Ординатура / Офтальмология / Английские материалы / Clinical Medicine in Optometric Practice_Muchnick_2007

Genitourinary

Symptoms of genitourinary problems include fever, genitourinary pain, bladder pain, pregnancy, blood in the urine, abnormal discharge, difficulty in voiding, incontinence, erectile dysfunction, disturbances in menses, and overproduction or underproduction of urine. Pertinent diagnoses include diabetes, interstitial cystitis, urinary tract infection, dietary ketoacidosis, and intrinsic renal disease and renal failure.

Musculoskeletal

The most common symptoms involving the immune system, connective tissues, and joints are fever, rash, joint pain, bone fracture, morning stiffness, soft tissue swelling, low back pain, and muscle pain or weakness. Some of the more common musculoskeletal diagnoses include gout, scleroderma, Reiter’s syndrome, rheumatoid arthritis, osteoarthritis, chronic fatigue syndrome, juvenile rheumatoid arthritis, ankylosing spondylitis, and systemic lupus erythematosus.

Integumentary

The integumentary system involves disorders that affect the skin, hair, and nails. Common symptoms include the presentation of a rash, skin lesion or nodule, skin itching or pain, skin discoloration, and loss or new growth of hair. Common diagnoses include eczema, psoriasis, skin cancer, acne rosacea, alopecia, vitiligo, allergic dermatitis, and infection (i.e., herpes simplex or zoster).

Endocrine

Common endocrine problems include pituitary disease, thyroid disease, pheochromocytoma, and diabetes mellitus. Significant symptoms include palpitations, weight changes, changes in hair and skin, emotional changes, and an increase in hunger, thirst, and urination.

Hematologic/Lymphatic

These conditions include cancer, blood disorders, and lymphatic problems. Common blood problems include the anemias and polycythemias. Lymph node swelling should be noted.

Allergic/Immunologic

Symptoms include fever, sneezing, coughing, skin rashes, throat swelling, and sudden onset of itching.

GENERAL HEALTH HISTORY

The general health history is an amplification of the review of systems. In general, the most significant and common systemic problems are noted here. These problems include asthma, thyroid disease, systemic hypertension, diabetes mellitus, and a history of myocardial infarction and stroke. The present status of each diagnosis should be noted with the name of the treating physician. The name of the patient’s primary medical physician and the date of her last physical should be noted in this section.

Neurologic

The patient should note any alteration or loss of senses, including sight, hearing, smell, taste, or touch. In addition, any alteration or loss of sensory or motor skills, as well as memory or recall, should be noted. Pertinent neurologic diagnoses include tumors, stroke, seizures, epilepsy, Alzheimer’s disease, Huntington’s disease, multiple sclerosis, myasthenia gravis, pseudotumor cerebri, and amyotrophic lateral sclerosis.

Psychiatric

Mental disorders can make history-taking more difficult because of possible communication problems. The most common psychiatric complaints and diagnoses include anxiety (attacks of palpitations, sweating, shaking and shortness of breath), phobias, stress, obsessive-compulsive disorder, depression, bipolar disorder, schizophrenia, and personality disorders. In addition, alcoholism and drug dependency may be noted here.

MEDICATIONS

All medications, both systemic and ocular, should be noted in a clear, concise manner. The notes should include the proper spelling of the medications (to avoid errors), the dosage, its frequency, and refills left. Any side effects of the medications should be noted.

SOCIAL HISTORY

The patient’s driving history, which is a particularly important reason for the patient to have an eye examination, should be included. In addition, the patient should be honest about use of alcohol, tobacco, and recreational drugs. Any present or past treatment of sexually transmitted diseases should be noted here.

FAMILY HISTORY

The family medical history should include blood relatives with asthma, thyroid disease, systemic hypertension, diabetes mellitus, and history of vascular disease, heart attack or stroke.

8 DIAGNOSTIC PROCEDURES

The family ocular history should include blood relatives with glaucoma and age-related macular degeneration.

HISTORY CHECKLIST

In practice, the history can be a challenge to doctors who wish to efficiently examine the patient in a reasonable amount of time. To expedite the process, many offices give patients a checklist history that lists pertinent questions in a “yes” or “no” format.

The checklist has several advantages. It is efficient, because the patient fills out the history while waiting to be called back for the examination. The list is as thorough as necessary to meet the requirements of the office and general medical and optometry standards. The patient can slowly and correctly answer a series of questions in a non-intimidating setting. It is an unemotional way to gather sensitive medical and social information such as a history of drug abuse or sexually transmitted diseases. The list is probably the best way to ask a female patient whether she is pregnant, and also allows the examiner to review the history before greeting the patient, thus sensitizing the doctor to the patient’s situation. For example, if the history indicates that a patient has a transmittable infection, the examiner can wear appropriate barrier protection.

The checklist history has some disadvantages. For the illiterate, elderly, or non-English-speaking patient, a checklist history can be intimidating if no family or friend is present to help the patient. The checklist may omit relevant questions or not focus on the area of concern to the patient. The list may not allow the patient to expand on a complaint. The checklist is impersonal and does not promote doctor-patient bonding. The examiner must take time to thoroughly review the checklist and then expand on important issues. The optometrist must use this time to forge the doctorpatient relationship.

SUMMARY

The history enables the optometrist to focus on pertinent tests and directs the course of the examination. Perhaps most importantly, the history helps the doctor to develop a personal connection with the patient.

BIBLIOGRAPHY

Billings JA, Stoeckle JD: The clinical encounter: a guide to the medical interview and case presentation, ed 2, St Louis, Mosby, 1999.

Buchwald D, Caralis PV, Gany F, et al: The medical interview across cultures, Patient Care 27:141, 1993.

Coulehan JL, Platt FW, Egener B, et al:“Let me see if I have this right…”: words that build empathy, Ann Intern Med 135: 221, 2001.

Cuilliton BJ: Doctor, are you there? Am J Med 109:602, 2000. Faust S, Drickey R: Working with interpreters, J Fam Pract

22:131, 1986.

Francis V, Korsch BM, Morris MJ: Gaps in doctor-patient communication, N Engl J Med 280:535, 1969.

Levinson W, Gorawara-Bhat R, Lamb J: A study of patient clues and physician responses in primary care and surgical settings, JAMA 284:1021, 2000.

Myerscough PR: Talking with patients: a basic clinical skill,

Oxford, Oxford University Press, 1992.

Ong LML, de Hases JCJM, Hoos AM, et al: Doctor-patient communication. A review of the literature, Soc Sci Med 40: 903, 1995.

Platt FW, Gasper DL, Couloehan JL., et al: “Tell me about yourself:” the patient-centered interview, Ann Intern Med 134(11):1083, 2001.

Steiner JF, Earnest MA:The language of medication-taking, Ann Intern Med 132:962, 2000.

Tomlinson J, Milgrom ET: Taking a sexual history, West J Med 170:284, 1999.

This chapter focuses on the art and science of the physical examination. An appreciation of clinical medicine is impossible without a sensitive understanding of the history, techniques, utility, and limita-

tions of physical diagnosis.

To detect disease, the earliest clinicians relied entirely on their observations of patients. Physical diagnosis advanced with refinements in the techniques of palpation and percussion. The introduction of instruments for auscultation allowed clinicians to evaluate sounds produced by the internal organs (Figure 2-1).

The techniques of observation, palpation, percussion, and auscultation provide the framework necessary to achieve the primary goals of the physical examination. The first goal is to provide the initial basis for making decisions regarding laboratory and radiologic testing. The second goal is to facilitate the doctorpatient relationship. Finally, the examination provides important baseline information.

To master those aspects of the physical examination that are integral to the optometric practice, the student must learn and perform the techniques in the clinical

setting. Only through repeated exposure to its methods and instrumentation can physical diagnosis as an art and discipline be appreciated and applied.

As science and medicine progress in complexity, the examination too often becomes impersonal. The physical examination encompasses the patient’s physical and emotional pain. The examination should be carried out with sensitivity and compassion.

OFFICE SANITATION

The presence of multiple patients in the optometry office increases the risk of contagious diseases. Our patients act as reservoirs for such pathogens, and disease can spread unseen among clinicians, support staff, and other patients. Patients with systemic infections such as tuberculosis, hepatitis, and HIV-AIDS, as well as topical disease such as epidemic keratoconjunctivitis, place the entire optometry office at risk.

The optometrist must ensure as much as possible that the office is not a source of infection. To this end, appropriate cleaning and sterilization protocols can help keep the office environment healthy.

All surfaces exposed to the constant flow of patients should be cleaned on a daily basis. Those areas most frequently touched by patients should be cleaned frequently. The pens used by patients to sign forms should not be shared by the support staff, and all writing utensils should be cleaned daily.

Patient’s hands are a significant source of contagions, so it may be appropriate for the front desk to offer every patient, particularly children, a premoistened towelette to clean the hands. These items can be purchased in bulk supply to reduce the overhead cost, and should be hypoallergenic and nonfragranced.

A common source of pathogenic spread is the optometry equipment. All environmental surfaces that patients come in contact with should be wiped down with an appropriate cleaning agent that will not denature the material of the equipment. Staff should clean

and dry the chinrest and headrest of the slit lamp before each examination. This practice will reassure the patient that the office follows sanitary protocols.

All hand-held instruments, such as ophthalmoscopes, retinoscopes, muscle lights, and occluders, should be wiped down daily. Hand-held cards, such as plastic Amsler grids, and color testing and stereo booklets, should be wiped down at least weekly.

Other environmental surfaces at risk include the phoropter, hand-held slit-lamp lenses, and the chin and headrests of keratometers, automated perimeters, the Heidelberg retinal tomograph (HRT), and the GDx nerve fiber analyzer (GDx) units and automated refractors.

The Goldmann tonometer tip should receive special attention, and staff should sterilize it before each examination by placing it in a 1:1000 solution of bleach

for a minimum of 15 minutes. In the busy practice, 2 tonotips alternately soaking can provide a ready- to-use Goldmann tonometer tip every 7½ minutes. Wiping the tonotip with alcohol or washing it with soap and water between examinations provides inadequate disinfection because some pathogens can survive this technique.

BARRIER PRECAUTIONS

Hand washing remains the single most effective way to decrease the spread of disease in the office environment. The clinician’s hands should be washed with soap before each examination, preferably in front of the patient for reassurance. Most patients greatly appreciate this practice and it strengthens the doctorpatient bond. A recent study indicated that neckties worn by doctors are a source of infectious agents. Ties often come into contact with multiple patients, and are rarely cleaned. To avoid contamination, the physician can secure the tie under a lab coat, frequently clean the tie, or (preferably) not wear a tie.

Clearly defined procedures are necessary to ensure the safety of health care workers. Of particular concern to optometrists are HIV-AIDS, hepatitis, and tuberculosis. The Centers for Disease Control and Prevention and Occupational Safety and Health Administration have established precautionary guidelines for health care workers who may be exposed to infectious materials or body fluids.

Gloves should be used when examining any patient with HIV-AIDS and any form of hepatitis (even if treated and resolved). In addition, gloves should be used when examining any patient with a topical exudative or pustular weeping from the eye. Gloves should be used when appropriating samples for conjunctival culturing and sensitivities. All gloves must be disposed of in an appropriate disposal container.

Masks should be used in cases of active tuberculosis with a coughing patient. If significant coughing is present, it is appropriate for the examiner to ask the patient to wear a mask to prevent infection of an unprotected staff member or patient. Cases of treated and resolved tuberculosis do not require the examiner to wear a mask.

When examining a patient with an active varicellazoster outbreak, any optometrist at risk (those who have never had chickenpox and those who have not received the varicella vaccine) should wear both a mask and gloves. A pregnant optometrist who has never had chickenpox and is not vaccinated should never examine a patient with an active varicella outbreak, even with appropriate barrier precautions, because of the risk of spread of the virus to the fetus. For this reason, female optometrists of child-bearing age should strongly consider receiving the varicella vac-

cine if they test negative for varicella antibodies. Eye protection is recommended in the optometry office if the possibility exists of splattering or aerosolization of body fluids.

All sharp instruments, such as disposable needles used to remove corneal foreign bodies or injections, should be handled with the utmost care. These items should never be recapped after usage, and should be disposed of in a clearly marked puncture-resistant (sharps) container. All optometrists who have direct contact with patients should complete the Hepatitis B vaccine series. It may be advisable for the optometrist to be tested for immunity first.

The hospital-based optometrist who is to examine a patient in isolation or is on special precautions should contact the institution’s infection control manual for guidelines concerning restrictions on entry into the room. In addition, the examiner may be required to wear protective attire, such as a gown, to enter the room.

Barrier precautions are used to protect the patient, examiner, office environment, and other patients, although the majority of patient encounters require no barrier precautions. When in doubt, it is appropriate to overreact. The examiner can truly never be too cautious.

BASIC PROCEDURES

The goal of the physical examination is to obtain valid information concerning the health of the optometry patient. The ocular findings may affect the ultimate general health assessment (for instance, a large refractive shift may indicate diabetes mellitus in an undiagnosed patient). Any systemic findings may likewise have ocular ramifications (for example, a child with uveitis is seen in the office with swollen knees and is ultimately tested for Lyme disease and juvenile rheumatoid arthritis).

Four primary skills are essential in performing an appropriate physical examination. These skills are observation, palpation, percussion, and auscultation. The physical examination requires detailed observation by the practitioner from the moment the patient is first greeted. The examiner should evaluate the general appearance of the patient with regard to posture, alertness, and nutritional state. Any asymmetry of the body should be noted, inspected, and evaluated. Any asymmetry of the eyes, for example, is significant. Unilateral ptosis, a drooping of one of the upper eyelids, may be a sign of Horner’s syndrome. If ptosis occurs with a fourth-nerve palsy, an immediate neurology consult with imaging to rule out an intracranial lesion is mandatory. Unilateral ptosis may be the result of a retrobulbar space-occupying lesion, and unilateral lid retraction may occur in Graves’ disease. Anisocoria, an

12 DIAGNOSTIC PROCEDURES

inequality in pupil sizes, may be caused by sympathetic or parasympathetic lesions.

After the initial observation, the examiner should touch the patient’s skin, a procedure known as palpation. Palpation of the body permits the examiner to assess any irregularity, enlargement, hardness, or heat associated with inflammation. To perform palpation, the clinician uses touch to evaluate the characteristics of an internal organ system. Most often the fingers and the palms of the hand are used because these are exquisitely sensitive detectors of underlying pressure and contour gradients. Palpation also facilitates a level of intimacy that encourages the development of the complex doctor/patient relationship (Figure 2-2).

The eyes are delicate and sensitive in many patients. Extraordinary care should be taken by the examiner in palpating the ocular and paraocular area. The examiner should perform crucial ocular palpation, including tactile judgment of proptosis, by placing the base of both forefingers of each hand against the closed lids of the patient’s eyes. Palpation of the globes by the tips of the forefingers can help the clinician estimate intraocular pressures in patients who are not suitable to applanation or noncontact tonometry. In addition, palpation of the preauricular lymph nodes, as well as the nodes of the neck, may help in the diagnosis of viral conjunctivitis.

The optometrist does not need to palpate below the clavicle. A swollen preauricular lymph node in the context of a viral conjunctivitis is managed in the optometry office. Swollen and perhaps painful neck masses must be referred to the patient’s primary care physician (PCP).

The examiner performs percussion by striking an area of the body to produce and evaluate the resulting

sound. Percussion provides information about the size of an underlying organ, the presence of fluid in a normally air-filled cavity, and the presence of excessive dilatation caused by trapped air. To perform percussion, the clinician’s left middle finger is placed firmly against the patient’s body. The tip of the right middle finger is then struck against the left middle finger to produce the resulting sound (Figures 2-3 and 2-4).

Each organ produces a characteristic sound that results from the shock wave of the percussion as it passes through various tissues. Changes in the organ’s size, density, or tissue composition result in characteristic changes in the sound produced. As the clinician gains experience with this skill, valuable predictions can be made concerning the health of an organ system.

FIGURE 2-3 ■ Percussion. The examiner’s left middle finger is placed over the site to be examined and pressed firmly on the skin.

FIGURE 2-2 ■ Palpation. Small areas of skin or underlying masses may be palpated by use of one or two fingers moved in a circular pattern. Large masses are palpated with all the fingers or with the palm.

FIGURE 2-4 ■ Percussion. The examiner’s right middle finger sharply strikes the left middle finger. The resulting sound is evaluated by the examiner.

FIGURE 2-5 ■ Auscultation of the carotid artery. The diaphragm of the stethoscope is used on the patient, who is sitting or supine. The patient’s head is turned away from the stethoscope and the patient holds his breath. The examiner listens to the carotid artery just above the clavicle, on the center of the neck, and just under the angle of the jaw.

Percussion need not be performed around the eyes or head. Most often, the physician will percuss internal organs, including the lungs to rule out collapse, and the abdomen to detect bladder distention.

With the addition of simple yet refined instruments, such as the stethoscope, auscultation has become an essential part of the physical examination. Listening with the stethoscope allows the examiner to detect adventitious lung sounds that suggest pneumonia or heart failure (see Chapter 9). Auscultation is also used to evaluate the heart for murmurs that suggest valvular dysfunction. Of particular interest to the optometrist is the use of auscultation to detect the presence of bruits caused by narrowing of blood vessels secondary to atherosclerosis. The carotid bruit is a significant finding in a patient experiencing the visual symptoms associated with a transient ischemic attack (TIA) (Figure 2-5).

THE INSTRUMENTS

The four cardinal skills of the physical examination are enhanced by the use of other medical instruments. The instruments used to examine the ears, nose, throat, larynx, esophagus, stomach, rectum, colon, and joints fall under the category of endoscopes. These scopes enable the examiner to look within the body through natural or surgically created holes. Simpler equipment is also used to help perform various tests. Refinements in these instruments have accelerated as each decade passes, but the decision to use this technology is costly, and the diagnosis ultimately depends on the human skills of history taking and physical examination.

Mandatory equipment for the routine physical examination includes the stethoscope for auscultation, the penlight for specific illumination and pupil testing, the otoscope for the ear examination, the ophthalmoscope for the eye examination, safety pins for sensory testing, a 128-Hz tuning fork for audition, and a reflex hammer for deep tendon reflex testing. Other equipment includes a nasal speculum and illuminator, sphygmomanometer for blood pressure measurement, tongue depressors, and cotton-tipped applicators. Barrier protection for the clinician and patient includes gloves, mask, and eye protection (Figure 2-6).

A

B

FIGURE 2-6 ■ A, The instruments of the physical examination. Included here are the stethoscope, penlight, otoscope, ophthalmoscope, safety pins, tuning fork, reflex hammer, nasal illuminator, sphygmomanometer, tongue depressor, and cotton-tipped applicators. B, Barrier protection for doctor and patient. Included here are mask and gloves.

THE LANGUAGE OF THE PHYSICAL EXAMINATION

Language is an important element of the physical examination. Although language is a means of communication, it can also be a source of confusion. Clinicians communicating with patients during the physical examination must be aware of the need to interpret medical terminology so that the patient understands it (Table 2-1). The language of the physical examination includes eponyms and colorful descriptives that can both frighten and confuse patients. Although eponyms bestow honor on clinicians who have made observations and disseminated them to their peers, they have no value in terms of description. In general, description is preferable to use of eponyms.

The sheer number of fascinating eponyms associated with the eye indicates how central the eye has been in the development of the physical examination. A few of the ocular signs of systemic disease that are denoted by eponyms include Adie’s tonic pupil, Brushfield’s spots of the iris, the Kayser-Fleischer corneal ring, Hollenhorst plaques of the retinal vasculature, and Homer’s syndrome.

A myriad of eponyms denote lid abnormalities associated with hyperthyroidism (see Chapter 12), such as von Graefe lid lag, the infrequent blinking known as Stellwag’s sign, the tremor of the closed lids known as Rosenbach’s sign, and the lag of the lower lid during globe elevation known as Griffith’s sign. A similar litany of famous names is attached to other important signs in the physical examination.

The physical examination sometimes uses colorful language to help describe a clinical observation. Numerous examples are associated with the eye. The copper-wiring associated with arteriosclerotic change in the retina, the nerve infarctions known as cottonwool spots, and the mutton fat precipitates of the cornea seen in granulomatous uveitis all illustrate colorful and descriptive language.

Similarly, sputum has been described with such terms as “rusty,” “currant jelly,” or “prune juice.” Each description indicates a certain type of infectious organism. The characteristic skin rash of chickenpox or its reactivation as herpes zoster is referred to as “dew drops on a petal.” In patients with cirrhosis of the liver, the dilated veins that may form around the umbilicus have been called the caput Medusa, named for the mythological goddess who had snakes in place of hair. These poetic descriptions all help visualization of the abnormalities being described.

VITAL SIGNS

The vital signs include measurements of the patient’s temperature, pulse, blood pressure, respiratory rate, height, and weight. Normal body temperature is de-

TABLE 2-1 SYSTEM-BY-SYSTEM USEFUL

VOCABULARY

fined as 98.6° F, but a patient’s temperature may be slightly higher or lower. A temperature elevation may be a sign of disease, indicating a reaction of the body to infection. Circadian variation sometimes causes people who are ill to have a normal temperature in the morning and an elevated temperature later in the day. Fevers tend to be highest at night (Figure 2-7). Any patient coming to the optometrist’s office with signs of systemic inflammation should have an oral temperature reading.

FIGURE 2-7 ■ Measuring the patient’s temperature. Use of an oral thermometer can determine a patient’s temperature. A sterile thermometer is shaken so that its initial reading is well below 98.6° F. It is placed beneath the tongue of a patient and read in 1 minute.

The pulse is assessed for rate and regularity. A normal rate is 50 to 70 ppm, but pulse rate may be lower in a young athlete or in an elderly heart patient with a disease of the conduction system. Elevated pulse rate occurs with increased respiration; this condition is known as normal sinus arrhythmia. Premature beats may be perceived as early, extra, or skipped beats, because a long pause follows the early beat. The pulse may be rapidly irregularly irregular, as with atrial fi- brillation (Figure 2-8). All optometric patients can be evaluated for pulse rate. If bradycardia (slow rate) or an irregular heartbeat is found in a glaucoma patient, the examiner should call the family physician before prescribing a beta-blocker for glaucoma treatment.

The clinician measures blood pressure with a sphygmomanometer and stethoscope by auscultating and evaluating changes in the pulse as pressure is released from the cuff (Figure 2-9). The first heart sound heard as pressure is released is the systolic pressure, or the pressure that is maximally achieved when the heart pumps. Continued auscultation reveals disappearance of the pulse, which represents the diastolic pressure, or the pressure during the filling phase of the heart. Blood pressure is arbitrarily judged to be high based on an accepted normal reading of 140/90 mm Hg or less, but blood pressure must be interpreted in the context of age, the relative excitement of the patient, and measurement limitations. For example, a very thick arm may produce an artificially elevated blood pressure, and the clinician must use a wide thigh cuff to determine pressure accurately. Blood pressure readings are mandatory for any optometric patient who is to be dilated with phenylephrine, because this sympathomimetic can raise systemic blood pressure temporarily.

FIGURE 2-8 ■ Measuring the patient’s pulse. The index finger, middle finger, and fourth finger are placed over the radial artery (wrist pulse) below the base of the patient’s thumb. The pulse is counted for 30 seconds and multiplied by 2 to get a pulse rate for 1 minute.

FIGURE 2-9 ■ Measuring the patient’s blood pressure. The sphygmomanometer provides an indirect measurement of blood pressure by detecting the appearance and disappearance of the Korotkoff sounds over an artery compressed by an air-filled bladder. Evaluation of both arms may be necessary.

Respiratory rate can be a clue to underlying breathing difficulties. In very ill patients, various types of respiratory patterns may indicate metabolic abnormalities or levels of coma. Dyspnea (difficulty in breathing) in a glaucoma patient may preclude the use of betablockers, because these drugs can exacerbate asthma.

Height and weight are important measurements. Changes in weight must be measured and ultimately explained. Significant weight gain is associated with pseudotumor cerebri, which causes elevated intracranial pressure. Headache and reduced visual acuity can accompany the papilledema that is secondary to elevated intracranial pressure. A significant finding in these

16 DIAGNOSTIC PROCEDURES

patients is often a history of recent weight gain. Height and weight can easily be measured in the optometrist’s office, or recent readings can be obtained with the patient’s permission from the family physician.

EXAMINATION OF THE SKIN

The skin, or integument, is the outer aspect or covering of the body and is the first system to be examined. The optometric evaluation of the skin is usually limited to the head, neck, arms, and hands. The detection of possible skin cancers is a critical element of this part of the physical examination. Skin cancers are detected by observation and confirmed by removal of tissue and subsequent examination under the microscope (biopsy). The patient may present with symptoms of skin disease, including pruritus (itching), a rash, and changes in skin, hair, or nails.

Examination of the facial skin can be useful to determine significant disease. Pigmented lesions such as seborrheic keratoses must be differentiated from melanoma. The characteristics of melanoma include irregular borders and surface details and changes in color. The inflamed tissue is red but may become white from necrosis or turn blue from deep invasion of the melanoma. Pigmented lesions should always be observed, measured, described, documented with drawings or photographs.

Many clinical diagnoses derive from observation of the facial skin. Skin coloring may be a risk factor in the development of skin cancer. The clinician should therefore caution a fair-skinned patient about the importance of sunscreen. Areas of redness and roughness, known as actinic keratoses, or sun damage, should be treated for cosmetic reasons and for their tendency to become malignant.

Thinning of the skin with visible vessels, called telangiectasias, may be a normal variation or the result of sun damage. Telangiectasias may also be spider angiomas, which when compressed seem to fill from the center with spider-like tentacles. Spider angiomas may indicate estrogen excess or may be related to a specific skin disease like acne rosacea.

Small papules or pimples may be normal variations or may require a referral to another physician for the treatment of acne. Blackheads around the eyes in older patients can be treated for cosmetic purposes.

The color of the facial skin is changed by the presence of some diseases. For example, pallor of the skin may indicate anemia, and a yellowing complexion may suggest underlying jaundice or liver disease.

Skin Terminology

Familiarity with the terminology used to describe skin lesions is important (Table 2-2). Localized changes in the color of usually flat red lesions of 1 cm or less in size

TABLE 2-2 BENIGN VS. MALIGNANT SKIN

CHARACTERISTICS

are called macules (for example, freckles). Elevated areas less than 1 cm in diameter are called papules (for example, acne). Rashes that have a flat, red area are called maculopapular. A patch is a macule greater than 1 cm in diameter (for example, vitiligo).

Raised areas greater than 1 cm are referred to as nodules. Plaques have a large surface area in relation to their height. For example, the skin lesion present in psoriasis is a scaling plaque. Plaques that are yellow are often called xanthomas, or they may be small seborrheic cysts. Xanthomas on the eyelid are known as xanthelasma and may be a sign of elevated cholesterol.

An elevation of the skin with a clear fluid accumulation of less than 1 cm just beneath the upper layer is called a vesicle. A cold sore is a type of vesicle. Accumulations of clear fluid larger than 1 cm are called bullae. Vesicles and bullae are clear because their fluid is not infected. An accumulation of fluid that is thicker, more opaque, and yellow, green, or orange is called a pustule and may indicate active infection.

In summary, the skin examination is divided into two parts. The first part consists of detection of pruritus or changes in skin color, hair, and nails. The second part consists of inspection and palpation of the hair, nails, and skin of the neck, face, back, chest, abdomen, arms, and legs. All lesions should be described and documented and clinicopathologic correlations made (see Chapter 16). Any suspicious skin lesion found during the optometric examination should be documented and the patient monitored or referred to the family physician or a dermatologist.

Review of Skin Symptoms

The appearance of a new rash or skin lesion on the head or neck should prompt an investigation. The optometrist should ascertain from the patient the specific time of onset and any changes in the rash over time.

Associated characteristics such as elevation, blistering, itching, tenderness, and numbness should be identified. New areas of skin involvement are significant.