Bates’ Visual Guide to Physical Examination

Volume 4: 4.5 Skin Head Face and Neck — Older Adult Video Transcript

Narrator: Inspect the patient’s skin. Note physiologic changes of aging such as thinning, loss of elastic tissue and turgor and wrinkling. There may be purple patches or macules termed actinic purpura that fade over time. These spots and patches come from blood that is leaked through poorly supported capillaries and spread within the dermis. Inspect for the benign lesions of aging such as comedones or blackheads on the cheeks or around the eyes. Look for cherry angiomas and seborrheic keratoses, raised yellowish lesions that feel greasy and velvety or wartlike. These are benign. In older bedbound patients, inspect the skin also for pressure sores or ulceration.

Next, conduct a careful inspection and palpation of the head and neck. With age, scalp hair loses its pigment, producing gray. Hair loss on the scalp is genetically determined. Inspect the eyelids, the bony orbit and the eye. In the eye may appear recessed from atrophy of the fat in the surrounding tissues. Observe any senile ptosis arising from the weakening of the levator palpebrae, relaxation of the scan, and increased weight of the upper eyelid. Note yellowing of the sclera and arcus senilis, a benign whitish ring around the limbus.

Test visual acuity using a Snellen chart. Note any presbyopia, the loss of near vision arising from decreased elasticity of the lens related to aging. The pupils should respond to light and near effort. Except for possible impairment and upward gaze, extraocular movements should remain intact. With an ophthalmoscope, carefully inspect the lenses and fundi. Inspect each lens carefully for any opacity. Do not depend on the flashlight alone because the lens may look clear superficially. In older adults, the fundi lose their youthful shine and light reflections and the arteries typically look narrower, paler, straighter and less brilliant. Assess the cup-to-disk ratio usually 1:2 or less. Inspect the fundi for macular degeneration with colloid bodies causing alterations in pigmentation called drusen.

Test hearing by occluding one ear and using the techniques for a whispered voice or use an audio scope. Be sure to inspect the ear canals for cerumen because removal can quickly improve hearing. Examine the oral cavity for odor, appearance and gingiva mucosa, any caries, mobility of the teeth and quantity of saliva. Inspect closely for lesions on any of the mucosal surfaces. Ask the patient to remove dentures so you can check the gums for denture sores. Continuing with your usual examination of the thyroid gland and lymph nodes.