geriatrics
Physical Examination of the Older Adult
Head and Neck
Normal age-related findings may include the following: Eyebrows that drop below the superior orbital rim Descent of the chin Loss of the angle between the submandibular line and neck Wrinkles Dry skin Thick terminal hairs on the ears, nose, upper lip, and chin The temporal arteries should be palpated for tenderness and thickening, which may indicate Treatment , suspicion of which requires immediate evaluation and treatment. Progressive descent of the nasal tip is a normal age-related finding. It may cause the upper and lower lateral cartilage to separate, enlarging and lengthening the nose. Normal age-related findings include the following: Loss of orbital fat: It may cause gradual sinking of the eye backward into the orbit (enophthalmos). Thus, enophthalmos is not necessarily a sign of dehydration in older adults. Enophthalmos is accompanied by deepening of the upper eyelid fold and slight obstruction of peripheral vision. Pseudoptosis (decreased size of the palpebral aperture) Entropion and Ectropion (inversion of lower eyelid margins) Entropion and Ectropion (eversion of lower eyelid margins) Arcus senilis (a white ring at the limbus) With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects. The Evaluation of the Ophthalmologic Patient should focus on testing visual acuity (eg, using a Snellen chart). Visual fields can be tested at the bedside by confrontation—ie, patients are asked to stare at the examiner so that the examiner can determine differences between their and the examiner’s visual field. However, such testing has low sensitivity for most visual disorders. Tonometry is occasionally done in primary care; however, it is usually done by ophthalmologists or optometrists as part of routine eye examinations or by ophthalmologists when a patient is referred to them because glaucoma is clinically suspected. Ophthalmoscopy is done to check for Cataract , optic nerve or For all older patients, an eye examination by an ophthalmologist or optometrist is recommended every 1 to 2 years because such an examination may be much more sensitive for certain common eye disorders (eg, glaucoma, cataracts, retinal disorders). The external auditory canal is examined for cerumen, especially if a hearing problem is noted during the interview. If a patient wears an external hearing aid, it is removed and examined. The ear mold and plastic tubing can become plugged with wax, or the battery may be dead, indicated by absence of a whistle (feedback) when the volume of the hearing aid is turned up. To evaluate hearing, examiners, with their face out of the patient’s view, whisper 3 to 6 random words or letters into each of the patient’s ears. If a patient correctly repeats at least half of these words for each ear, hearing is considered functional for one-on-one conversations. Patients with presbycusis (age-related, gradual, bilateral, symmetric, and predominantly high-frequency hearing deficits) are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audioscope, if available, is also recommended because the testing sounds are standardized; thus, this evaluation can be useful when multiple providers are caring for a patient. Patients are asked whether hearing loss interferes with social, work, or family functioning, or they may be given the Screening (HHIE), a self-assessment tool designed to determine the effects of hearing loss on the emotional and social adjustment of older adults. If hearing loss interferes with functioning or if the HHIE score is positive, they are referred for formal audiologic testing. The mouth is examined for bleeding or swollen gums, loose or broken teeth, fungal infections, and signs of cancer (eg, leukoplakia, erythroplakia, ulceration, mass). Findings may include Darkened teeth: Due to extrinsic stains and less translucent enamel, which occur with aging Fissures in the mouth and tongue and a tongue that sticks to the buccal mucosa: Due to Xerostomia None Erythematous, edematous gingiva that bleeds easily: Usually indicating a gingival or periodontal disorder Bad breath: Possibly indicating oral disorders (eg, Caries , ), and atrophied papillae on the sides of the tongue. In edentulous patients, the tongue may enlarge to facilitate chewing; however, enlargement may also indicate Amyloidosis or Denture problems should be removed before the mouth is examined. Dentures increase risk of oral candidiasis and resorption of the alveolar ridges. Inflammation of the palatal mucosa and ulcers of the alveolar ridges may result from poorly fitting dentures. The interior of the mouth is palpated. A swollen, firm, and tender parotid gland may indicate parotitis, particularly in dehydrated patients; pus may be expressed from Stensen duct when bacterial parotitis is present. The infecting organisms are often staphylococci. Painful, inflamed, fissured lesions at the lip commissures ( Cheilitis (lip inflammation) ) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection. This joint should be evaluated for Osteoarthritis (osteoarthrosis), a common age-related change. The joint can degenerate as teeth are lost and compressive forces in the joint become excessive. Degeneration may be indicated by joint crepitus felt at the head of the condyle as patients lower and raise their jaw, by painful jaw movements, or by both. The thyroid gland, which is located in the front of the neck, wrapped around the trachea, is examined for enlargement and nodules. Carotid pulses due to transmitted heart murmurs can be differentiated from those due to carotid artery stenosis by moving the stethoscope up the neck: A transmitted heart murmur becomes softer; the bruit of carotid artery stenosis becomes louder. Bruits due to carotid artery stenosis suggest systemic atherosclerosis. Whether asymptomatic patients with carotid bruits require evaluation or treatment for cerebrovascular disease is unclear. The neck is checked for flexibility. Resistance to passive flexion, extension, and lateral rotation may indicate a cervical spine disorder. Resistance to flexion and extension can also occur in patients with meningitis, but unless meningitis is accompanied by a cervical spine disorder, the neck can be rotated passively from side to side without resistance. 