Assessment Findings
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Transcript of Assessment Findings
8/8/2019 Assessment Findings
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ASSESSMENT FINDINGS:
1. InspectionExternal structures
a. Eyebrows
NORMAL: even hair distribution,even alignment, equalmovement as facial
expression changes
ABNORMAL: absence of the lateralthird of the eyebrows(e.g., myxedema)uneven alignmentunequal or absentmovement as facial
expression changesscaliness
b. Eyelashes
NORMAL: eyelashes present andevenly distributed along
the eyelid margins
ABNORMAL:eyelashes absent or unevenly distributed
along the eyelid margins
c. Eyelids
NORMAL: skin intact, similar in color to the face, smooth and
uniformno sclera visible abovethe corneas and irideswhen the eyelids areopenability to completely closethe eyelidsupper eyelid margins at
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or near the limbus (theborder between thecornea and sclera) whenthe eyelids are openblinking symmetrical,
present, at 15 - 20 blinksper minute
ABNORMAL: lid lag - a rim of scleravisible above the corneasand irides
ptosis - drooping of the
upper eyelid
epicanthus - vertical foldof skin that lies over theinner canthus
ectropion - margin of thelower eyelid is turnedoutward
entropion - margin of thelower eyelid is turnedinward
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periorbital edema -swelling and puffinessaround the eyelid
blepharitis -inflammation of theeyelids
sty (acute hordeolum) -
redness, tenderness, andswelling around a hair follicle on the eyelid
margin
chalazion - beady,
nontender nodule on theskin around the eyelid(chronic inflammation of
the meibomian gland)
xanthelasma - slightly
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raised, yellowish, wellcircumscribedplaques onthe skin around the eyelidherniated fat - bulging of the lower eyelids, bulging
of the inner third of the
upper eyelids, or both
retracted eyelid -
retraction of the upper eyelid which results in arim of sclera between the
upper eyelid and corneasand irides and a wideeyedstareblinking asymmetrical,absent, less than 15 or greater than 20 blinks per minute
d. Lacrimal gland
and nasolacrimalgland
NORMAL: absence of a bulge in theouter third of the upper eyelids
ABNORMAL: dacryoadenitis -
inflammation of thelacrimal glandcharacterized by pain,redness, and swelling inthe outer third of the
upper eyelid
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e. Lacrimal sac andnasolacrimal sac
NORMAL: puncta mucosa pink,nonedematousabsence of dischargeabsence of tearingabsence of swellingbetween the nose andlower eyelids
ABNORMAL: dacryocystitis -inflammation of the
lacrimal sac andnasolacrimal ductcharacterized by pain,redness, and swellingbetween the nose and
lower eyelid
f. Conjunctiva andsclera
NORMAL: bulbar conjunctiva istransparent with tinyvessels visiblesclera is blue-white,shiny, smooth, moistpalpebral conjunctiva is
pink, shiny, smooth,moist
ABNORMAL: Jaundice - sclera yelloworange
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conjunctivitis - diffuse,dilated, reddened bulbar conjunctival vessels thattend to be maximal in theperiphery
subconjunctivalhemorrhage - sharpy
demarcated, bright redarea that fades over daysto yellow then
disappears.
pterygium - triangular
thickening of the bulbar conjunctiva, usually onthe nasal side, that grows
across the cornea
pinguecula - yellowishwhite,triangular noduleon the bulbar conjunctiva
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on either side of the iris
g. Cornea, lens andpupil
NORMAL: cornea transparentlens, visible through thepupil, transparen
anterior chamber, visiblethrough the cornea,transparent
ABNORMAL: arcus senilis - thin,grayish-white arc or circlein the cornea, not quite at
the edge of the cornea
corneal scar - superficialgrayish-white opacity in
the cornea
nuclear cataract -central grayish-white
opacity in the lens
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peripheral corticalcataract - peripheralgrayish-white opacity inthe lens that producesspokelike shadows that
point inward
hyphema - accumulationof blood in the aqueousfluid of the anterior
chamber
hypopyon -accumulation of purulentmaterial in the aqueousfluid of the anterior
chamber
monocular blindness -shining a penlight into ablind eye produces nopupillary response in the
blind or good eye,whereas shining apenlight into the normaleye produces normalpupillary responses inboth the blind and goodeye
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mydriasis - dilated, fixedpupils (greater than 7
millimeters)
miosis - constricted,fixed pupils (less than 3millimeters)
anisocoria - slightly
unequal pupil size
oculomotor nerve
damage - unilateral,dilated pupil that reactsneither to light or accommodationaccompanied bydeviation of the affectedeye downward and ptosisof the eyelid of theaffected eye
Argyll-Robertson pupil- small, irregular pupilsthat do not react to light,but react to
accommodation
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Tonic (Adie's) pupil -unilateral, large pupil thathas a sluggish or absentreaction to light, and a
sluggish reaction toaccommodation
Horner's syndrome -unilateral, small, regular pupil that reacts to lightand accommodationaccompanied by ptosis of the eyelid of the affected
eye and lack of tearing
iritis -ciliary injection of the iris accompanied bymoderate, aching, deeppain; decreased vision;absent ocular discharge,and a clear or cloudy
corneairides inconsistent color