
76932-5_18/MediaObjects/432594_1_En_18_Fig1_HTML.jpg

https://img.medscapestatic.com/pi/meds/ckb/51/8351tn.jpg

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0096b5927a42/gr1_lrg.jpg
 Seborrhea. oily skin; dandruff

https://onlinelibrary.wiley.com/cms/asset/f2f3086d-1ba3-4aee-99ce-62b0b95e3fba/jocd13669-fig-
0001-m.jpg

 Xerosis. dry skin

https://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/
image_article_collections/mcgraw_hill_skin_atlases/childhood_skin_problems/CAPD_xerosis.jpg?
resize=646px:*&output-quality=100

 Pruritus. Itchiness

https://clf1.medpagetoday.com/assets/images/resource-center/cs-atopic-dermatitis-600x400%20(1).jpg
 Alopecia. Hair loss

https://hips.hearstapps.com/hmg-prod.s3.amazonaws.com/images/articles/2015/11/gettyimages-
155357954-alopecia-areata-christian-martinez-kempin-1518549048.jpg

 Pallor. Paleness of the skin and mucous membrane

https://lh3.googleusercontent.com/proxy/OKatbzdRZQC-8Ch11zXg7zyVzBmO-
p1afDzQxYMdSXxqpsZbfmrmv0VdKscKdVQz50vFAmqPM8N8sTMtdBYRRFOB5gSAxbuUhHuMb8wEKJO
0fCVKW_58Lt-mXm0AWH9_83yKi067OfKR
  Erythema. Redness of the skin

https://cdn-prod.medicalnewstoday.com/content/images/articles/323/323801/erythema-multiforme-on-a-
childs-elbows-br-image-credit-dermnet-new-zealand-br.jpg

 Cyanosis. Bluish discoloration of the skin due to inadequate

oxygenation

https://www.physio-pedia.com/images/thumb/9/9b/Peripheral_Cyanosis.jpg/300px-
Peripheral_Cyanosis.jpg

https://image.shutterstock.com/image-photo/cyanotic-lips-tongue-central-cyanosis-260nw-
1578710419.jpg
 Jaundice. Yellowish discoloration of the skin, junction of the hand
and soft palate in the mouth and in the sclera.

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q=tbn:ANd9GcSHXm41etqD8z0Aia5rddRCnySwXbM1ADRLjA&usqp=CAU

 Diaphoresis. Profuse sweating

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v=1584931581

 Edema. Accumulation of fluid in the intracellular spaces. It is

characterized by swelling.

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severe_pitting.jpg?w=1155&h=758
 Anasarca. Generalized edema (edema of the whole body)

https://www.epainassist.com/assets/endocrinal-system/2020/what-anasarca.jpg
 Poor skin Turgor. Inability of a pinched up large fold of skin to return
to place promptly when released. Indicative of dehydration

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https://images.slideplayer.com/12/3450839/slides/slide_8.jpg
 Skin lesions with blue-green fluorescence with use of Wood’s
light. Indicates fungal infection (tinea capitis-scalp ringworm)

https://www.researchgate.net/profile/Helmut-Sies-2/publication/13109043/figure/fig1/
AS:667206849409035@1536085917566/Lesions-treated-for-6-h-with-20-ALA-and-illuminated-with-
Woods-light-Black-dotted.png

 Dull, coarse or brittle scalp hair

https://post.greatist.com/wp-content/uploads/2019/10/Frizzy_Hair_732x549-thumbnail.jpg
  Hirsutism. Excess body hair in females. This may indicate endocrine
problems.

https://www.msdmanuals.com/-/media/manual/professional/images/m1700060-excessive-facial-hair-
in-a-woman-science-photo-library.jpg?thn=0&sc_lang=en

ASSESSMENT OF THE NAILS

 Inspect and palpate for the color, shape, configuration and texture of
the nails:
 Check for nail grooming and cleanliness
 Note for nail color and markings
 Observe for the shape of the patient’s nails
 Palpate to assess texture and consistency, noting whether nail
plate is attached to nailbed
 Test capillary refill in nailbeds by pressing the nail tip briefly
and watching for color change

COMMON NAIL COLOR ABNORMAL FINDINGS

LEUKONYCHIA SPLINTER LINDSEY’S NAILS
(Mees Hands) HEMORRHAGE (Hald and Half Nails)
S
  Koilonychia. Spoon-shaped or concave fingernails. This may indicate
iron-deficiency anemia.

https://i0.wp.com/images-prod.healthline.com/hlcmsresource/images/topic_centers/642x361_Spoon_Nails.jpg?
w=1155&h=758

 Onycholysis. Fungal infection of fingernails.

PRIMARY SKIN LESIONS
LESION DESCRIP EXAMPL
TION ES
Macule Freckles,
flat
moles,
petechia,
rubella,vi
tiligo,
port wine
Flat, stains,
nonpalpa ecchymos
ble skin is
color
change(co
lor may
be brown,
white,
tan,
purple,
red)
which is
less than
1 cm in
diameter
with well
circumscr
ibed
border

Patch Flat, non

palpable
skin color
change(co
lor may
be brown,
white,
tan,
purple,
red)
which is
more
than 1 cm
in
diameter
and may
have an
irregular
border
Papule

Elevated,
palpable,
solid
mass with
a
Warts,
circumscr
elevated
ibed
nevi
border
and is
less than
0.5cm in
diameter

Plaque Elevated, Psoriasis,

palpable, eczema,
solid
mass with
a
circumscr
ibed
border
and is
more
than
0.5cm in
 diameter

Nodule, Tumor Elevated,

palpable,
solid
mass that
extends
deeper
into the
dermis
than a
papule:

NODULE: Nodule:
0.5–2 cm melanom
in a,
diameter hemangio
and ma
usually
with well
circumscr Tumor:
ibed Carcinom
border a

TUMOR:
greater
than 1–2
cm in
diameter
do not
always
have
sharp
borders
Vesicle, Bulla Circumsc
ribed,
elevated, Vesicle:
palpable herpes
epidermal zoster,
mass chickenp
containin ox,
g serous scabies
fluid:
Bulla:
VESICLE: Contact
less than dermatiti
0.5 cm in s, large
diameter second-
degree
BULLA: burns,
greater bullous
than 0.5 impetigo
cm in
diameter
Wheal An
elevated,
mass with
irregular
borders
which
may vary
in size Insect
and color; bite, hive,
It is angioede
usually ma
caused by
the
movemen
tof serous
fluid into
the
dermis
Pustule Acne,
impetigo,
A pus-
furuncles
filled
,
vesicle or
carbuncle
bulla
s,
folliculitis

SECONDARY SKIN LESIONS

Erosion Loss of Ruptured
superficial vesicles,
epidermis scratch
that does marks
not
extend to
dermis;
depressed,
 moist area
Ulcer
Skin loss
extending
Stasis
past
ulcer of
epidermis
venous
extending
insufficie
up to the
ncy,
upper
pressure
papillary
Ulcer
layer of
the dermis

Fissure
Linear
Chapped
crack in
lips or
the skin
hands,
that may
athlete’s
extend to
foot
dermis

Scales Flakes
secondary
to
desquamat
ed, dead
Epitheliu
m that
may Dandruff,
adhere to psoriasis,
skin dry skin,
surface; pityriasis
color rosea
varies
(silvery,
white);
texture
varies
(thick,
fine)
Crust Dried
residue of
serum, Residue
blood, or left after
pus on vesicle
skin rupture:
Surface; impetigo,
Large, herpes,
adherent eczema
crust is a
scab
Scar Skin mark
left after Healed
healing of wound or
a wound surgical
or lesion; incision
represents
 replaceme
nt by
connective
tissue of
the injured
tissue
Young
scars: red
or purple
Mature
scars:
white or
glistening

Keloid Hypertrop
hied scar
tissue
secondary Keloid of
to ear
excessive piercing
collagen or
formation surgical
during incision
healing;
elevated,
irregular

SKIN LESION ARRANGEMENT AND DISTRIBUTION

Linear (Serpiginous) Annular
Lesions that form a line or snakelike Lesions that are arranged in a circular pattern
shape
Discrete Confluent

Lesions that are separate and distinct

Lesions that merge and run together

Generalized Zosteriform

Lesions that are scattered over the

body Lesions that are arranged along a nerve root
VASCULAR LESIONS
PETECHIA (PL. PETECHIAE) ECCHYMOSIS (PL. ECCHYMOSES)

Round red or purple macule Round or irregular macular lesions

which is usually about 1-2 mm which are generally larger than
in diameter petechia; color varies and usually
changes (black, yellow)
CHERRY ANGIOMA SPIDER ANGIOMA

A red, arteriole lesion which has a

A papular and round lesion central body with radiating branches
which is usually red or
purple in color

HEAD AND FACE

Inspection and palpation
 Inspect and palpate scalp for masses, hair, color and texture, and
cranium.
 Inspect face: asymmetry, expression
 Palpate the temporal artery, then the temporo-mandibular joint as
the patient opens and closes the mouth
 Palpate the maxillary sinuses and the frontal sinuses for
tenderness.
 Have the patient sit in a comfortable position.
 Face the patient with your head at the same level as the patient’s
head.
 Observe the general size and contour of the skull. Note any
deformities, depressions, lumps, or tenderness:
 Normocephalic
 Microcephalic
 macrocephalic

 Examine the patient’s hair. Note its quantity, distribution, texture,

and pattern of loss, if any.
 Part the hair in several places and look for scaliness, lumps,
nevi, or other lesions.
 Place the finger pads on the scalp and palpate all of its surface,
beginning in the frontal area and continuing over the parietal,
temporal and occipital areas

 Note the patient’s facial expression and contours. Observe for

asymmetry, involuntary movements, edema, and masses.
 Palpate bilaterally (simultaneously) for the temporal artery by placing
the finger pads immediately in front of the tragus of the ear
  Auscultate for the temporal artery using the bell of the stethoscope
 Using the pads of the middle and index finger, palpate for the
temporomandibular joint located anterior to the ears:
 While palpating, ask the patient to open and clench jaw
 Note for the relative smoothness of the movement as the patient
opens and clenches jaw

 Auscultate for the TMJ by placing the bell of the stethoscope over the
joint while letting the patient open and close mouth
 Note for any clicking sound made as the patient opens and
clenches jaw

Normal findings
 The Patient is normocephalic – round symmetric skull that is
appropriately related to body size, the scalp is normally smooth, there
is no tenderness to palpation.
 The temporal artery is palpable between the eye and top of the ear’’
 The temporomandibular joint (below the temporal artery and anterior
to the tragus) has smooth movement as the patient opens his/her
mouth, with no limitation and tenderness.
 The facial structures are symmetric (eyebrows, palpebral fissures,
nasolabial folds and side of the mouth)
 No tenderness over the maxillary sinuses (on each side of the face)
and frontal sinuses (above the eyebrows)

Abnormal Findings
 Deformities: microcephaly (abnormally small head), macrocephaly
(abnormally large head), lumps, depressions and protrusions.
 https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/quick-reference-handbook/images/Fig.-
11.pt-1.jpg

 Temporal artery looks more tortuous, feels hardened and tender with
temporal arteries.

http://2.bp.blogspot.com/-yihQNj3WYAg/Us7NISWQyBI/AAAAAAAACXA/h8jzAktw5ZI/s1600/
Temporal-Arteritis.jpg

 Crepitation, limited range of motion or tenderness of the

temporomandibular joint.

https://www.ratradentalcenter.com/img/temporomandibular-disorder.jpg

 Asymmetry of the face may indicate central brain lesion

 https://cdn.shopify.com/s/files/1/1228/8298/files/image006_large.png?v=1588234674

 Edema of the face occurs first especially around he eyes (periorbital)

and the cheeks where subcutaneous tissue is relatively loose.

https://www.medicaljournals.se/acta/html-editor/html-img/5435/5435_17975.png

EYES
Inspection
a. Eyeballs (globes) for protrusion
b. Palpebral fissures (longitudinal openings between the eyelids) – for
width and symmetry
c. Lid margins – for scaling, secretions, erythema (redness), position of
the lashes
d. Bulbar and palpebral conjunctivae for congestion and color
 Bulbar conjunctiva – membranous covering of the sclera.
Contains blood vessels
 Palpebral conjunctiva – membranous covering of the inside of
the upper and lower lids. Contains blood vessels.
e. Sclera – for color, iris – for color
f. Pupils – for size, shape, symmetry, reaction to light and
accommodation (ability of the lens to adjust to objects at varying
distances)

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146599805-

Normal Findings
a. There is no protrusion of eyeballs. (Protrusion of eyeballs-
exophthalmos is a manifestation of hyperthyroidism)
b. Palpebral Fissures – appear equal in size when the eyes are open
 Upper Lid – covers a small portion of the iris and cornea
 Lower Lid – margin is just below the junction of the cornea and
sclera. There is no ptosis (drooping of the eyelids).
 https://www.researchgate.net/profile/Ethylin-Jabs/publication/260374650/figure/fig5/
AS:616357683032074@1523962531964/Aberrant-palpebral-fissure-narrowing-with-attempted-
horizontal-gaze-A-Baseline-eye-and.png

c. Lid Margins – are clear, lacrimal ducts opening (puncta) are evident at
the nasal ends of the upper and lower lids
 Eyelashes – normally are evenly distributed and turn outward.
d. Bulbar Conjunctiva (cover of sclera) – consists of transparent red
blood vessels (which may become dilated and produce the
characteristic “bloodshot” eye). Palpebral conjunctiva – are pink and
clear (conjunctivitis – inflammation of the conjunctiva surfaces).
e. Sclera – should be white and clear

g. Visual Acuity. Check a Snellen Chart (with or without eyeglasses)

 The Snellen’s Eye Chart
 The Snellen alphabet chart is issued to measure visual
acuity. It has lines of letters arranged in decreasing size.
 Position the patient 20 feet away from the chart
 Ask the patient to v=cover one ye with opaque card. Test
right eye first, then the left eye then both byes
 If the patient wears eye glasses or contact lenses, leave
them on. Remove only reading glasses because they will
blur distance vision
 Ask the patient to read through the chart to the smallest
line possible.
 Record the result using numeric fractions at the end of
the last successful line read. Indicate of some letters were
missed or if corrective lenses were worn. Example: O.D.
20/30 -2 with glasses. (O.D. means right eye)
  to test for near vision, have the patient hold a special handheld
card (rosenbaum card) 14 inches from his/her face and read the
letters starting from the top without moving it
 test each eye separately

Normal Findings (Snellen chart)

 Normal result of the Snellen test is 20/20 (which indicates normal
vision)
 The numerator indicates distance of the patient from the chart
 The denominator indicates the distance at which the normal eye can
read the letter
Abnormal Findings (Snellen chart)
 If the denominator is increased (20/30 or greater), the patient has
myopia (nearsightedness)

 If the denominator is decreased (20/15 or less), the patient has

hyperopia (farsightedness)

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 If the result is 20/200, the patient is legally blind. He is not allowed to
drive.

Note: Hesitancy, squinting, leaning forward, misreading letters may

indicate decreased visual acuity.

 Myopia. Nearsightedness

https://s3.amazonaws.com/ecp-uploads/wp-content/uploads/sites/2470/2021/01/
myopia-2-diagram-sqr.jpg

 Hyperopia. Farsightedness

https://cdn.britannica.com/44/63344-050-D20C0E4A/farsightedness-glasses-Hyperopia-
lenses-effort-object-focus.jpg
  Presbyopia. Loss of accommodation due to the aging process.
It is characterized by farsightedness.

https://www.netmeds.com/images/cms/wysiwyg/blog/
2020/08/1597990541_presbyopia_big_600.jpg

 Assess for the patient’s color vision:

 Have the patient sit comfortably and occlude one eye
 Hold the test plates (ishihara plates) 14 inches from the
patient’s face and ask the patient to identify the symbol seen on
the plate
 Repeat the test on the other eye

Terms associated with color vision problems:

 Achromatopsia
 Deuteranopia
 Protanopia
 Tritanopia

 Assess for the patient’s visual fields (confrontation technique)

 Sit or stand approximately 2 to 3 feet opposite the patient, with
your eyes at the same level as that of the patient
 Have the patient cover the right eye with the right hand or an
occluder
 Cover your left eye in the same manner
 Have the patient look at your uncovered eye with his/her
uncovered eye
 Hold your freehand at arm’s length equidistant from you and the
patient and move it or a held object such as a pen into your and
the patient’s field of vision from nasal, temporal, superior,
inferior and oblique angles
 Ask the patient to say “now” when your hand is seen moving into
the field of vision. Use your own visual fields as the control of
comparison to the patient’s visual field
 Repeat the procedure for the other eye
 Assess for the patient’s external eye and lacrimal apparatus
 Observe patient’s eyelids for drooping, infection, tumors or other
abnormalities
 Note the distribution of the eyelashes and eyebrows
 Ask the patient to look at your nose
 Observe for the blinking of the patient’s eyes
 Ask the patient to close eyes and then open them afterwards
 Identify the area of the lacrimal gland. Note any swelling or
enlargement of the gland or elevation of the eyelid. Note any
enlargement, swelling, redness, increased tearing, or exudates in
the area of the lacrimal sac at the inner canthus
 Compare to the other eye in order to determine whether there is
unilateral or bilateral involvement
 Palpate the lacrimal glands:
 Ask the patient to look up
 Press on the lower lid close to the medial canthus, just
inside the rim of the bony orbit

 Assess for the patient’s extra ocular muscle function:

 Perform the corneal light reflex
 Partially darken the room
 Ask the patient to stare straight ahead
 Through the use of a penlight, shine the light on the
bridge of the patient’s nose
 Pupils – normally constricts with increasing light and
accommodation. Pupils are normally round, 3 to 5 mm in size (PERRLA –
PUPILS EQUAL, ROUND, REACTIVE TO LIGHT ACCOMMODATION)
Pinpoint and dilated pupils indicate neurologic problems.

 Perform the cover-uncover test:

 Let the patient stare at the wall behind you
 Ask the patient to cover one eye with hand or an occluder
 Ask the patient to uncover the eye
 Carefully observe the patient’s eyes for any movement
 Assess for the cardinal positions of gaze:
 While in front of the client, position index finger at 12
inches away from the client’s nose
 Ask the client to look at your finger and follow it with
his/her gaze as you move it through the six cardinal
positions of gaze
 Observe for any involuntary eye movements

 Assess for the anterior segment structures of the patient’s

eyes
 Inspect the sclera for color, exudates, lesions and foreign
bodies
 To assess for the cornea:
 Shine a penlight directly on the cornea of the
patient
 Move the light bilaterally and view the cornea from
that angle, noting color, discharge and lesions
 Do this for both the patient’s eyes
 Inspect the iris for color, nodules and vascularity
 To assess for the pupils:
 Note the shape and size of the pupils in millimeters
 Move a penlight from the side to the front of one eye
allowing the light to shine on the other eye
 Observe the pupillary reaction in that eye (this is
the direct light reflex). Note the size of the pupil
receiving light stimulus and the speed of pupillary
response to light
 Repeat in the other eye
 Move the penlight in front of one eye and observe
the other eye for pupillary constriction (this is the
consensual light reflex)
 Repeat the procedure on the other eye
 Assess for accommodation:
 Instruct the patient to shift the gaze to a
distant object for about 30 seconds
 Instruct the patient to then look at your
finger or an object held in your hand about
10cm from the patient
 Note the reaction and size of the pupil
 To assess for the bulbar conjunctiva, separate the lid
margins with the fingers
 Have the patient look up, down and to the right and
left
 Inspect the surface of the bulbar conjunctiva for
color, redness, swelling, exudates or foreign bodies
 With the thumb, gently pull the lower lid
downwards and inspect the conjunctiva for color,
inflammation, edema, lesions or foreign bodies

 To assess for the palpebral conjunctiva:

 Ask the patient to close his/her eyes
 Place a sterile, cotton tipped applicator about 1cm
above the lid margin
 Gently exert downward pressure on the applicator
while pulling the eyelashes upward to evert the lid
 Inspect the palpebral conjunctiva for redness,
swelling, exudates or foreign bodies
 When done, gently release the eyelashes and have
the patient blink
 Repeat for the other eye
 Assess for the posterior segment structures of the patient’s
eyes:

 Darken the room. Switch on the ophthalmoscope light

and turn the lens discuntil you see the large round beam
of white light.Shine the light on the back ofyour hand to
check the type of light, its desired brightness, and the
electricalcharge of the ophthalmoscope.
 Turn the lens disc to the 0 diopter (a diopter is a unit that
measures the power of a lens to converge or diverge light).
At this diopter the lens neither convergesnor diverges
light. Keep your finger on the edge of the lens disc so you
can turnthe disc to focus the lens when you examine the
fundus.
 Remember, hold the ophthalmoscope in your right hand
to examine the patient’s right eye; hold it in your left hand
to examine the patient’s left eye. This keeps youfrom
 bumping the patient’s nose and gives you more mobility
and closer rangefor visualizing the fundus.
 Hold the ophthalmoscope firmly braced against the medial
aspect of yourbony orbit, with the handle tilted laterally at
about a 20° slant from the vertical.Check to make sure
you can see clearly through the aperture. Instruct
thepatient to look slightly up and over your shoulder at a
point directly ahead onthe wall.
 Place yourself about 15 inches away from the patient and
at an angle 15° lateralto the patient’s line of vision. Shine
the light beam on the pupil and look for the orange glow
in the pupil—the red reflex. Note any opacities
interrupting the redreflex.
 Now, place the thumb of your other hand across the
patient’s eyebrow (thistechnique helps keep you steady
but is not essential). Keeping the light beamfocused on
the red reflex, move in with the ophthalmoscope on the
15° angletoward the pupil until you are very close to it,
almost touching the patient’seyelashes.
 First, locate the optic disc. Look for the round yellowish
orange structure described above. If you do not see it at
first, follow a blood vessel centrally until you do. You can
tell which direction is central by noting the angles at
which vessels branch—the vessel size becomes
progressively larger at each junction as you approach the
disc.
 Now, bring the optic disc into sharp focus by adjusting
the lens of your ophthalmoscope. If both you and the
patient have no refractive errors, the retina should be in
focus at 0 diopters. (A diopter is a unit that measures the
power of a lens to converge or diverge light.) If structures
are blurred, rotate the lens disc until you find the
sharpest focus.
 Inspect the optic disc. Note the following features:
 The sharpness or clarity of the disc outline. The
nasal portion of the disc margin may be somewhat
blurred, a normal finding.
 The color of the disc, normally yellowish orange to
creamy pink. White or pigmented crescents may
ring the disc, a normal finding.
 The size of the central physiologic cup, if present. It
is usually yellowish white. The horizontal diameter
is usually less than half the horizontal diameter of
the disc.
 The presence of venous pulsations. In a normal
person, pulsations in the retinal veins as they
emerge from the central portion of the disc may or
may not be present.
  The comparative symmetry of the eyes and findings
in the fundi
 Inspect the retina, including arteries and veins as they
extend to the periphery, arteriovenous crossings, the
fovea, and the macula.
 Follow the vessels peripherally in each of four directions,
noting their relative sizes and the character of the
arteriovenous crossings. Identify any lesions of the
surrounding retina and note their size, shape, color, and
distribution. As you search the retina, move your head
and instrument as a unit, using the patient’s pupil as an
imaginary fulcrum.
 Finally, by directing your light beam laterally or by asking
the patient to look directly into the light, inspect the fovea
and surrounding macula. Except in older people, the tiny
bright reflection at the center of the fovea helps to orient
you. Shimmering light reflections in the macular area are
common in young people.
 Inspect the anterior structures. Look for opacities in the
vitreous or lens by rotating the lens disc progressively to
diopters of around +10 or +12. This technique allows you
to focus on the more anterior structures in the eye.

https://storage.googleapis.com/stateless-precision-vision/2019/06/
b3a54ecc0915f9347c3f53fa31d161fe_XL-scaled.jpg
Palpation
 Determine the strength of the upper eyelids by attempting to open
closed lid against resistance
 Palpate eyeballs (Globes) through closed lid for tenderness and
tension,
Normal Findings
 The examiner should not be able to open the eyelids when the patient
is squeezing them shut.
 Eyeballs normally are not tender when palpated.

Fundoscopic Examination – darken the room

 Use an ophthalmoscope to inspect ocular fundus

a. Red retinal reflex – check the transparency of the anterior and

posterior chambers, it can be spotted by the examiner while standing
30 cm from the eye. It is the red glow filling the person’s pupil.
b. Cornea – check for transparency. It should be transparent
c. Lens – check for transparency. It should be transparent. Retina can
be seen.
d. Retina – check for color, pigmentation, hemorrhages and exudates of
elevation, cupping
e. Optic disc – check for color, distinction of margins, pigmentation,
degree of elevation, cupping
f. Macula – check for color. (Lies at a distance 2 optic disc diameters
laterally from the optic disc)
g. Blood vessels - check for diameter, arteriovenous ratio; origin and
course, venous arterial crossings.
 Arteries is smaller and lighter in color than the veins

Abnormal Findings
 Photophobia. Is inability to tolerate light

https://www.verywellhealth.com/thmb/ud5r2RNGvBpHNnBm0yi8Sv2ZMOs=/
1500x1000/filters:no_upscale():max_bytes(150000):strip_icc()/overview-of-photophobia-
4586489-e89556eedc8a4bea885e6cd8ac4ee1b3.png
 Strabismus. Is deviation of the eye. Also called squinting

https://s3.amazonaws.com/higherlogicdownload/AAPOS/Contacts/16198f24-

 Diplopia. Double Vision

https://marvel-b1-cdn.bc0a.com/f00000000038905/www.aao.org/image.axd?
id=520873e6-0a07-4348-b9b8-262b556347e9&t=637517026939430000
 Lacrimation. Tearing

https://i.ytimg.com/vi/ke3umAwxd2Q/hqdefault.jpg

 Epiphora. Excessive tearing

https://theyenews.com/wp-content/uploads/2020/09/How-to-Stop-Watery-Eyes-
Epiphora-3.jpg
 Scotoma. Blind spot in the visual field

https://i.pinimg.com/736x/18/06/87/180687a48577288feec50a7335da2997.jpg

 Nystagmus. Rolling of the eyeballs.

https://media.springernature.com/lw685/springer-static/image/art
%3A10.1186%2Fs12886-019-1270-3/MediaObjects/12886_2019_1270_Fig1_HTML.png

 Lid Lag. Seeing a white rim of sclera between the lid and the
iris.
 https://www.frontiersin.org/files/MyHome%20Article%20Library/
255862/255862_Thumb_400.jpg

 Ptosis of the eyelid. Dropping of upper eyelid.

https://www.imo.es/sites/default/files/field_header/patologia/ptosis-infantil1.jpg

 Ectro pion. The lower lid is rolled outward. The lower

conjunctiva is exposed.

https://www.imo.es/sites/default/files/field_header/patologia/ectropion-antes.jpg

 Entropion. The lower eyelid is rolled inward. The eye lashes are
constantly rubbing the cornea.
 https://healthjade.com/wp-content/uploads/2018/03/entropion.jpg

 Exophthalmus. Protruding eyeballs

https://www.centerforfacialappearances.com/wp-content/uploads/2020/04/Thyroid-Eye-Disease.jpg

 Enophthalmus. Sunken eyeballs

https://www.imo.es/sites/default/files/field_header/patologia/Enoftalmos.jpg
EARS AND HEARING

Equipment: Tuning Fork, Otoscope

Inspection
a. Pinna – examine for size, shape, color, lesions, masses
b. External Canal – with an otoscope, inspect the canak for ischarges,
impacted cerumen, inflammation, masses or foreign bodies
 External canal is normally clear with minimal cerumen
c. Tympanic Membrane – examine for color, luster, shape, position,
transparency, integrity and scarring
 Tympanic membrane is normally gray in color and intact
To Examine with Otoscope
1. Hold the helix of the ear and gently pull the pinna upward and back
toward the occiput to straighten the external canal.
2. Gently insert the lighted otoscope, using an earpiece that is
comfortable size of the patient
3. Once the otoscope is in place, put your eye to the eyepiece and
examine the external canal.

Palpation

a. Pinna (auricle) – examine for tenderness, consistency of the cartilage,

swelling. Move pinna and push tragus for tenderness’
Mechanical Test for Hearing
 Whisper Voice Test
 Tuning Fork Test – Weber, Rinne

a. Whisper Voice Test

 The examiner stands at arm’s length (0.6m) behind the patient
(to prevent lip reading)
 Cover the ear not being tested
  Whisper 2-syllable words
A patient with normal hearing can hear a whispered word from
approximately arms’ length and a watch from 30 cm (12inches).
The patient should hear the sound equally well in both ears, that
is, there is no lateralization.
b. Weber Test – test for lateralization of vibration. Place the
rounded tip of the handle of the vibrating tuning fork in the middle of
the scalp, near the forehead. Normally, sound is heard in the center of
the head or equally in both ears.

c. Rinne Test – compares air and bone conduction. Place vibrating

tuning fork on the mastoid process behind the ear and have the
patient tell you when the vibration stops.

 Then quickly hold the vibrating end of the tuning fork near the
opening of the ear canal (2 inches away) and ask if the patient
can hear it.
 Normally, sound should be heard after vibration can no longer
be felt, that is, air conduction (AC) is better than bone
conduction (BC).
Abnormal findings
 Otalgia. Earache

https://image.shutterstock.com/image-vector/acute-otitis-media-air-filled-260nw-1652641315.jpg

 Otorrhea. Ear discharge

https://www.healthbenefitstimes.com/glossary/wp-content/uploads/2020/03/Otorrhea.jpg
 Presbycusis. Hearing loss due to old age

https://www.starkey.com/-/media/International/US/Images/blog/2017/Cartoons/Presbycusis.jpeg

 Tinnitus. Ringing of the ear

https://image.shutterstock.com/image-vector/tinnitus-disorder-ringing-sound-ear-260nw-
1792815616.jpg

 Vertigo. Feels like the room spins or the person feels like he/she spins

https://i.ytimg.com/vi/kx4mQB0QzvQ/maxresdefault.jpg

 microtia. Small ears; smaller than 4cm. vertically

 https://earcommunity.org/wp-content/uploads/2011/12/Grades-of-Microtia1-e1343342425174.png

 Macrotia. Large ear; larger than 10cm vertically.

https://www.researchgate.net/profile/Ralph-Magritz-2/publication/261444612/figure/fig13/
AS:668296475062276@1536345704084/Macrotia-a-Markings-for-the-modified-Gersuny-technique-b-
Intraoperative-situation-with_Q640.jpg

 Impacted cerumen. Hardened earwax

https://i.ytimg.com/vi/P63_m_dXXWk/maxresdefault.jpg

 Otitis media. Infection of the middle ear

 https://media.springernature.com/lw685/springer-static/image/art
%3A10.1038%2Fnrdp.2016.63/MediaObjects/
41572_2016_Article_BFnrdp201663_Fig5_HTML.jpg

 Otitis externa. Infection of the external ear

https://www.ncbi.nlm.nih.gov/books/NBK556055/bin/otitis__ext.jpg