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External Observation
PURPOSE To identify gross abnormalities in the patient
EQUIPMENT
·No specific equipment is called for. A penlight may facilitate certain observations.
SET-UP
·There is no specific set-
STEP-BY-STEP PROCEDURE
1. Be observant.
2. In general, look for anything odd or unusual about the patient and any asymmetries between one side of the body and the other, paying particular attention to the face.
3. Observation includes certain specific points of reference:
a. the patient’s posture, including head tilts, gait, and carriage
b. the patient’s head, face, and accessory ocular structures
c. the patient’s eyes: their placement in his head, the conjunctiva, cornea, iris, and lens.
4. Compare the patient’s features to your concept of an expected normal appearance. Compare one side of his body and face to the other to note any asymmetries.
RECORDING
·If in your professional judgment the patient is normal in areas observed, record WNL, which means “within normal limits.”
·Describe any abnormalities or asymmetries you observe.
EXAMPLES
·Ext: WNL
·Ext: OD larger than OS and lower in face by 1 cm |
