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Physical Assessment of the Child and Adolescent: an Overview of Normal Vs

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Physical Assessment of the Child And Adolescent: An Overview of Normal vs. Abnormal Physical Examination Findings WENDY L. WRIGHT, MS, RN, ARNP, FNP, FAANP, FAAN ADULT/FAMILY NURSE PRACTITIONER OWNER – WRIGHT & ASSOCIATES FAMILY HEALTHCARE @ AMHERST AND @ CONCORD OWNER – PARTNERS IN HEALTHCARE EDUCATION 1 Disclosures Speaker Bureau: Sanofi-Pasteur, Merck, Pfizer, AbbVie, Biohaven Consultant: Sanofi-Pasteur,, Pfizer, Merck, GSK 2 Wright, 2021 1 Objectives Upon completion of this lecture, the participant will be able to: Describe the essential components of a comprehensive physical examination on a child and adolescent Identify normal vs abnormal physical examination findings Identify special maneuvers which can identify pathology in children and adolscent 3 Let’s Talk About Some Common Problems 4 Wright, 2021 2 Eye Complaint: History Chief complaint HPI, including the following associated symptoms: Pain, itching, discharge, tearing, blurring, visual acuity changes, foreign body sensation, photophobia, halo vision 5 History (continued) Present status of visual function Corrective lens, glasses and use Last eye examination Medications Systemic Ocular Allergies Past history Ocular disease Systemic disease 6 Wright, 2021 3 History (continued) Surgeries (if pertinent) Family History Ocular diseases Systemic diseases 7 Physical Examination Eyebrows Note quantity and distribution of hair Note any scaling or lesions **Eyebrows are symmetrical and evenly distributed; No dryness, scaling, or thinning of the lateral 1/3. **Thinning of the lateral 1/3 of the eyebrow- hypothyroidism **Scaling-seborrheic dermatitis 8 Wright, 2021 4 Eyelids Lids should close in unison to cover the entire eye Upper lid margin rests on the superior border of the iris Lower lid margin rests on the inferior border of the iris Palpebral fissure: Space between the upper and lower lid ** Lids close in unison to cover entire eye. The upper lid margin is at the superior border of the iris and the lower lid is at the inferior border of the iris. 9 Abnormalities of Eyelids Widening of the palpebral fissure Hyperthyroidism (Exophthalmos) Decrease in palpebral fissure size Dehydration (Enophthalmos) Ptosis Cranial Nerve III Dysfunction Muscular Dystrophy 10 Wright, 2021 5 Exophthalmos 11 Ptosis 12 Wright, 2021 6 Lid Margins Lid Margins Skin tone Inversion or Eversion Lesions ** The lid margins are appropriately colored; No lesions, edema, inversion or eversion. 13 Abnormalities of the Lid Margins Lesions: Hordeolum, Chalazion Edema: Allergic Conjunctivitis, Crying, Infection Entropion: Inversion of Lid Margin Spasm or scarring of the lid Eyelashes often invert and irritate the conjunctiva and cornea Ectropion: Eversion of Lid Margin Aging Exposes the conjunctiva to bacteria Eye does not drain properly-tearing 14 Wright, 2021 7 Entropion 15 Ectropion 16 Wright, 2021 8 Eyelashes Note Color Distribution Direction in which they point Discharge **Eyelashes are ____ in color, evenly distributed, outward pointing; No discharge or thinning. 17 Abnormalities of Eyelashes Thinning Make-up Trichotillomania Alopecia Discharge Conjunctivitis Blepharitis Dacryocystitis 18 Wright, 2021 9 Blepharitis 19 Dacryocystitis 20 Wright, 2021 10 Conjunctiva Conjunctiva Clear covering over the visible parts of the eye (except the cornea) Protective covering for the eye Bulbar Clear covering and the blood vessels that cover the sclera Palpebral Conjunctiva Thin covering above and below the eyeball Forms deep recesses that fold forward to join the eyelid 21 Normal Conjunctiva 22 Wright, 2021 11 Conjunctiva Bulbar and Palpebral Conjunctiva Color Injection Lesions Foreign bodies **Conjunctiva is clear and appropriately colored; No injection, pallor, lesions, or foreign bodies. 23 Abnormalities of the Conjunctiva Injection Conjunctivitis, Irritation from Contact Lens, Iritis, Glaucoma Pallor Anemia Lesions Pterygium: An opaque, triangular shaped conjunctival lesion usually seen nasally and able to extend over the cornea. May interfere with vision. Pinguecula: Yellow nodules usually seen at 3 and 9 o’clock on the conjunctiva. No visual changes. 24 Wright, 2021 12 Pinguecula 25 Pterygium 26 Wright, 2021 13 Sclera Sclera White portion of the eye May look buff-colored or pale yellow in the periphery Note Color Texture Lesions **Sclera are white, smooth; No lesions or icterus. 27 Sclera 28 Wright, 2021 14 Abnormalities of Sclera Yellow sclera Physiologic or pathologic jaundice Resolving subconjunctival hemorrhage Red appearing sclera Subconjunctival Hemorrhages Note: It is actually the bulbar conjunctiva not the sclera that becomes jaundiced or red. 29 Excessive Vomitting Causing Subconjunctival Hemorrhages 30 Wright, 2021 15 Cornea Cornea Portion of the anterior aspect of the eye which when viewed from the side, protrudes forward Transparent covering that protects the eye Avascular covering over the iris and pupil Note (Use a penlight and view from the side) Appearance Shiny Lesions Corneal Light Reflex 31 Cornea 32 Wright, 2021 16 Cornea **Cornea are smooth, transparent, and shiny; No lesions or opacities. Corneal light reflex is symmetric bilaterally. 33 Abnormalities of the Cornea Arc Corneal arcus or arcus senilis Thin gray-white arc or circle that lies close to the edge of the cornea or edge of the iris Causes: aging, african americans, hyperlipidemia Abrasion Mild injury to the cornea Causes include foreign body, trauma, contact lens Symptoms: pain, photophobia, discharge 34 Wright, 2021 17 Corneal Abrasion 35 Herpes Simplex 36 Wright, 2021 18 Abnormalities of the Cornea Corneal Ulceration Opacities Cataracts Scarring Asymmetric Corneal Light Reflex Strabismus (esotropia or exotropia) 37 Corneal Ulcer 38 Wright, 2021 19 Asymmetric Corneal Light Reflex 39 Exodeviation 40 Wright, 2021 20 Iris Iris Colored portion of the eye Contains muscle that surround the pupil and control pupillary size These muscles are innervated by CN III Note Appearance Shape 41 Iris Note Color Detail Anterior Chamber ** Iris is round, symmetric, ____ in color, and with clear detail. The anterior chamber is without blood or pus. 42 Wright, 2021 21 Iris 43 Abnormalities of the Iris Hyphema: Blood in the anterior chamber Trauma Hypopion: Pus in the anterior chamber Infection Anterior uveitis (formerly, iritis): Moderate pain, decreased vision, pupil is small and will become irregular over time Becomes irregular because the swelling distorts the pupil Associated with many systemic disorders Rheumatoid arthritis, SLE, Ankylosing spondylitis 44 Wright, 2021 22 Abnormalities of the Iris Iris Color Is Not Identical Heterochromia Iridis If this is seen, suspect Horner’s syndrome Horner’s syndrome: Sympathetic nerve disruption, most often in the neck. Iris is lighter in color, ptosis of eyelid, loss of sweating on forehead, and pupil is smaller (all on the affected side) Brushfield Spots Down’s Syndrome 45 Pupils Pupils Normally round Range in size from 3-7 mm Allow images and light to enter They change in size to adjust for light and to focus on an image Note Size Shape Regularity 46 Wright, 2021 23 Pupils Note Symmetry Newborn Response to direct light Older child Response to direct and consensual light ** Pupils are ____mm, round, regular and equal bilaterally and respond briskly to direct and consensual light. 47 Abnormalities of the Pupils Aniscoria: Inequality of the pupils Normal Variation: Respond normally to light Increase in Intracranial Pressure Acute Angle Closure Glaucoma Severe pain Decreased vision Pupil is dilated Cornea is cloudy Increase in intraocular pressure 48 Wright, 2021 24 Abnormalities of the Pupils Miosis Equally constricted pupils Drugs, morphine, bright light Mydriasis Equally dilated pupils Anticholinergic agents, mushrooms, increased intracranial pressure Inability to accommodate Cranial nerve defect (III, IV, VI) 49 Visual Acuity Visual Acuity Test of central vision Controlled by cranial nerve II (Optic) Use a Snellen Chart (wall or hand-held) Stand 20 feet from wall chart Place hand held Snellen 13 inches from face 50 Wright, 2021 25 Visual Acuity Infants Central vision is present, may just see light Optimum distance for visualization: 8-12 inches Assess by checking direct and consensual response to light, blinking, extending the head in response to a bright light (Optical blink reflex) and blinking in response to a quick movement of an object toward the eye 2-4 weeks, should be able to fixate on objects 5-6 weeks, coordinated eye movements 51 Visual Acuity Child Vision: 20/200 at 1 year old, 20/40 at 3, 20/30 at 4-5 years of age No test that accurately measures acuity in child < 3 Can test using a hand-held Snellen chart or a wall chart Letters and Lazy E are the best tests Older Child and Adult Adult visual acuity is reached at approximately 6 years of age 52 Wright, 2021 26 Visual Acuity Visual Acuity is ____OD, ____OS, and ____OU (corrected or uncorrected) 53 Abnormalities of Visual Acuity Absence of a direct or consensual response to light, absence of blinking, negative optical blink reflex, or failure to blink when an object is moved quickly toward the eye: Blindness Asymmetric Visual Acuity: Amblyopia 54 Wright, 2021 27 Red Eye Differential falls into the following categories Infections with or without trauma (conjunctivitis) Inflammation with or without trauma (uveitis) Vascular (subconjunctival
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