EXTERNAL

EXAMINATION
DR. IBNU GILANG SYAWALI
 SITUATING THE PATIENT
• Usually patient sits in the examining chair
• Young children can sit on their parent’s lap
• Uncooperative infants or toddler can be
laid flat on a bed or hold by the parent’s
• Very young infants can be swaddled
BEFORE YOU START …

1. Examiner usually conducts a brief visual survey (medical, neurological

or dermatological signs)
2. It may occur during pre-examination conversation or history taking
3. Examiner can recognize a disease pattern by initial observation
4. Examination should be done in well lit room
5. During this observation, note the patient’s demeanor, mental illness,
complexion, nutritional health, and an abnormal movements
• Focusing on ocular adnexa can reveal skin condition, such as rosacea, and other disorders
that can affect the eye.
• The examiner can look for any disturbance in the following sequence :
1. Head & face : bones, muscles, nerves and blood vessels, skin, lymph nodes,
mouth, nose, and paranasal sinuses.
2. Orbit
3. Eyelids
4. Lacrimal systems
 INSPECTION
• Visual survey to the external eye
• The basic equipment should be readily prepared at the exam room
• Clinical assessment : 1. Look for symmetry
2. Compare to normal values
3. Mass is measured in its longest dimension and its
perpendicular
INSPECTION OF HEAD & FACE
• Sketch of patient’s face can use to document abnormalities
• For children, measurements of the occipitofrontal circumference, weight
and height can help asses developmental delay.
• What to inspect ?
1. Facial asymmetry 4. Clefting Syndrome
2. Craniofacial bone development 5. Hemifacial atrophy
3. Old trauma 6. Facial muscle mobility
FACIAL ASYMMETRY
CRANIAL BONE DEVELOPMENT
OLD TRAUMA
INSPECTION OF HEAD & FACE
• Inspect dermal and vascular changes in the face
• Use of magnifying glass (+20 D lens, direct ophthalmoscope or 2x-3x
binocular loop) can help assessing skin lesions.
• Noted the skin abnormalities :
1. Size 4. Margin
2. Elevation 5. Distribution
3. Color 6. Surface changes
 COMMON ABNORMALITIES OF THE SKIN

Erythema Cyst Papilloma Keratosis Ulcer Papule Plaque

Pustule Verruca Crusting Eschar

Vesicle Eczema
PLEASE ASSES THIS SKIN LESION

Size :

Color :

Distribution :

Elevation :

Margin :

Mobility :

Surface changes :
PLEASE ASSES THIS SKIN LESION

Size :

Color :

Distribution :

Elevation :

Margin :

Mobility :

Surface changes :
INSPECTION OF ORBIT
• Measure the interchantal distance and interpupillary distance (IPD)
• Normal inner interchantal distance (IICD) : 30 mm
• Normal outer interchantal distance (OICD) : 89-92 mm (??)
• Normal interpupillary distance (IPD) : 50-75 mm, mean : 61 mm (adult)
40 mm (5 years old)
30 mm (newborn)
Number may vary depending on sex and etnichs (4 mm)
INSPECTION OF ORBIT
INSPECTION OF ORBIT
How to measure IPD ?
1. Measure the distance between the center of pupil
2. Measure the distance between temporal limbus of one eye and nasal limbus of the
other eye

What is the significance ?

3. Hypertelorism
4. Telechantus  Down syndrome, Turner syndrome, etc
 INSPECTION OF ORBIT
How to check for exophthalmos/endophthalmos ?
1. Ask patient to tilt head forward
2. Look over patient’s forehead and eyebrows from above. Examiners
may have to stand up
3. Elevate both upper eyelids as the patient maintain primary position
4. Note the position of the front of each globe in relationship to the
other.
5. Record any disparity between 2 eyeballs of more than 2 mm
INSPECTION OF THE EYELID
• Evaluate the symmetry and relative position of the
eyebrows
• Note the following : position of eyelashes relative to
the globe, density of the lashes, color, movement,
and presence of scar or injury
• Specific abnormalities should be drawn and
described in the medical record
• Illuminate the mass to determine solid or cystic mass
 INSPECTION OF THE EYELID
• The upper eyelid usually hides the top 1.5 mm of the cornea
• To asses eyelid closure, ask the patient to blink and and then close
both eyes gently.
• Any gap that allow exposure of the ocular surface is noted and
measured.