HEENT Bates

What are the causes of vertigo?

Vertigo represents vestibular disease. Peripharal causes in the inner ear include: 1. Benign positional vertigo 2. Labyrinthitis 3. Menieres disease Central neurologic causes in the cerebellum or brainstem (may be associated with ataxia, diplopia and dysarthria) include: 1. Cerebral vascular disease 2. Posterior fossa tumor 3. Migraine p210

Differentiate between vertigo, presyncope and disequilibrium.

Vertigo: Sensation of true rotational movement of the patient or the surroundings Presyncope: Feeling light-headed, weak in legs, or about to faint Disequilibrium: Feel unsteady or loss of balance. p210

What can cause vertigo?

Vestibular disease usually from peripheral causes in the inner ear: benign positional vertigo, labyrinthitis, meniere's disease

How does the nasal mucosa appear in viral rhinitis? in allergic rhinitis?

Viral - red and swollen Allergic - pale, bluish, or red

What can cause rhinorrhea?

Viral infections, allergic rhinitis ("hay fever") and vasomotor rhinitis. Itching favors allergic cause

Causes of rhinorrhea (3)

Viral infections, allergic rhinitis (hay fever), vasomort rhinitis

Nasal mucosa is reddened and swollen in:

Viral rhinitis

Presbyopia

Vision condition in which the shape of the crystalline lens of your eye changes. These changes make it difficult to focus on close objects.

Example of prodrome (early sx indicating onset of illness/disease) with migraine?

Visual aura, spark photopsias (flashed of light), fortifications (zig-zag arcs of light), scotomata (area of visual loss with surrounding normal vision)

What does moving speck or strands suggest?

Vitreous floaters

What do moving specks or strands in the patients visual filed suggest____.

Vitreous floaters. p208

Painless unilateral vision loss

Vitreous hemorrhage Macular degeneration Cataracts Retinal detachment Retinal vein occlusion Central retinal artery occlusion

Sudden unilateral visual loss with no pain suggests?

Vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion or central retina artery occlusion.

What are the most likely causes for acute hoarseness?

Voice overuse and acute viral laryngitis

Hypertensive Retinopathy With Macular Star

Punctate exudates are readily visible: some are scattered; others radiate from the fovea to form a macular star. Note the two small, soft exudates about 1 disc diameter from the disc. Find the flame-shaped hemorrhages sweeping toward 7 o'clock and 8 o'clock; a few more may be seen toward 10 o'clock. These two fundi show changes typical of accelerated (malignant) hypertension and are often accompanied by papilledema

Mydriasis

Pupil DILATION

Tonic Pupil (Adie's Pupil)

Pupil is large, regular, and usually unilateral. Reaction to light is severely reduced and slowed, or even absent. Near reaction, although very slow, is present. Slow accommodation causes blurred vision. Deep tendon reflexes are often decreased.

Red Reflex

Pupil should glow orange when you shine the light of the opthalmoscope on it. If not, there's an opacity in the eye.

Aniscoria

Pupillary inequality of .5 mm or less (benign if reactions are normal)

Diptheria

Rare; dull red, and grey exudate present on the uvula, pharynx, and tongue

What does sudden, bilateral and painless visual loss suggest?

Reaction to medications that change refraction: - cholinergics - anticholinergics - steroids

Palpable tenderness or step-offs of the skull may suggest?

Recent head trauma

Herpes Simplex

Recurrent and painful vesicular eruptions of the lips and surrounding skin

Exudative Tonsillitis

Red throat with white exudate; sore throat and fever. It is frequently caused by a viral infection, type of pharyngitis.

Viral Rhinitis

Reddened mucosa and swollen

Gingivitis

Reddening of gingiva

Nasal mucosa

Redder than oral mucosa

What is indicated with redness of the gums around the teeth? What blackness of the gums around the teeth?

Redness - gingivitis Blackness - lead poisoning

Neovascularization

Refers to the formation of new blood vessels. They are more numerous, more tortuous, and narrower than other blood vessels in the area and form disorderly looking red arcades. A common feature of the proliferative stage of diabetic retinopathy. The vessels may grow into the vitreous, where retinal detachment or hemorrhage may cause loss of vision.

Define aphthous?

Repeated formation of benign and non-contagious mouth ulcers in otherwise healthy individuals

Arteries wall = full and tortuous Light reflex = increased w/ a bright copper color

Retinal arteries in copper wiring

Arterial wall = less transparent Light reflex = narrowed Focal narrowing (in the middle)

Retinal arteries in hypertension

Prominent short process and prominent handle suggests:

Retracted Drum

Where does a cluster HA arise? (location)

Retro-orbital

Cluster headaches found in

Retro-orbital areas

small lumps on the helix or antihelix that can alos be found on hands, elbows, or knees

Rheumatoid nodules

Cricoid cartilage

Ring-shaped cartilage of the larynx

Rings and Crescents

Rings and crescents are often seen around the optic disc. These are developmental variations that appear as either white sclera, black retinal pigment, or both, especially along the temporal border of the disc. Rings and crescents are not part of the disc itself and should not be included in your estimate of disc diameter

Tori Mandibulares

Rounded bony growths on the inner surfaces of the mandible are typically bilateral, asymptomatic, and harmless.

severe and sudden onset HA pathology

SAH

neck anterior triangle

SCM laterally, midline of neck medially

neck posterior triangle

SCM, trapezius, clavicle

SNS and PSNS innervation of the iris

SNS dilates the pupil. Pupil constriction is PSNS.

Eyebrow scaliness seen in

Seborrheic dermatitis

What does redness and scaling on scalp indicate?

Seborrheic dermatitis or psoriasis

Generalized Lymphadenopathy

Seen in HIV/AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.

Vertigo

Sensation of true rotational movement of patient or surroundings

Having trouble understanding speech, complaining that others mumble, and noisy environments makes it worse suggests __________ loss.

Sensorineural

What kind of hearing loss is present in a patient that has particular trouble understanding speech? They often complain that others mumble, and noisy environments make hearing worse.

Sensorineural hearing loss - this results from an external and middle ear problem

What can be indicated when fresh blood or crusting is seen at the nasal septum?

Septal perforation, which includes: - trauma - surgery - intranasal use of cocaine or amphetamines

Two most important attributes of a headache

Severity and chronologic pattern EX: if severe and sudden subarachnoid hemorrhage or meningitis.

What are the two most important attributes of a HA?

Severity and chronology

Most important attributes of a headache

Severity: severe and sudden-subarachnoid hemorrhage or meningitis Chronologic pattern- Episodic and tend to peak- migraine and cluster headaches New and persisting- Tumors, abscess, or mass lesion

Assess corneal light reflex

Shine a light in either eye noting where the "shine spot" is and making sure it's in the same position in both

Tips for thyroid palpating

Short necks- hyperextension Flex neck slightly forward and to the side

Cover/Uncover Test ??????? (unilateral test)

Shows TROPIAS: Eg) cover L eye -- if nothing happens to the R eye, they must be R eye dominant NOW cover R eye and inspect the L -- check to see if there is any correcting movement; notice where the movement is going to. (bottom of the eye to the middle = L hypotropia), etc.

Feeling light-headed, weak in the legs or about to faint indicate?

Signs of pre syncope from arrhythmia, orthostatic hypotension or vasovagal stimulation.

Dryness may occur from impaired secretion in

Sjogren's syndrome

Xanthelasma

Slightly raised, yellowish, well-circumscribed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders.

Where is the blind spot?

Slightly temporal, along the horizontal line.

Macular degeneration

Slow central vision loss

Peutz-Jeghers Syndrome

Small brown pigmented spots in the dermal later of the lips, buccal mucosa, and perioral area; high risk for gastrointestinal cancers

Argyll Robertson pupils

Small, irregular pupils that accommodate but do not react to light. Seen in central nervous system syphilis.

Superficial Retinal Hemorrhages

Small, linear, flame-shaped, red streaks in the fundi, shaped by the superficial bundles of nerve fibers that radiate from the optic disc in the pattern illustrated

Shotty nodes

Small, mobile, discrete, nontender nodes, which are normal for that person.

Deep Retinal Hemorrhages

Small, rounded, slightly irregular red spots that are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. -DIABETES

Causes of chronic hoarsness

Smoking, allergy, voice abuse, hypothyroidism, chronic infections (i.e. tuberculosis, tumors)

Obtaining Distant Visual Acuity

Snellen Charts

Thyroid palpation

Soft in Grave's disease Firm in Hashimoto's and malignancy Tender is thyroiditis Nodules can also occur, both benign or malignant

Characteristics of the thyroid with..Graves, Hashimotos thyroiditis, Malignancy, Thyroiditis

Soft in graves Firm in Hashimotos and in malignancy Tenderness in Thyroiditis

Copper Wiring

Sometimes the arteries, especially those close to the disc, become full and somewhat tortuous and develop an increased light reflex with a bright coppery luster.

Septal perforation

Sources include; trauma, surgery, and intranasal use of cocaine or amphetamines (the later 2 can cause septal ulceration)

What can be indicated with lateral sparseness of the eyebrows? Scaliness of the eyebrows?

Sparseness - hypothyroidism Scaliness - seborrheic dermatitis

Carcinoma of the lip

Squamous cell carcinoma usually affects the lower lip; may appear scaly plaque with or without crust or as a nodular lesion

Parotid ducts

Stensen's Ducts Open onto the buccal mucosa, near the upper second molar

Which condition is most commonly known to produce tonsillar exudates in a patient:

Streptococcal pharyngitis

Fever, pharyngeal exudates, anterior lymphdenopathy, especially in the absence of cough suggests... ____________ ______________

Streptococcal pharyngitis (strep throat)

If headache is severe and of sudden onset

Subarachnoid hemorrhage or meningitis

Patient presents with severe and sudden onset of HA what should you consider?

Subarachnoid hemorrhage or meningitis

Thunderclap headaches reaching maximal intensity over several minutes occur in 70% of patients with _______.

Subarachnoid hemorrhage. They are often preceded by a sentinel leak headache from a vascular leak into the subarachnoid space. p206

What is indicated from an eye with leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area?

Subconjunctival hemorrhage

Asymmetric protrusion of the tongue

Suggests lesion of cranial nerve XII

Postauricular lymph node

Superficial nodes over mastoid process. Infection from inner or outer ear drain here

Anterior cervical lymph nodes

Superficially anterior to the sternocleidomastoid muscle. Indicate infections in the mouth, tongue, pharynx, larynx, thyroid, or trachea

Extraocular muscles associated with CN IV

Superior oblique (medial, bottom)

Extraocular Muscles

Superior, Inferior, Lateral and Medial Rectii muscles Superior and Inferior Oblique muscles

Papilledema

Swelling of the optic disc and bulging of the physiologic cup. Can be caused by increased ICP, swelling of the optic nerve head, and intraxonal edema. This is a worrying sign- consider meningitis, subarachnoid hemorrhage, trauma, and mass lesions

Testing for Direct and Consensual Light Reflex

Swinging Flashlight Test Will shine light in one eye and look at the reactivity in that eye; put the light in the same eye again & look at opposite eye (consensual REPEAT IN BOTH EYES

Testing for RAPD (relative afferent pupillary defect -- optic nerve damage)

Swinging Light Test in dark room Eg) L sided optic nerve damage Shine light at one R eye and you get a direct pupil constriction response, as well as L eye consensual constriction response. Shine light on L eye and both pupils dilate * if decrease in constriction or widening of pupil there's reduced stimulus to the affected eye)

Acute Angle Glaucoma

Sx: Decrease vision, Dilated, fixed pupil, Cornea is steamy, cloudy, extreme pain, halos around lights, photophobia, headache

Symtoms of acute bacterial sinusitis (4)

Symptoms appearing agter a URI, pain bending forward, maxillary toothache, tenderness over sinuses

Acute Sinusitis

Symptoms such as: localized tenderness, pain, fever, and nasal discharge

Common symptoms and physical findings of Graves' Ophthalmopathy are

Symptoms: diplopia, tearing, grittiness, and pain from corneal exposure Physical findings: exophthalmos, lid retraction, EOM dysfunction, ocular pain, lacrimation

True or false: pain in the ear can be referred from other structures in the mouth, throat, or neck

TRUE! Bing bing bing!

Retinal detatchment

Tear the retina and fluid may pass through a retinal tear, lifting the retina off the back of the eye Flashing lights, new or increased floaters, painless

Tension headaches found in...

Temporal areas

Where does a tension HA arise? (location)

Temporal areas

Homonymous hemanopsia

Temporal defect in visual field of one eye, nasal defect in the other eye

Abnormal lymph node findings

Tender nodes indicate infection or inflammation. Hard, fixed nodes suggest malignancy. If you find either, rexamine the regions they drain. Examine other lymph nodes to tell whether it's regional or generalized lymphadenopathy.

Abnormal nodes

Tender nodes- suggest inflammation Hard or fixed nodes- suggest malignancy (Enlargement of the supraclavicular node; especially on the left suggests metastasis from thoracic or abdominal malignancy)

What does a tender lymph node suggest? A hard or fixed node?

Tender: inflammation Hard/fixed: malignancy

Test of Otitis Media

Tenderness behind the ear- push on the mastoid process to check for this.

Furuncle or local infection

Tenderness of the nasal tip or alae suggests this

Vitreous floaters

Moving specks or strands

Labial frenulum

Mucosal fold connects each lip with the gingiva

Hereditary Hemorrhagic Telangiectasia

Multiple red spots on the lips; autosomal dominate endothelial disorder causing vascular fragility and ateriovascular malformations

What do the different muscles in the eye do?

Muscle or iris control pupillary size. Muscles of ciliary body control the thickness of the lens: allowing eye to focus on near or distant objects.

Ambylopia

Muscle weakness of the eye. Treated by patching the "good" eye so that the other strengthens.

Tinnitus

Musical ringing or a rushing or roaring noise in one or both ears

Difficulty with distances suggests ____.

Myopia (nearsightedness). p208

Weber Test Results:

NORMAL: hear the sound in both ears In unilateral CONDUCTIVE HEARING LOSS, sound is heard in the impaired ear (it seems louder) In unilateral SENSORINEURAL HEARING LOSS, sound is heard in the good ear Ex: With someone who has potential hearing loss in the right ear, they will tell you they hear better in either the R side or the L side

Ulcers result from

Nasal use of cocaine

What are common symptoms that accompany a migraine?

Nausea and vomiting (but can also occur with brain tumors and subarachnoid hemorrhage).

Myopia

Nearsightedness Vision condition in which people can see close objects clearly, but objects farther away appear blurred.

Myopia

Nearsightedness (problems with distance)

Proliferative Retinopathy, Advanced

Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity.

Hyperthyroidism

Nervousness, tremors Weight loss with increased appetite Excessive sweating and heat intolerance Tachycardia; palpitations increased SBP, decreased DBP Warm, smooth, moist skin Diarrhea Fine hair

AC>BC

Neural hearing loss

Primary Headaches

No identifiable underlying cause: migraines, tension, cluster

Exostoses

Nonmalignant overgrowths in ear canals

Exostoses

Nonmalignant overgrowths in ear canals, non-tender

Exostoses

Nontender, nonmalignant nodules, covered by normal skin, which can form in the ear canal and may block you from seeing the ear drum.

Arterial wall = transparent Light reflex = narrowed (1/4 diameter of blood column) B/c it's transparent, a vein crossing the

Normal retinal arteries

Normal Cornea and Lens findings

Normal: translucent, flat, sclera visible beneath

Confrontation Test

For visual field testing. Start from the temporal fields, about two feet lateral to their eardrums. Patient should see both sets of fingers at the same time. If not, then have them cover the eye on the side that they saw first, and cover your opposite-side eye and try again, moving from the affected area to the part with better vision. Ie, patient sees the fingers on their right side before the left side. So, suspect left defect. Patient covers right eye, you cover left eye, make eye contact with patient, begin wiggling fingers from patient's left side towards their midline.

normal small yellow spots in buccal mucose or lips

Fordyce spots

Rinne Test Results:

Normally the sound is heard longer through air than through bone in both ears (AC > BC).

Epistaxis

Nosebleed

Conjunctivitis (Vision)

Not affected except for temporary mild blurring due to discharge

Slow central visual loss occur with?

Nuclear cataract, macular degneration

Physical examination of the NOSE step 3

Test CN 1 (olfactory=sensory) - occlude the opposite nares - two scents (will be provided)

1st step after the physical examination of the ear (both internal and externally) is to ______

Test gross hearing with the whispered voice test - ask the pt. to block one ear with finder while you check the auditory acuity in the opposite ear. - rub fingers together 3 ft. from the unobstructed ear and then move fingers in until patient can hear the rubbing

Normal vs Abnormal Whispered Voice Test for Auditory Acuity

Test includes 3 number/letter combinations for each ear NORMAL: correct initial sequence/second test..pt repeats at least 3 of 6 numbers/letters ABNORMAL: 4 of 6 numbers/letters are incorrect

Physical Examination of the EYE: Step 1 Visual Acuity

Testing CN II: (OPTIC --> SENSORY) 1. Obtain Distant Visual Acuity 2. Obtain Near Visual Acuity 3. Record Correct Findings

Visual acuity is expressed in two numbers (Snellen eye chart) e.g., 20/200. What does each number represent?

Numerator: the distance of the patient from the chart. Denominator: the distance at which a normal eye can read the line of letters 20/200 means that at 20 ft the pt can read print that a person with normal vision could read at 200 ft. The larger the second number the worse the vision. p.221

A fine, rhythmic, oscillation of the eyes

Nystagmus

pain with tug test

OE but not OM

eternal ear HL causes

OE, trauma, sq. cell carcinoma, benign bony growths

red bulging of an acute purulent drum indicates

OM

tenderness behind the ear suggests

OM

the amber drum of a serous effusion indicates

OM

Physical Examination of the EYE: Step 11 Inspect the Anterior Chamber

Oblique lighting for Crescent Shadow With light shining, directly from the temporal side, looking for a crescentic shadow on the medial side of the iris, because the iris is normally fairly flat, and forms a relatively open angle with the cornea (this lighting should cast on shadow)

Silver Wiring

Occasionally a portion of a narrowed artery develops such an opaque wall that no blood is visible within it. It is then called a silver wire artery.

Horizontal Defect- eyes

Occlusion of a branch of the central retinal artery may cause a horizontal (altitudinal) defect. Ischemia of the optic nerve can produce a similar defect.

What are warning signs for HA?

Frequency or severity over 3 month, sudden onset of "thunderclap", after age 50, worse with changes in position, precipitated by valsalva maneuver, other sx such a fever/night sweats/weight loss, presence of cancer/HIV/infection/pregnancy, head trauma, neck stiffness or focal neurologic deficits.

Structures of the neck

From most superior downwards: Hyoid Thyroid cartilage (notched) Cricoid cartilage Lobes of the thyroid (just above the suprasternal notch) Trachea

What is a secondary headache?

From underlying structural systemic or infectious causes such as: meningitis or subarachnoid hemorrhage and may be life threatening

CN III

Oculomotor -- Motor principally responsible for moving the R eye (inferior oblique, medial rectus, superior rectus, inferior rectus muscles)

one dilated pupil that is fixed to light; ptosis of the affected eye is almost always present

Oculomotor nerve (CN 3) paralysis

Subconjunctival Hemorrhage (significance)

Often none. May result from trauma, bleeding disorders, or sudden increase in venous pressure, as from cough

Cataracts

Opacities of the lenses visible through the pupil. Risk factors are older age, smoking, diabetes, corticosteroid use.

What is the first question to ask when examining a patient's ears? If a patient has noticed hearing loss, what kinds of questions should you ask?

Open ended question - How is your hearing? - have you had any trouble with your ears? If a patient has noticed hearing loss: - does it involve one or both ears? - did is start suddenly or gradually? - what are the associated symptoms, if any?

Peripheral visual loss occur with?

Open-angle glaucoma

What is the first thing to ask when examining a pt's eyes? When do you pursue details, based on their answer?

Open-ended question - How is your vision? - Have you had any trouble with your eyes? Pursue details if pt reports a change in vision

Absence of a red reflex suggests:

Opicaity of lens (cataract), detached retina, or retinoblastoma in children

Why would a RAPD dt L sided optic nerve damage cause pupillary dilation in both eyes?

Optic nerve damage in the L eye causes reduced afferent signals and also reduced efferent signals to both pupils, so the net effect is dilation.

Valsalva maneuver?

The action of attempting to exhale with the nostrils and mouth closed. Causes pressure in middle ear and chest.

Horner's Syndrome

The affected pupil, though small, reacts briskly to light and near effort. Ptosis of the eyelid is present, perhaps with loss of sweating on the forehead. In congenital Horner's syndrome, the involved iris is lighter in color than its fellow (heterochromia)

What to inspect in oral examination?

Oral cavity, decayed or loose teeth, inflammation of the gingiva and signs of periodontal disease (bleeding, pus, recession of the gums and bad breath). Also inspect the mucous membranes, the palate, the oral floor, and the surfaces of the tongue for ulcers and leukoplakia, waning signs for oral cancer and HIV disease

Drugs that causes nasal stuffiness

Oral contraceptives Reserpine Guanethidine Alcohol Cocaine

Drugs that cause stuffiness (4)

Oral contraceptives, alcohol, reserpine, guanethidine

What drugs may cause nasal stuffiness?

Oral contraceptives, reserpine, guanethidine, alcohol, cocaine

The Middle Ear is composed of

Ossicles (the malleus [note the handle and short process] the incus, and the stapes), umbo, pars flaccid and pars tensa Tympanic Membrane Eustachian tube

Describe the different locations of ear pain.

Otitis externa - pain occurs int he external canal Otitis media - pain in the inner ear (if respiratory infection) Pain may also be referred from other structures in the mouth, throat or neck. p209

Ear pain associated with other symptoms of respiratory infection/referred from mouth/throat/neck suggests...

Otitis media

Red, bulging, ear drum indicates:

Otitis media

Soft wax discharge, debris from inflammation, rash in ear canal suggests...

Otitis media

Thrush

Overgrowth if candida yeast in the mouth Should be able to be scraped off

If coughing /sneezing/valsalva position worsens headache it could be...

Pain from brain tumor, acute sinusitis

Otitis media

Pain in the inner ear

Otitis externa

Pain occurs in the external canal

Nasal polyps

Pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses

Allergic Rhinitis

Pale, bluish, or red

What is the opening between the eyelids called?

Palpebral fissure

What suggests hyperthyroidism?

Palpitations, involuntary weight loss, intolerance to heat

What can cause vertical diplopia?

Palsy of CN III or IV

What can cause horizontal diplopia?

Palsy of cranial nerve (CN) III or VI

Swelling of optic disc and anterior bulging of physiologic cup

Papilledema

intracranial pressure causes edema along the optic nerve

Papilledema

Causes of enlarged blind spot

Papilledema, glaucoma, optic neuritis

Phases of the Hearing Pathway

The conductive phase is from the external ear through the middle ear. Causes of conductive hearing loss include otitis media, trauma, overgrowths of bone or epithelium, congenital conditions of the middle ear, cholesteatomas or tumors in the middle ear, otosclerosis, and perforation of the tympanic membrane. The sensorineural phase is the cochlea and cochlear nerve. Causes of sensorineural hearing loss include congenital conditions of the inner ear, presbycusis, viral infections such as rubella and CMV, Meniere's disease, noise exposure, and acoustic neuroma.

Oculomotor Nerve (CN III) Paralysis

The dilated pupil is fixed to light and near effort. Ptosis of the upper eyelid and lateral deviation of the eye are almost always present.

Otoscope exam of otitis media

The drum is red and bulging (acute purulent otitis media) or amber (serous effusion).

What is a visual field?

The entire area seen by an eye when it looks at a central point.

Left Cranial Nerve III Paralysis- straight ahead

The eye is pulled outward by action of the CN VI. Upward, downward, and inward movements are impaired or lost. Ptosis and pupillary dilation may be associated.

Nephrotic Syndrome

The face is edematous and often pale. Swelling usually appears first around the eyes and in the morning. The eyes may become slitlike when edema is severe.

Cushing's Syndrome

The increased adrenal cortisol production of Cushing's syndrome produces a round or "moon" face with red cheeks. Excessive hair growth may be present in the mustache and sideburn areas and on the chin

Cover/uncover test

Patient looks at your nose and covers L eye with a card. Shine a light on the R side of the R eye. Both eyes will move towards the right (outward for the R, inward for the L covered eye). When you remove the cover, the left will move outward and the right inward. Looks for muscle balance.

holes in the eardrum from purulent infections of the middle ear

Perforation of the drum

Open-angle glaucoma

Peripheral vision loss

small brown pigmented spots in the dermal layers, buccal mucosa, and perioral area

Peutx-Jeghers Syndrome

Enlarged, tender lymph nodes accompany ___________

Pharyngitis

What do soft lumps on scalp indicate?

Pilar cysts (wens)

Normal eardrum appearance

Pinkish gray and clear, not retracted or bulging. Malleus, incus, and umbo visible

Hirsutism occurs in women with what condition?

Polycystic ovary syndrome

Posterior cervical lymph nodes

Posterior to sternocleidomastoid muscle and anterior to trapezius muscle. Probe gently around muscle. Indicate mono or viral illness

What do light rays focus in a hyperopic patient?

Posterior to the retina

Causes of Sensorinural Hearing Loss

Presbyacusis

Diplopia in one eye with the other closed suggests?

Problem in the cornea or lens

Sensorinerual loss is due to problems in the _______ ______, __________ nerve, connections to the __________.

Problems in inner ear, cochlear nerve, connections to the brain

Conductive hearing loss

Problems in the external or middle ear Can be caused by foreign body or perforated eardrum Occurs in childhood and young adulthood, up to 40 Usually able to visualize abnormality in the ear Little effects on sound Hearing improves in noisy environment; pt's voice soft Weber- lateralizes to impaired ear; vibrations improves Rinne- Bone conduction longer than or equal to air Air conduction is impaired

What is conductive hearing loss?

Problems in the external or middle ear: noisy environment may help

Sensorineural hearing loss

Problems in the inner ear, cochlear nerve, or connections Can be caused by loud noises, infections, trauma, etc Occurs in middle or later years No visible problem in the ear Higher register of sound lost, Trouble hearing speech Worse in noisy environments; pt's voice loud Weber- lateralizes to good ear Rinne- Air conduction longer than bone conduction

What is sensorineural hearing loss?

Problems in the inner ear, the cochlear or its central connections in the brain: particular trouble understanding speech, often complaining that others mumble, noisy environments make it worse

Peripheral contact

Produces spokelike shadows that point—gray against black, as seen with a flashlight, or black against red with an ophthalmoscope. A dilated pupil, as shown here, facilitates this observation.

Headache warning signs

Progressively frequent or severe over a 3-month period. Sudden onset like a "thunderclap" or "the worst headache of my life". New onset after age 50 years. Aggravated or relieved by change in position. Precipitated by Valsalva maneuver. Associated symptoms of fever, night sweats, or weight loss. Presence of cancer, HIV infection, or pregnancy. Recent head trauma. Associated papilledema, neck stiffness, or focal neurologic deficits.

Abnormal protursion of eyeball

Proptosis or Exophthalmos

What is the tear fluid and where does it come from?

Protects the conjunctiva and cornea from drying, inhibits microbial growth and gives a smooth optical surface to the cornea. Comes from the meibomian glands, conjunctival glands and lacrimal gland. Tear fluid drains medially through two tiny holes called lacrimal punch and then pass into the lacrimal sac and on into the nose through the nasolacrimal duct.

Temporal hemianopsia

Pt can't see temporal sides

20/40 corrected vision

Pt. can read the 40 line with glasses (a correction)

Ptosis

Ptosis is a drooping of the upper lid. Causes include myasthenia gravis, damage to the oculomotor nerve, and damage to the sympathetic nerve supply (Horner's syndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.

Tug Test

Pulling the auricle back and pushing on the tragus. If painful, suspect otitis externa (ear canal inflammation).

Acromegaly

The increased growth hormone of acromegaly produces enlargement of both bone and soft tissues. The head is elongated, with bony prominence of the forehead, nose, and lower jaw. Soft tissues of the nose, lips, and ears also enlarge. The facial features appear generally coarsened.

What does it mean for the patient when a crescentic shadow is present during lateral illumination of the iris?

The iris is abnormally far forward, forming a very narrows angle with the cornea - Increased risk for acute narrow-angle glaucoma

Left Cranial Nerve IV Paralysis- looking down/right

The left eye cannot look down when turned inward. Deviation is maximum in this direction.

Anterior triangle of the neck

The mandible above, the sternomastoird laterally, and the midline of the neck

Normal Retinal Artery and Arteriovenous (AV) Crossing

The normal arterial wall is transparent; only the column of blood can usually be seen. The normal light reflex is narrow—about one-fourth the diameter of the blood column. Because the arterial wall is transparent, a vein crossing beneath the artery can be seen right up to the column of blood on either side.

Myxedema

The patient with severe hypothyroidism (myxedema) has a dull, puffy facies. The edema, often pronounced around the eyes, does not pit with pressure. The hair and eyebrows are dry, coarse, and thinned. The skin is dry.

Physiologic Cupping

The physiologic cup is a small whitish depression in the optic disc, the entry point for the retinal vessels. Although sometimes absent, the cup is usually visible either centrally or toward the temporal side of the disc. Grayish spots are often seen at its base.

What does 20/40 corrected mean?

The pt could read the 40 line with glasses (a correction)

Posterior triangle of the neck

The sternomastoid muscle, the trapezius, and the clavicle

Concealment or AV nicking

The vein appears to stop abruptly on either side of the artery.

Tapering

The vein appears to taper down on either side of the artery

Banking

The vein is twisted on the distal side of the artery and forms a dark, wide knuckle.

What can nausea and vomiting indicate?

They are common with migraine but also occur with brain tumors and subarachnoid hemorrhage

What causes secondary headaches?

They arise from underlying structural, systemic or infectious causes such as meningitis or subarachnoid hemorrhage and may be life-threatening. p206

Supraclavicular lymph nodes

Think malignancy!. Hook finger over clavicle lateral to sternocleidomastoid. If you feel them it is always a cause for concern

Chondrodermatitis Helicis.

This chronic inflammatory lesion starts as a painful, tender papule on the helix or antihelix. Here the upper lesion is at a later stage of ulceration and crusting. Reddening may occur. Biopsy is needed to rule out carcinoma

Hairy Leukoplakia

This does NOT scrape off Smokers Pre-cancerous Tx is generally to quit smoking

Anatomy of the TYMPANIC MEMBRANE

This is an image of the R ear

Tracheal deviation may signify

Thorax issues such as mediastinal mass, atelectasis, opr large pneumothorax

Thunderclap Headaches

Thunderclap headaches that reach maximum intensity over several minutes occur in 70% of patients with subarachnoid hemorrhage. Often preceded by sentinel leak headache (vascular leak into subarachnoid space).

What happens with presence of a goiter?

Thyroid function may be increased, decreased or normal.

Microaneurysms

Tiny, round, red spots commonly seen in and around the macular area. -DIABETIC RETINOPATHY

Sore tongue results from... (2)

Local lesions, systemic illness

Angioedema

Localized subcutaneous or submucosal swelling caused by leakage of intravascular fluid into interstitial tissue Mast cells cause urticaria and pruritus Swelling only usually in bradykinin mediators Usually benign and resolves in 24-48 hours

Thyroid Gland

Located above the suprasternal notch, spans the second, third, and fourth tracheal rings just below the cricoid cartilage

Occipital lymph node

Located at base of skull. Indicate infection in scalp or outer ear

Why is it important to ask about family history when asking the pt about their headache?

Genetic inheritance appears to be present in 30%-50% of patients with migraine

Can migraine headaches be genetically inherited?

Genetic inheritance appears to be present in 30-50% of patients with migraine. p207

Bleeding gums caused by...

Gingivitis

Swollen interdental papillae, redness of gingiva suggests:

Gingivitis

What causes bleeding gums?

Gingivitis

Leading cause of blindness

Glaucoma

An enlarged blind spot occurs in conditions affecting the optic nerve such as ____, ____ and ___.

Glaucoma Optic neuritis Papilledema

Dark, crescent shadow on iris increases the risk of

Glaucoma (iris bows abnormally foward forming a narrow angle with the cornea)

Enlarged blind spot in:

Glaucoma, optic neuritis, papilledema

increased pressure leads to backward depression of the disc

Glaucomatous cupping

Iron Deficiency Anemia

Glositis - red, beefy tongue

Elarged thyroid gland

Goiter

Discussing Tonsil Size

Grade 0: Tonsils absent Grade 1: hidden behind tonsillar pillars Grade 2: Extend to pillars Grade 3: Visible beyond pillars Grade 4: Enarged to midline

Soft thyroid lobes

Grave's disease

thyroid gland is soft in

Grave's disease

Inward/outward deviation of eyes or abnormal protrusion seen in

Graves' disease, ocular tumors

Gingiva

Gums; Light skinned- pale or coral pink and lightly stippled Dark skinned- diffusely or partly brown

diffuse lymphadenopath suggests

HIV or AIDS

generalized lymphadenophy is seen in pts with

HIV or AIDS mono lymphoma leukemia sarcoidosis

Generalized lymphadenopathy is seen in

HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis

Generalized Lymphadenopathy is seen in what conditions?

HIV/AIDS mono lymphoma leukemia sarcoidosis

generalized lymphadenopathy pathology

HIV/AIDs, infectious mono, lymphoma, leukemia, sarcoidosis

yellowish-brown or black elongated papillae on tongue's dorsum o Benign and associated with: antibiotic therapy, candida infection, or poor dental hygiene

Hair tongue

tongue looks like candida, but cannot be scraped off

Hairy leukoplakia, seen in HIV and AIDs

Submandibular lymph nodes

Halfway between angle and tip of mandible. Infections of mouth mucosa, floor of mouth, face nose, or maxillary sinus drain here

firm thyroid lobes

Hashimoto's thyroiditis and malignancy

thyroid is firm in

Hashimoto's thyroiditis and malignancy

Cover Test ???????

Have Px look at an Object. Cover 1 eye, and observe movement of UNCOVERED eye. Observe uncovered eye to see if it takes up fixation. Eg) L exotropic eye When R eye is covered, L eye will lose exotropia and "take up fixation" of the object.

Jugular vein examination

Head elevated to 30 degrees

contraindications for mydriatic drops:

Head injury, coma, suspicion of narrow angle glaucoma

Loss of venous pulsations signifies:

Head trauma, meningitis, mass lesions, elevated intracranial pressure

Most common symptom (30% general population)

Headache

What is a common cause of jugular venous distention (JVD)?

Heart failure

One-sided visual loss occur with?

Hemianopsia and quadratic defects

Retrosternal goiters symptoms

Hoarseness Shortness of breath Stridor Dysphagia (Often benign 85%; occur in 5th decade)

Visual field defects that are all or party temporal include

Homonymous Hemianopsia, Bitemporal Hemianopsia, and Quadrantic Defects (p222)

Compare benign anisocoria with

Horner's syndrome, oculomotor nerve paralysis, and tonic pupil

one small pupil that reacts with light; ptosis of the affected eye is present, w/sometimes loss of sweating on the forehead

Horner's syndrome:

What does an enlarged skull signify?

Hydrocephalus or Paget's disease of bone

Proptosis caused by, abnormal protrusion of the eyeballs leading to stare on frontal gaze:

Hyperhyroidism

Difficulty with close work suggests_____ or _____.

Hyperopia (farsightedness) or presbyopia (aging vision) p208

A localized systolic or continuous bruit may be heard in what thyroid condition

Hyperthyroidism

Poor convergence of the eyes can indicate what?

Hyperthyroidism

Poor convergence seen in:

Hyperthyroidism

What is indicated when a rim of sclera is visible above the iris with downward gaze (lid lag)?

Hyperthyroidism

note the rim of sclera from proptosis, an abnormal protrusion of the eyeballs leading to a characteristics stare on frontal gaze

Hyperthyroidism, If unilateral, consider an orbital tumor or retrobulbar hemorrhage from trauma

Hair differences in hypo vs hyperthyroidism

Hyperthyroidism: fine hair Hypothyroidism: coarse hair

Lateral sparseness of eyebrows

Hypothyroidism

What are possible causes for longterm (>2 weeks) hoarseness?

Hypothyroidism, reflux, vocal cord nodules, head and neck caners, neurologic disorders (Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis).

Lateral sparseness of eyebrows seen in:

Hypothyroidsim

Using a Snellen Chart

Ideally, from 20 feet away, cover one eye with a card, and count the smallest line for which they get more than half the letters right. Note if they used corrective lenses.

Thyroid cartilage

Identified by the notch on its superior edge

Marcus Gunn Pupil (afferent pupillary defect)

If left sided optic nerve damage is present, the pupils will usually behave as follows: when the light is shown into the normal right eye, there is brisk pupillary constriction of both pupils (direct response on the right and consensual response on the left). when the light is then swung over to the abnormal left eye, partial dilation of both pupils will occur. The afferent stimus on the left is reduced, thus, the efferent signals to both pupils will also be reduced and a net dilation will occur.

What to look for in the visual examination?

Look for clouding of the lens (cataracts), mottling of the macula, variations in retinal pigmentation, sub retinal hemorrhage or exudates (macular degeneration) and changes in color and size of the optic disc (glaucoma).

What to look for on scalp during examination?

Look for scaliness, lumps, nevi or other lesions

Visual pathway

Images enter eye and are reflected onto the retina, upside down and left-to-right reversed (so something seen in the upper nasal part of the field lands on the lower temporal part of the retina). The signal is conducted through retina, optic nerve, through optic chiasm to the optic tract, then to a curving tract called the optic radiation. Finally, ends in the visual cortex in the occipital lobe.

Define myopia

Impaired far vision (aka nearsightedness)

Define hyperopia

Impaired near vision (aka farsightedness)

Parotid

Lymph node in between the preauricular and tonsillar

Define presbyopia

Impaired near vision, found in middle-aged and older people. A presbyopic person often sees better when the card is farther away. p.222

Supraclavicular nodes

Lymph nodes almost behind the clavicle (deep in the angle formed by the clavicle and the sternomastoid)

Posterior cervical nodes

Lymph nodes along the trapezius above the clavicle (along the anterior edge of the trapezius)

Tonsillar nodes

Lymph nodes at the back of the jaw (angle of the mandible)

Occipital nodes

Lymph nodes at the base of the skull

Posterior auricular nodes

Lymph nodes behind the ears near the base (superficial to the mastoid process)

Deep cervical chain nodes

Lymph nodes deep to the sternomastoid

Preauricular nodes

Lymph nodes in front of the ear

Submental nodes

Lymph nodes midline behind the chin (behind the mandible)

Superficial cervical nodes

Lymph nodes under the ears (superficial to the sternomastoid)

Tonsils

In adults may be small or even absent

Ectropion

In ectropion, the margin of the lower lid is turned outward, exposing the palpebral conjunctiva. When the punctum of the lower lid turns outward, the eye no longer drains well, and tearing occurs. Ectropion is also more common in the elderly

Preauricular lymph nodes

In front of ear. Indicate infection in eye, middle ear or partoids

What is considered legally blind? (2 categories)

In the US: 1. Vision in better eye, corrected by glasses, is 20/200 or less. OR 2. Constricted field of vision: 20 degrees or less in the better eye p. 223

Nonproliferative Retinopathy, Severe

In the superior temporal quadrant, note the large retinal hemorrhage between two cotton-wool patches, beading of the retinal vein just above them, and tiny tortuous retinal vessels above the superior temporal artery.

Hard/fixed lymph nodes suggest:

Malignancy

What does an enlarged cup to disk ratio suggest?

Increased intraocular pressure - chronic open-angle glaucoma

Glaucomatous Cupping (Process)

Increased pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy. The base of the enlarged cup is pale.

What is another name for a relative afferent pupillary defect (RAPD)?

Marcus Gunn Pupil - Yhe most common pupillary abnormality.

Excessive tearing is a sign that there is either increased production or impaired drainage. What are conditions that could be indicated by each of these causes?

Increased production - conjunctival inflammation, corneal irritation Impaired drainage - ectropion, nasolacrimal duct obstruction

Asymmetry of the corneal reflection (white light reflection) indicates a deviation from normal ocular alignment. What does a temporal light reflection on one cornea indicated?

Indicates a nasal deviation of the eye

Thyroid bruit

Indicates hyperthyroidism

What is indicated with localized sinus tenderness? What are some commonly associated symptoms with this? What diagnostic test could be used?

Indication: acute sinusitis (frontal or maxillary) Symptoms: fever, pain, nasal discharge Diagnostic test: transillumination of the sinuses

Tender lymph nodes suggest:

Inflammation

Angular cheilitis

Inflammation and small cracks in one or both corners of the mouth.

Pharyngitis

Inflammation of the pharynx, reddened without exudate, tender lymph nodes

Labial Mucosa

Inside part of front lip

Physical Examination of the EAR process INSPECTION

Inspect Ears --- AURICLES: note the correct position MASTOID REGION CANAL FOR DISCHARGE

What suggests hypothyroidism?

Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism

Hypertensive Retinopathy

Marked arteriolar-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present. A cotton-wool spot is seen just superior to the disc. Incidental disc drusen are also present but are unrelated to hypertension

Physical Examination of the EYE: Step 10 Inspect the Iris

Markings should be clearly defined

Tracheal deviation

Masses in the neck may push the trachea to one side; also can signify atelectasis or large pneumothorax

Two types of angioedema

Mast cells in allergic and NSAID rxn, and ACE-inhibitor from bradykinin

Function: muscles of the iris vs muscles of the ciliary body

Iris: control pupillary size; Ciliary Body: control the thickness of the lens allowing the eye to focus on near or distant objects

What is a "medication for overuse headache"?

It is indicated if it is present >=15 days a month for 3 months and reverts to <!5 days a month when the medication is discontinued. p207

Nasal Septum

Medial wall of each nasal cavity; made of bone and cartilage

Hyoid bone

Just below the mandible

low-grad vascular tumor associated with herpes virus, deep purple lesions

Kaposi's sarcoma

small white specks that resemble grains of salt in mouth

Koplik's spots

Connects lip with gingiva

Labial frenulum

Vertigo suggests problem in these places:

Labrynths of inner ear, peripheral lesions of CN VIII, or lesions in central pathways/nuclei in brain

Subconjunctival Hemorrhage (Pattern of Redness)

Leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area that resolves over 2 weeks

The eye is always pulled outward; cannot move up, down, or inwards

Left cranial nerve 3 paralysis

The left eye cannot look down when turned inward

Left cranial nerve 4 paralysis

Esotropia when looking straight forward Maximum esotropia when looking to the right

Left cranial nerve 6 paralysis

What is suggested with asymmetrical protrusion of the tongue??

Lesion of CN XII

Asymmetric protrusion of tongue suggests

Lesion of CN XII (Hypoglossal)

Where is diplopia seen?

Lesions in the brainstem or cerebellum or weakness or paralysis of one or more extraocular muscles

What does a fixed defect in a patient's vision (called a scotoma) suggest?

Lesions in the retina of visual pathway

What does fixed defects or scotomas suggest?

Lesions in the retina or visual pathways

Scotomas (fixed defects, areas where the patient cannot see) suggest ___.

Lesions in the retina or visual pathways. p208

Buccal mucosa

Lines the cheeks

Connects tongue to floor of the mouth

Lingual Frenulum

What can be indicated if there is any overuse of analgesics, ergotamines, or triptans?

Medication of overuse headache - if present 15 or more days a month for 3 months and reverts to less than 15 days a month is medication is discontinued

Pts. with chronic daily headaches taking symptomatic meds 2+ days per week might have...

Medication overuse

Painless bilateral vision loss

Medications (anticholinergics, cholinergics, and steroids)

Sudden bilateral visual loss with no pain suggests?

Medications that change refraction such as cholinergic, anticholinergics and steroids

Sudden bilateral + PAINLESS visual loss may be due to ____.

Medications that change refraction such as cholinergic, anticholinergics and steroids. p208

Medullated Nerve Fibers

Medullated nerve fibers are a much less common but dramatic finding. Appearing as irregular white patches with feathered margins, they obscure the disc edge and retinal vessels. They have no pathologic significance.

Taking a history of the oropharynx

Lips - lesions - dryness Mouth, Teeth, Tongue - pain - lesions - too much or too little saliva - dental & periodontol changes - difficulties with chewing - malocclusion - difficulties with speaking Pharynx - pain - hoarseness - swallowing problems - respiratory problems - lump - hemorrhage - referred pain - foreign body - weight loss

Tinnitus + hearing loss + vertigo =

Meniere disease. Note: Tinnitus is a perceived sound that has no external stimulus. It is a common symptom, increasing in frequency with age. p209

Patient presents with tinnitus and hearing loss and vertigo, what does this suggest?

Meniere's disease

Tinnitus + hearing loss + vertigo suggests...

Meniere's disease

Tinnitus associated with hearing loss and vertigo

Meniere's disease

Tinnitus when associated with hearing loss and vertigo suggests

Meniere's disease

Papilledema suggests:

Meningitis, subarachnoid hemorrhage, trauma, mass lesions

Nasal polyps come from:

Middle meatus

Primary headaches

Migraine Tension Cluster Chronic daily headaches

What is indicated if a headache is associated with unusual feelings, such as euphoria, cravings, fatigue, dizziness, changes in vision, numbness, and weakness?

Migraine --> 60-70% symptoms prodrome prior to onset

Episodic headaches that peak over several hours

Migraine and Tension

Unilateral HA occur with which?

Migraine and cluster HA

Unilateral headaches found in...

Migraine and cluster headaches

Contrast the presentation of migraine, cluster and tension headaches.

Migraine headaches: UNILATERAL Tension headaches: TEMPORAL AREAS Cluster headaches: RETRO-ORBITAL p207

What is a primary headache?

Migraine, tension, cluster and chronic daily HA

What is indicated if a headache is associated with visual aura, such as flashes of light, fortification or zigzag arcs of light, and scotomata (area of visual loss with surrounding normal vision)?

Migraines

Associated symptoms of nausea and vomiting associated with...

Migraines, brain tumors, subarachnoid hemorrhage

Conjunctivitis (Pain)

Mild discomfort rather than pain

Miosis and Mydriasis

Miosis is constriction of pupils Mydriasis is dilation of pupils

Corneal Injury or Infection (pain)

Moderate to severe, superficial

Acute Iritis (pain)

Moderate, aching, deep

Headache

Most common symptom in clinical practice

What does the absence of a red reflex suggest?

Most commonly, cataracts (opacity of the lens) or loss of vitreous Less commonly, detached retina or retinoblastoma in children

What should be suspected if a patient has any persistent nodule or ulcer, red or white, on the tongue (especially if it is indurated)?

Tongue cancer

Streptococcal Pharyngitis

Tonsillar exudate

deposit of uric acid crystals on the helix or antihelix

Tophi: characteristics of gout

A benign midline lump of hard palate of roof of mouth

Torus palatinus

What are local causes of epistaxis?

Trauma (especially nose-picking), inflammation, drying and crusting of the nasal mucosa, tumors and foreign bodies

CN IV

Trigeminal -- Motor principally responsible for moving the left eye (superior oblique muscle)

What should you consider with a new and persisting, progressively severe HA?

Tumor, abscess or mass lesion

New and persisting, progressively severe headaches raise concern for...

Tumor, abscess, mass lesions

Onset of bilateral visual loss is gradual what does that suggest?

Typically from cataracts or macular degeneration

Sudden unilateral visual loss with pain suggests?

Typically in cornea and anterior chamber: corneal ulcer, uveitis, traumatic hyphema, acute glaucoma

acute bacterial sinusitis

URI sxs >7 days, prurulent drainage, facial pain

Viral sinusitis vs Bacterial sinusitis

URI symptoms persist for more than 7 days Purulent drainage Facial pain

Chancre of Primary Syphilis

Ulcerated papule with an indurated edge; appears 3-6 weeks after initial infection

Migraine headaches

Unilateral 70%, bifrontal or global 30% Throbbing or aching; severity varies Rapid onset 1-2 hours Duration 4-72 hours Aura in 30%; photophobia, phonophobia, nausea/vomiting Worsens with alcohol, foods, stress, menses Improves in quiet, dark rooms; sleep

Equal Pupils and One Blind Eye

Unilateral blindness does not cause anisocoria as long as the sympathetic and parasympathetic innervation to both irises is normal. A light directed into the seeing eye produces a direct reaction in that eye and a consensual reaction in the blind eye. A light directed into the blind eye, however, causes no response in either eye.

Sound is heard in the impaired ear in:

Unilateral conductive hearing loss

Sound is heard in the impaired ear in:

Unilateral conductive hearing loss, caused by otoscleosis otitis media, perforation of eardrum, and cerumen

Sound is heard in the good ear in:

Unilateral sensorineural hearing loss

Cluster headaches

Unilateral, usually behind or around the eye or temple Deep, continuous, severe Abrupt onset; peaks with in minutes Duration up to 3 hours Lacrimation, rhinorrhea, miosis, ptosis, eye edema, infection Worsens sensitivity to alcohol during attack

What presents with an acute or chronic otitis media?

Unusually soft wax, debris from inflammation or rash in the ear canal or discharge through a perforated eardrum

EOM test order

Using finger or pencil. Make an H, starting with extreme right right and up right and down extreme left left and up left and down Look for nystagmus as well as symmetric movements of the eyes.

Tension headaches

Usually bilateral or generalized to back of head or neck Steady; pressing or tightening;nonthrobbing mild-moderate Gradual onest Duration 30 minutes - 7 days photophobia, phonophobia Worsens with sustained tension Improves with massage, relaxation

What does painful, sudden. unilateral visual loss suggest?

Usually originates from cornea and anterior chamber: - corneal ulcer - uveitis - traumatic hyphema - acute glaucoma - optic neuritis (from MS) Note: immediate referral is warranted for patients with painful, sudden, unilateral visual loss

Nasal exam findings (viral rhinitis versus allergic rhinitis)

VIRAL=mucosa is red and swollen ALLERGIC= mucosa may be pale, bluish, or red

Cause of conductive deafness

[results from problems in the external or middle ear] the sound is coming from the outside to about the malleus/incus - blockage of ear canal - perforation of TM - fluid in the middle ear - damage to ossicles

Torus palatinus

a benign midline bony growth/lump of the hard palate (roof of the mouth)

feeling unsteady, lightheaded, or "dizzy in the legs" sometimes suggests

a cardiovascular etiology

discharge of mucopurulent material from the puncta suggests

a obstructed nasolacrimal duct

Each tarsal plate of the eyelid contains

a parallel row of meibomian glands which open on the lid margin

Legal Blindness

a person is considered legally blind when vision in the better eye corrected by glasses is 20/200 or less. this can also result from a constricted field of vision.

contraindications for mydriatic drops (for pupillary dilation)

1) head injury and coma, in which continuing observations of pupillary reactions are exxential, and 2) any suspicion of narrow angle glaucoma

Name 5 medications that affect hearing.

1. Aminoglycosides 2. Aspirin 3. NSAIDs 4. Quinine 5. Furosemide p209

List 3 causes of presyncope.

1. Arrhythmia

N/V are common with migraines. What other conditions might they occur with?

1. Brain tutors 2. Subarachnoid hemorrhage p207

Name 2 causes of GRADUAL bilateral vision loss.

1. Cataracts 2. Macular degeneration p208

Two types of hearing loss and diagnostic question for each:

1. Conductive loss - do you have special difficulty understanding people as they talk? 2. Sensorineural loss - what happens in a noisy environment?

When performing the Rinne test (AC and BC), what results are expected with conductive hearing loss and with sensorineural hearing loss?

1. Conductive: BC=AC or BC>AC 2. Sensorineural: AC>BC

Physical Examination of the EYE: Step 4 Determine Position and Alignment

1. Describe AP Position: (size, shape, symmetry) - not symmetrical and aligned if one protrudes 2. Perform Hirschberg Test 3. Describe deviation (strabismus) - Tropias - Phorias 4. Perform Cover Test 5. Perform Cover/uncover test

What are two contraindications for mydriatic drops?

1. Head injury and coma (because pupillary reaction observations are essential) 2. Any suspicion of acute angle glaucoma

Contraindications for mydriatic drops include

1. Head injury and coma, in which continuing observations of pupillary reactions are essential 2. Any suspicion of narrow-angle glaucoma

One-sided loss occurs in _____ and _____.

1. Hemianopsia 2. Quadrantic defects p208

Identifying midline structures of the neck

1. Hyoid bone just below the mandible 2. The thyroid cartilage readily identified by the notch on its superior edge 3. The cricoid cartilage 4. The tracheal rings 5. The thyroid gland

Physical examination of the NOSE step 1

1. INSPECT and PALPATE - purcuss the sinuses check for symmetry and tenderness

6 causes of earaches

1. acute otitis media 2. otitis externa 3. furunculosis 4. mastoiditis 5. malignancy 6. referred pain (teeth/tongue/TMJ, tonsillitis, herpes zostor, carcinoma of pharynx, cervical spondylosis)

2 types of hearing loss

1. conductive loss 2. sensorineural loss

One sided nasal congestion is caused by (5)

1. deviated nasal septum 2. nasal polyp 3. foreign body 4. granuloma (wegener's) 5. carcinoma

aura, change in vision, numbness/weakness in arm or leg associated with...

1/3 of people with migraine patients

Physical Examination of the Oropharynx step 10

10. palpate the tongue wearing gloves examine the tongue for lesions palpate both under and over and on sides to ensure no lesions 2x2: gauze allows you to better grasp the tongue when its moving around bimanual exam: use both hands

what size tuning fork do you use for vibratory sensation

100-400Hz

Physical Examination of the Oropharynx step 11

11. palpate the saltatory ducts WHARTON: under the tongue-one hand intramural the other extraoral move in a circular motion STENSON: on the buccal mucosa (parotid ducts) feel for

Physical Examination of the Oropharynx step 12

12. palpate and percuss the teeth using nail of finger or tongue depressor,tap on the tooth

Physical Examination of the Oropharynx step 2

2. inspect the lips ovserve their color and moisture, and not any lumps, ulcers, cracking, or scaliness, not cyanosis, or pallor

legally blind

20/200 or less

"Legally blind"

20/200 or less in better eye, corrected

Visual Acuity

20/200; at 20ft the Pat. can read a print that a person with normal vision could read at 200ft.

Nasal turbinates (names/how many, covered by, found where, landmarks)

3 (superior turbinate, middle turbinate, inferior turbinate); covered by a highly vascular mucous membrane; found laterally and protrude into the nasal cavity; each turbinate is a groove or meatus

ossicles

3 bones of middle ear, malleus/incus/stapes, transform sound vibrations into mechanical waves

Physical Examination of the Oropharynx step 3

3. Inspect the oral mucosa - look into the mouth with a good light and the help of a tounge lade - look for color, ulcers, white patches, and nodules

Genetic inheritance appears to be present in ____ to _____ % of patients with migraine.

30-50

What percentage of patients with migraine have genetically inherited it?

30-50%

genetic inheritance of migraines

30-50% of patients with migraines

Teeth

32 adult teeth; 16 in each jaw

Horizontal diplopia occurs in

3rd or 4th nerve palsy

Vertical diplopia occurs in

3rd or 6th nerve palsy

Physical Examination of the Oropharynx step 4

4. Inspect the gum and gingiva - gingiva should be pale or coral pink or partly brown in dark skin people - can be lightly stippled (marked by specks or small dots) - look for swelling or users of the gingiva

abnormal results of whispered ear test

4/6 letters incorrect, refer to audiometry

what is the clinical normal decibel range

40

in the right ear the cone of light is at what clock position

5

Physical Examination of the Oropharynx step 5

5. Inspect the roof of the mouth - hard palate - soft palate inspect color and architecture of the palate color-no lesions or growths w light

what Hz tuning fork is usually used

512

what tuning fork is used to test auditory function

512-1024Hz

Physical Examination of the Oropharynx step 6

6. Inspect the tongue and the floor of the mouth -inspect the color and texture of the tongue and floor - look for lesions w light

What percentage of patients with migraine have a symptom prodrome prior to onset

60-70%

Feelings of euphoria, food cravings, fatigue, or dizziness prior to onset

60-70% of Migraines

in the left ear the cone of light is at what clock position

7

Physical Examination of the Oropharynx step 7

7. Determine the function of CN XII (hypoglossal - motor) STICK TONGUE STRAIGHT OUT: if asymmetrical, may have lesion *** If suspect, check for cheek push - have them put their tongue to their cheek

Physical Examination of the Oropharynx step 1

1. Inspect the teeth for dentition and oral health looking for lesions or dentition ( teeth in the dental arch), make sure gingiva is firmly attached to the teeth and mandible maxilla, (look to see if any teeth are missing, discolored, or misshapen, or abnormal position. Check for loose ones with your gloved hand look for malocclusion (crowding or severely misaligned teeth)

Name two causes of diplopia.

1. Lesions in the brainstem or cerebellum 2. Weakness or paralysis of one or more extra ocular muscles (AS in horizontal diplopia from palsy of CN II or VI, or vertical diplopia from palsy of CN III or IV) Note: Diplopia in ONE EYE, with the other closed, suggests a problem in the CORNEA OR LENS. p209

Physical Examination of the EYE: Step 12 Inspect the Pupils

1. Measure Size: on our card use the black circles of varying sizes to measure pupil size should be between 3 and 5 mm 2. Take Note of Shape 3. Take note of Symmetry 4. Test for Direct and Consensual Light Reflex 5. Test for RAPD 6. Test for Near Reaction

Name 2 types of headaches that are episodic and tend to peak over several hours.

1. Migraine 2. Tension p207

Primary headaches include which 3 types of headaches?

1. Migraine 2. Tension 3. Cluster 4. Chronic daily p206

Slow central visual loss occurs in ____ and ____.

1. Nuclear cataract 2. Macular degeneration p208

Headache Warning Signs ("red flags" that need prompt investigation)

1. Progressively frequent or severe over a 3-month period 2. Sudden onset like a "thunderclap" or "the worst headache of my life" 3. New onset after age 50 years 4. Aggravated or relieved by change in position 5. Precipitated by Valsalva maneuver 6. Associated symptoms of fever, night sweats, or weight loss 7. Presence of cancer, HIV infection, or pregnancy 8. Recent head trauma 9. Associated papilledema, neck stiffness, or focal neurologic deficits

Best way to ask about vertigo:

"do you have feelings of being pulled to the ground or off to one side?"

Cross-Cover Test ????????

"the patient that says they start getting double vision when they are driving in the car late at night..." etc. Shows PHORIAS: cover one eye and see if there is movement, then go to the other eye and see if there is movement (this is subtle) Eg) If you go back and forth bw the eye, breaking fusion/communication bw the eyes, and both eyes move in, then normally they are both exophoric.

Physical Examination of the EYE: Step 2 Screen Visual Fields by Confrontation

*flying fingers!* - UNILATERAL: have patient cover an eye; do wiggle test only on side that is UNCOVERED * right eye is open come on their right side with wiggling fingers - BILATERAL: have them tell you when they see the fingers- start from behind the test and work your way in and forward

Depress Lower Lid

*inspect the sclera and palperbral conjunctive for color * note vascular pattern against the white sclera background look for any nodules or swelling

Anatomy of the OROPHARYNX

*know all of them!

Spread Upper and Lower Lid

*open both lids with finger and thumb, on the brow of the bones of the cheek and brow *ask the patient to look to each side and down - good view of the sclera, and bulbar conjunctiva (not palpebral conductive) note color and any lesions

Hairy tongue

- "Hairy" yellowish to brown and black elongated papillae on tongue's dorsum - Benign condition associated with Abx therapy, Candida infection and poor dental hygeine - can occur spontaneously

Diphtheria

- Acute infection caused by cornyebacterium diphtheriae - Dull red throat and a gray exudate (pseudomembrane) present on uvula, pharynx, and tongue -> airway may become obstructed

Serous effusion

- Amber fluid behind eardrum, air bubbles sometimes present - Causes: viral URT infections (otitis media) or sudden changes in atmos presure (otitic barotrauma from flying, diving) -> eustachian tube can't equalize air pressure in middle ear and outside air -> air absorbed from middle ear into blood and serous fluid accum there instead - Sx: fullness and popping, mild conduction hearing loss, pain (sometimes)

Abrasion of teeth with notching

- Biting surfaces of teeth become abraded/notched by recurrent trauma (biting nails, opening bobby pins between teeth) - Sides of teeth show normal contours; size and spacing of teeth unaffected

Acute otitis media with purulent effusion

- Bulging eardrum (laterally, toward examiner's eye), loss of landmarks, redness near umbo and dilated vessels in all segments of drum (diffuse redness) - Spontaneous rupture of drum can occur -> discharge of purulent material into ear canal - Causes: bacterial infection from S. pneu and H. infl; sx: earache, fever, conduct. hearing loss - More common in chilren

Marginal gingivitis

- Common in teens and young adults - Gingiva reddened and swollen, interdental papillae blunted, swollen and red - Brushing teeth makes gums bleed - Plaque (soft white film in salivary salts, protein and bacteria) is NOT readily visible

Kaposi's Sarcoma in AIDS

- Deep purple color lesion, may be raised or flat - Lesions suggest Kaposi's sarcoma = low-grade vascular tumor associated with human herpesvirus 8; 1/3 of pts with this have lesions in oral cavity - Other affected sites = GI tracts and lungs - ARV therapy has reduced prevalence of dz

Tympanosclerosis

- Deposition of hyaline material within layers of tympanic membrane, can follow severe episodes of otitis media - Doesn't impair hearing usually - Also shown here: healed perforation (large oval in upper post drum); retracted drum (pulled medially, short process protrudes sharply, and handle is pulled inward at umbo and appears more horizontal)

Geographic tongue

- Dorsum shows scattered smooth red areas denuded of papillae; together with normal rough and coated areas give maplike pattern that changes over time - Normal variant

Koplik's Spots

- Early sign of measles - rash appears within a day - Small white specks that resemble grains of salt on a red background appearing on buccal mucosa near 1st and 2nd molars

Erosion of teeth

- Erosion of enamel from lingual surfaces of upper incisors, exposing yellow-brown dentin - Results from recurrent regurgitation of stomach contents (bulimia)

Where is the pain located in: - Otitis externa - Otitis media

- External canal - Inner ear

Define: - Hyperopia - Presbyopia - Myopia

- Farsightedness - Aging vision: impaired near vision- often sees better far - Nearsightedness

Describe hair in: - Hyperthyroidism - Hypothyrodism

- Fine hair - Coarse hair

What are conditions where general lymphadenopathy is noted?

- HIV/AIDS - infectious mononucleosis - lymphoma - leukemia - sarcoidosis (collections of inflammatory cells, granulomas, throughout the body)

Perforation of the Drum

- Holes in the eardrum from purulent infections of middle ear - Can be central (shown here - don't extend to margin of drum) or marginal (involve margin) - Reddened ring of granulation tissue surrounds perforation = chronic infection - Scarred eardrum, no landmarks visible, discharge may drain through hole - Hole closes in healing process -> thin memb

Gingival hyperplasia

- Hyperplasia enlarges gums, which become swollen into heaped-up masses that may cover teeth - May also see redness of inflammation - Causes: puberty, pregnancy, phenytoin therapy and leukemia

Attrition of teeth; recession of gums

- In elderly people, chewing surfaces of teeth worn down by repetitive use so that yellow-brown dentin becomes exposed (called attrition) - Also note: recession of gums which has exposed roots of teeth (gives "long tooth" appearance)

Abnormal Cornea and Lens findings

- Injected (bloodshot) - Chemosis (edema) - Opacities (cataract) - Lacerations - Subconjunctival - hemorrhage

Large normal tonsils

- Large without being infected, especially in children - Can protrude medially beyond pillars and even to midline - Shown here: pink tonsils, touch sides of uvula and obscure pharynx

Actinic cheilitis

- Lip loses normal redness and may become scaly, thickened and slightly everted - Causes: excessive sun (fair-skinned men who work outdoors are often affected) - Primarily in lower lip, carcinoma of lip possible

Angioedema

- Localized subcutaneous or submucosal swelling caused by leakage of IVF into interstitial tissue - If vasc perm triggered by mast cells in allergic and NSAID rxns look for uriticaria and pruritis - Usually benign and resolves in 24-48 hrs; life-threatening when involves larynx, tongue, upper airway

What is a common cause of poor central vision in older adults? What retinopathy is commonly seen with this?

- Macular degeneration - Drusen (undigested cellular debris) are commonly seen

If a patient with hearing loss is also experiencing earache or vertigo, what could be the issue?

- Medications that might affect hearing (include: aminoglycosides, aspirin, NSAIDS, quinine, and furosemide) - sustained exposure to loud noise

Torus Palatinus

- Midline bony growth in hard palate - Fairly common; size and lobulation varies; harmless

What can be indicated if a headache is unilateral?

- Migraines and cluster headache - tension --> temporal area - cluster --> may be retro-orbital

Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome)

- Multiple small red spots on lips, also visible on oral mucosa and fingertips - Autosomal dominant d/o causes by vascular fragility and arteriovascular malformations (AVMs in lungs and brain = life-threatening hemorrhage) - Common = nosebleeds, GI bleeding, iron deficiency anemia

Fordyce Granules (Spots)

- Normal sebaceous glands appear as small yellowish spots in buccal mucosa OR on lips - Spots usually not numerous

Fissured tongue

- Normal variant, appears with age - Can become irritated with food debris accumulation

Physical Examination of the EYE: Step 9 Observe the Cornea

- Note opacities (cataracts), defects, or foreign body - look for injected (bloodshot), chemises (edema), lacerations or subconjuctival hemorrhage - Assess for corneal reflex (CN V: Trigeminal -- Sensory & Motor)

Bullous Myringitis

- Painful hemorrhagic vesicles on tympanic membrane, ear canal or both - Causes: mycoplasma, viral, and bacterial otitis media - Sx: earache, blood-tinged discharge, conductive hearing loss - Shown here: two large bullae on drum, reddened drum, obscured landmarks

Aphthous Ulcer

- Painful, round or oval ulccer that is white or yellowish and surrounded by a halo of reddened mucosa - Heals in 7-10 days, can recur

Mucous patch of syphilis

- Painless lesion of secondary syphilis, highly infectious - Slightly raised, oval and covered by grayish membrane - May be multiple or occur elsewhere in mouth

What can be indicated if the uvula deviates?

- Peritonsillar abscess - CN X paralysis (soft palate fails to rise, deviation to opposite side)

Peutz-Jeghers syndrome

- Prominent small brown pigmented spots in dermal layers of lips, buccal mucosa, and perioral area; also on hands/feet and rarely on nose and mouth - Skin changes accompany many intest polyps - Autosomal dominant d/o - increased risk of GI and other cancers ranges from 40-90%

Herpes simplex (cold sore)

- Recurrent and painful vesicular eruptions of lips and surrounding skin - Small cluster of vesicles -> rupture -> yellow-brown crusts form; 10-14 days to heal

Pregnancy epulis (Pyogenic granuloma, pregnancy tumor)

- Red purple papules of granulation tissue form in interdental papillae & sometimes on fingers - Red, soft, painless and usually bleed easily - Occur in 1-5% of pregnancies and usually regress after delivery - Note: accompanying gingivitis

Exudative tonsillitis

- Red throat with white exudate on tonsils - Together with fever, enlarged cervical nodes = increased chance of group A streptococcal infection or infectious mononucleosis (mono -- Deirde)

Tori Mandibulares

- Rounded bony growths on inner surfaces of mandible - Typically bilateral, asymptomatic and harmless

Varicose veins on tongue

- Small purplish or blue-black round swellings appearing under tongue with age - No clinical significance

Petechiae buccal mucosa

- Small red spots caused by blood that escapes from capillaries into tissues - In buccal mucosa: caused by accidental cheek biting - In oral cavity: due to infection, decreased platelets, or trauma

Hutchinson's teeth in congenital syphilis

- Smaller and more widely spaced than normal and notched on biting surfaces - Sides of teeth taper down toward biting edges - Upper central incisors of permanent teet are most often affeted

Smooth tongue (Atrophic Glossitis)

- Smooth and often sore tongue that has lost its papillae suggests a deficiency in riboflavin, niacin, folic acid, vit B12, pyridoxine, iron or tx with chemotherapy

Angular chelitis

- Softening of skin at angles -> fissuring - Saliva wets and macerates infolded skin, leading to 2ndary infection with candida - Causes: nutritional deficiency, overclosure of mouth, and in those with no teeth or ill-fitting dentures

Septum (normal findings)

- The septum is highly vascular (pink and vascular when healthy)

Candidiasis

- Thick white coating from Candida infection (infection can occur without coating) - Can be scraped off, would see red raw surface underneath - Seen in immunosuppression from chem or prednisone therapy

Leukoplakia tobacco

- Thickened white patch anywhere in oral mucosa; benign reactive process of squamous epithelium may lead to cancer (need for biopsy) - Shown here: from tobacco chewing - Another risk factor: HPV infection

Carcinoma, floor of mouth

- Ulcerated lession is in a common location for carcinoma - Medially, note reddened area of mucosa (called erythroplakia) -- suspicious for malignancy

Chancre of primary syphilis

- Ulcerated papule with indurated edge appears 3-6 weeks post infection with spirochete Trep pallidum - On lip: may resemble carcinoma or crusted cold sore - Also common in pharynx, anus, vagina but may escape detection since are painless, nonsuppurative and heal spontaneously - Infectious! Wear gloves

Acute necrotizing ulcerative gingivitis

- Uncommon, occurs suddenly in adolescents and young adults accompanied by fever, malaise and enlarged lymph nodes - Ulcers develop in interdental papillae -> destructive process spreads along gum margins, where a grayish pseudomembrane forms - Red, painful gums bleed easily; foul breath

Leukoplakia oral mucosa

- Undersurface of tongue appears painted white with persisting painless white patch in oral mucosa - Raise possibility of squamous cell carcinoma and require biopsy

Squamous cell carcinoma of lip

- Usually affects lower lip (like act chelitis) - Can appear as scaly papule, ulcer with/without crust, or as a nodular lesion (illustrated here) - Risk factors: fair skin and prolonged exposure to sun

Hairy leukoplakia

- White, raised areas with a feathery corrugated pattern that cannot be removed (unlike candidiasis) - Most often affects sides of tongue - Seen in HIV and AIDS

Thrush on palate

- Yeast infection from Candida species - Thick, white plaques are adherent to underlying mucosa, can appear elsewhere on mouth - Predisposing factors: 1) prolonged tx with Abx or corticosteroids 2) AIDS

What is indicated when a patient experiences pain with movement of the auricle and tragus?

- acute otitis externa NOT otitis media

What does peripheral visual loss suggest?

- advanced open-angle glaucoma

6. Perforation of the TM

- after repeated infections - traums

Nasal polyps are pale saclike growths of inflamed tissue that obstruct the air passage or sinuses. What are some causes of this?

- allergic rhinitis -aspirin sensitivity - asthma - chronic sinus infection - cystic fibrosis

Taking a history of the NOSE

- blockage - discharge - sneezing - pain - changes in sense of smell - deformity

Cancer of the Tongue

- can be very subtle - why you need to palpate the tongue

What does gradual, bilateral visual loss suggest?

- cataracts - macular degeneration

Physical Examination of the EYE: Step 8 Observe the entire Conjunctiva and Sclera

- depress lower lid - spread upper and lower lid - have patient look in all directions - evert the upper lid

What does one-sided visual loss suggest?

- hemianopsia - quadrantic defects

When the thyroid gland is retrosternal, below the suprasternal notch, is is often not palpable. What symptoms are with seen retrosternal goiters?

- hoarseness - shortness of breath - stridor - dysphagia from tracheal compression - neck hyperextension and arm elevation may cause flushing form dilatation of the external jugular veins and obstruction of the thoracic inlet

4. Mastoiditis

- inflammation/infection behind the ear (of the process over the bone)

Abnormal Conjunctiva

- injected (bloodshot) or pale (anemia) - Chemosis - edema - Opacities - Lacerations - Subconjunctival hemorrhage

What can cause tracheal deviation?

- masses in the neck Thorax problems, such as: - mediastinal mass - atelectasis - large pneumothorax

What is indicated if a headache is episodic and peaks over several hours? If it is also new and persisting, getting progressively severe?

- migraine/tension headache - concern for tumor, abscess or mass lesion

What can be indicated is a headache is associated with nausea and vomiting?

- migraines - brain tumors - subarachnoid hemorrhage

What does slow central visual loss suggest?

- nuclear cataract - macular degeneration

"Red flags" for headaches (9):

- progressively frequent or severe over 3 month period - sudden onset like a "thunderclap" or "worse headache of my life," with maximal intensity over several minutes (70% of patients have subarachnoid hemorrhage) - new onset after 50 years of age - aggravated or relieved by change in position - precipitated by Valsalva maneuver - associated with fever, night sweats, or weight loss - presence of cancer, HIV infection, or pregnancy - recent head trauma - associated papilledema, neck stiffness, or focal neurologic deficits

What causes loss of mobility of the TM?

- serous effusion - thickened TM drum - purulent otitis media

What is indicated if a headache is severe with sudden onset (2)?

- subarachnoid hemorrhage - meningitis

History of the Eye (Review of Systems)

- visual acuity/blurred - vision/visual loss - last eye examination - pain - inflammation/redness - discharge - tearing or dryness (Dryness is a sign of a systemic issue) - visual difficulties - double vision - scotomata - floaters or flashers

What do moving specks or strands in the patient's vision suggest?

- vitreous floaters

What does painless, sudden, unilateral visual loss suggest?

- vitreous hemorrhage from diabetes or trauma - macular degeneration - retinal detachment - retinal vein occlusion - central retinal artery occlusion

Normal Sclera

- white (jaunidice = yellow) - no swelling - no injection (blood shot)

Transillumination of the Frontal Sinus (place light where, look for, absence of glow suggests)

-deep under each brow, close to the nose -look for dim red glow transmitted through air filled frontal sinus to FORHEAD -absence suggests a thickened mucosa or secretions in the frontal sinus, but may also result from developmental absence of one or both sinuses

Transillumination of the Maxillary Sinus (place light where, look for, absence of glow suggests)

-shine light downward from just below the inner aspect of each eye -look through the open mouth at the hard palate for reddish glow -absence of glow suggests thickened mucosa or secretions in the maxillary sinus

How to check for an APD (test name, steps, what occurs, also termed)

-swinging flashlight test; -1. light shines into normal right eye & there is brisk constriction of both pupils 2. light swings over to the abnormal left eye, partial dilation of both pupils will occur -the afferent stimulus on the left is reduced so the efferent signals to both pupils are also reduced and a net dilation occurs -afferent pupillary defect aka Marcus Gunn pupil, the most common pupillary abnormality

Left Homonymous Hemianopsia (right optic radiation)

A complete interruption of fibers in the optic radiation, produces a visual defect similar to that produced by a lesion of the optic tract.

Tophi

A deposit of uric acid crystals characteristic of chronic tophaceous gout. It appears as hard nodules in the helix or antihelix and may discharge chalky white crystals through the skin. It also may appear near the joints, hands

Kayser-Fleischer Ring.

A golden to red brown ring, sometimes shading to green or blue, from copper deposition in the periphery of the cornea found in Wilson's disease.

Open-Angle Glaucoma

A gradual loss of vision as a result of the loss of retinal ganglion in cell axons. There is initial loss of peripheral visual fields, and pallow and increasing size of teh optic cup. It is the leading cause of blindness in African Americans, and the second leading cause of blindness overall

Pinguecula

A harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. Appears frequently with aging, first on the nasal and then on the temporal side.

Bitemporal Hemianopsia (optic chiasm)

A lesion at the optic chiasm, may involve only fibers crossing over to the opposite side. Since these fibers originate in the nasal half of each retina, visual loss involves the temporal half of each field.

If the patient sticks out their tongue and it is not symmetrical, what does that indicate?

A lesion of CN XII (hypoglossal)

Blind Right Eye (right optic nerve)

A lesion of the optic nerve and, of course, of the eye itself, produces unilateral blindness

Left Homonymous Hemianopsia (right optic tract)

A lesion of the optic tract, interrupts fibers originating on the same side of both eyes. Visual loss in the eyes is, therefore, similar (homonymous) and involves half of each field (hemianopsia).

Episcleritis

A localized ocular inflammation of the episcleral vessels. Vessels appear movable over the scleral surface. May be nodular or show only redness and dilated vessels. Seen in rheumatoid arthritis, Sjögren's syndrome, and herpes zoster.

Nuclear cataract

A nuclear cataract looks gray when seen by a flashlight. If the pupil is widely dilated, the gray opacity is surrounded by a black rim.

Sty

A painful, tender, red infection in a gland at the margin of the eyelid.

Homonymous Left Superior Quadrantic Defect (right optic radiation, partial)

A partial lesion of the optic radiation in the temporal lobe, may involve only a portion of the nerve fibers, producing, for example, a homonymous quadrantic defect.

Physiologic Cup

A ring around the optic disc

Congenital hearing loss may be from ____.

A single gene mutation. p209

Chalazion

A subacute nontender, usually painless nodule involving a blocked meibomian gland. May become acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin.

Corneal Scar

A superficial grayish white opacity in the cornea, secondary to an old injury or to inflammation. Size and shape are variable. Do not confuse with the opaque lens of a cataract, visible on a deeper plane and only through the pupil.

Dacryocystitis

A swelling between the lower eyelid and nose. An acute inflammation (illustrated) is painful, red, and tender. Chronic inflammation is associated with obstruction of the nasolacrimal duct. Tearing is prominent, and pressure on the sac produces regurgitation of material through the puncta of the eyelids.

Corneal Arcus

A thin grayish white arc or circle not quite at the edge of the cornea. Accompanies normal aging but also seen in younger people, especially African Americans. In young people, suggests possible hyperlipoproteinemia. Usually benign.

Pterygium.

A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur. May interfere with vision as it encroaches on the pupil

Actinic Cheilitis

Actinic cheilitis results from excessive exposure to sunlight and affects primarily the lower lip. Fair-skinned men who work outdoors are most often affected. The lip loses its normal redness and may become scaly, somewhat thickened, and slightly everted. Because solar damage predisposes to carcinoma of the lip, examine such skin lesions carefull

What does the canal look like in a patient with acute otitis externa? Chronic otitis externa?

Acute - canal narrowed, swollen, moist, pale, and tender Chronic - skin of canal is thickened, red, and itchy

Acute Angle Closure Glaucoma (significance)

Acute increase in intraocular pressure constitutes an emergency

What is indicated with moderate, deep, and aching eye pain, with ciliary injection/diffusely red conjunctiva? Note, vision is decreased with photophobia. Pupils are small and irregular

Acute iritis

Soft wax, debris from inflammation or rash int he ear canal, or discharge through a perforated eardrum is present in _____.

Acute or chronic otitis media. p209

Local sinus tenderness with pain, fever, and nasal discharge suggests

Acute sinusitis

Valsalva maneuver may increase the pain from what?

Acute sinusitis of from a mass lesion due to changing intracranial pressure

What can be indicated if sneezing, coughing, and/or changing position affect headache?

Acute sinusitis or mass lesion due to changes in intracranial pressure - valsalva maneuvers may increase pain

Normal teeth (adult number, 1st molar at what age, 2nd molar at what age, 3rd molar at what age?)

Adult=32 teeth/16 in each jaw 1st molar=at 6 years old 2nd molar=at 12-years old 3rd molar=wisdom tooth)

Peripheral loss occurs in ____.

Advanced open-angle glaucoma p208

Presbyopia

Aging vision (impaired near vision)

Paranasal sinuses

Air-filled cavities within the bones of the skull; only frontal and maxillary sinuses are readily accessible to the examiner

Opening of the parotid duct

Aka Stenson's duct. On the buccal mucosa, near the upper second molar.

Nostril Bump is aka

Ala nasi

Nasal mucosa is pale, bluish, or red in

Allergic rhinitis

Condition that can have polyps

Allergic rhinitis Aspirin sensitivity Asthma Chronic sinus infections Cystic fibrosis

Causes of rhinorrhea

Allergic rhinitis Viral infection Vasomotor rhinitis Drug-induced rhinitis (use of decongestants or cocaine)

Medications that can affect hearing

Aminoglycosides Aspirin NSAIDs Quinine Furosemide

What medications may affect hearing?

Aminoglycosides, aspirin, NSAIDs, quinine and furosemide

7. Cholesteatoma

An abnormal sebaceous growth behind the TM, often caused by repeated infections, cysts. Can cause permanent hearing loss, dizziness, or facial paralysis. A buildup of tissue (skin tissue) that is built up behind the ear

Angioedema

Angioedema is a localized subcutaneous or submucosal swelling caused by leakage of intravascular fluid into interstitial tissue

fissuring at the angles of the mouth

Angular cheilitis

Where do light rays focus in a myopic patient? Do retinal structures look smaller or large than normal?

Anterior to the retina Larger than normal

What drugs contribute to epistaxis?

Anticoagulants, NSAIDs and coagulopathies

medication causes of epistaxis

Anticoagulants, NSAIDs, and coagulopathies

What to look for on skull during examination?

Any deformities, depressions, lumps or tenderness

Alveolar mucosa

Area below gingiva, but above labial mucosa

Testing the near reaction is helpful in diagnosing

Argyll Robertson and tonic (Adie's) pupils

Small, irregular pupils: if do not react to light

Argyll Robertson pupils; seen in CNS syphilis

Secondary Headaches

Arise from other conditions: withdrawal of medication, glaucoma, sinusitis, meningitis, subarachnoid hemorrhage, brain tumor, giant cell arteritis, post-concussion

Secondary headaches

Arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life threatening.

Identifying arteries and veins in the retina

Arteries are light red and 2/3 of the size of veins, with a light reflex that is bright in color. Veins are dark red, larger, and have little or no light reflex.

Retinal arteries vs retinal veins

Arteries= smaller (2/3-3/4 the diameter of veins), light red, bright light reflex Veins= larger, dark red, inconspicuous or absent

Taking a history of the EAR

Ask even if they aren't coming in with a CC of ear pain - itch - pain - discharge - deafness - tinnitus - dizziness Also ask about ototoxic drugs (gentamycin, diuretics), trauma, barotrauma, systemic disease such as multiple sclerosis, prior ear surgery

Lid Lag

Associated with hyperthyroidism. Normally, as the eyes move up and down, the lid should follow, slightly overlapping the iris throughout the movement. If you see the sclera above the iris, it means the lid is lagging.

Acute Iritis (Significance)

Associated with systemic infection, Herpes zoster, tuberculosis; refer promptly

What to look for on face during examination?

Asymmetry, involuntary movements, edema and masses

Tonsillar lymph nodes

At angle of mandible. Infections of mouth, pharynx, larynx, thyroid, trachea, and tonsils would drain here

Opening of the submandibular gland ducts

At the base of the tongue, one on each side of the frenulum.

Vision of 20/200 means...

At twenty feet, the patient can read print that a person with normal vision could read at 200 ft (larger second number = worse vision)

What suggests central neurologic causes in the cerebellum or brainstem? (Ex: cerebral vascular disease or posture loss tumor and migraine )

Ataxia, diplopia and dysarthria

A 26 y/o female presents to your office with a c/o sore throat, fever, severe fatigue and anorexia for the past week. She reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend experienced similar symptoms recently. Which of the following is the best differential diagnosis?

B) Infectious mononucleosis, hepatitis, acute pharyngitis, acute HIV infection, secondary syphilis

Conjunctivitis (Significance)

Bacterial, viral, and other infections; highly contagious; allergy; irritation

Submental lymph nodes

Behind tip of mandible. Infections from the mouth or lower lip drain here

Why might one eye blink at a different rate than the other?

Bells Palsy

Black Hairy Tongue

Benign condition Caused by ingestions of things, smoking, pepto bismol

Where are tonsils located

Between the anterior and posterior pillars. May or may not be visible in adults.

What can be indicated with bilateral proptosis (abnormal protrusion of the eyeballs)? Unilateral proptosis?

Bilateral - hyperthyroidism Unilateral - orbital tumor, retrobulbar hemorrhage

What is indicated with bilateral diplopia? Unilateral diplopia?

Bilateral diplopia - lesions in the brainstem or cerebellum - paralysis of one or more EOMs - horizontal diplopia (palsy of CN III or VI - vertical diplopia (palsy of CN III or IV Unilateral diplopia - problem in the cornea or lens

Types of Hemianopsia

Bitemporal hemianopsia- they can see the middle, ie right eye sees on its left side and left eye sees on its right side. Homonymous Hemianopsia- both eyes are missing either the left side of the visual field or the right side of the visual field.

Red inflamed lid margins, often with crusting:

Blepharitis

Central Retinal Vein Occlusion

Blood and Thunder

Upper third of nose

Bone

Hard palate

Bony front part of the roof of the mouth

Myopia and hyperopia

Both are refractive errors. In myopia, the light rays focus anterior to the retina. This causes nearsightedness In hyperopia, they focus on a point posterior to the retina, causing farsightedness.

Convergence and Accomodation

Both parts of shifting the gaze to a near object. Accommodation is a change in the shape of the lens and cannot be observed. Convergence is an EOM.

Lead Poisoning

Burton line; Very thin, black-blue line visible along the margin of the gums, at the base of the teeth

1/3 of patients with migraine experience

a visual aura, such as spark photopsias (flashes of light), fortifications (zig-zag arcs of light), and scotoma (area of visual loss with surrounding normal vision)

A 30 y/o male comes to your office c/o "night sweats " x 1 month. He smokes a pack of cigarettes a day, when he can get them. After some time he admits to associated symptoms of cough and swollen glands. Which of the following choices most accurately reflects a differential diagnosis for this patient?

C) Tuberculosis, Acute HIV infection, Lymphoma, Leukemia

A 35 yof presents with intermittent episodes of vertigo, tinnitus, nausea and hearing loss within the past week. DiDx?

C) Vestibular neuronitis, labyrinthitis, benign positional vertigo, Meniere's disease, Acoustic neuroma

Primary headaches include...

Caused by problems of overactivity of pain-sensitive structures in your head. Examples include: migraine, tension, cluster, chronic daily headaches

Sudden unilateral loss that is PAINFUL suggests which 7 conditions.

Causes are usually in the cornea and anterior chamber as in: 1. Corneal ulcer 2. Uveitis 3. Traumatic hyphema 4. Acute glaucoma 5. Optic neuritis from MS may also be painful. Requires immediate referral. p208

Painful bilateral vision loss

Chemical or radiation exposure

What does sudden, bilateral and painful visual loss suggest?

Chemical or radiation exposure

Sudden bilateral visual loss with pain suggests?

Chemical or radiation exposures

Sudden bilateral + PAINFUL visual loss may be due to ____.

Chemical or radiation exposures. p208

chronic inflammatory lesion that starts as a painful papule on the helix or antihelix

Chondrodermatitis helicis:

Skin of ear canal is thickened, red, and itchy in addition to being swollen

Chronic Otis Externa

Parotid Gland Enlargement

Chronic bilateral asymptomatic parotid gland enlargement may be associated with obesity, diabetes, cirrhosis, and other conditions. Note the swellings anterior to the ear lobes and above the angles of the jaw. Gradual unilateral enlargement suggests neoplasm. Acute enlargement is seen in mumps.

Aqueous Humor and Cataract formaiton

Ciliary body produces Aqueous Humor (AH) AH travels from the posterior chamber to the Anterior Chamber and drains through the Canal of Schlemm. If the Canal of Schlemm is blocked then pressure builds and the LENS is pushed forward.

Corneal Injury or Infection/acute iritis/ acute angle closure glaucoma (pattern of redness)

Ciliary injection: dilation of deeper vessels that are visible as radiating vessels or a reddish violet flush aroundthe limbus. Ciliary injection is an important sign of these three conditions but may not be apparent. The eye may be diffusely red instead. Other clues of these more serious disorders are pain, decreased vision, unequal pupils, and a clouded cornea.

Herpes Simplex Lesion

Classic is a vesicular lesion Very painful

Define conjunctiva and its two components:

Clear mucous membrane: - Bulbar conjunctiva: covers most of the anterior eyeball, adhering loosely to the underlying tissue and meets cornea at the limbus - Palpebral conjunctiva: lines the eyelids

Acute Iritis (cornea)

Clear or slightly clouded; injection confined to corneal limbus

Optic Atrophy (Appearance)

Color white Tiny disc vessels absent Seen in optic neuritis, multiple sclerosis, temporal arteritis

Normal Eye

Color yellowish orange to creamy pink Disc vessels tiny Disc margins sharp (except perhaps nasally) The physiologic cup is located centrally or somewhat temporally. It may be conspicuous or absent. Its diameter from side to side is usually less than half that of the disc.

What to look for on the skin during examination?

Color, pigmentation, texture thickness, hair distribution, lesions, hair loss

Deviation of lower septum

Common and may be easily visible; seldom obstructs air flow

Tongue Cancer

Common in men older than 50, smokers, tobacco chewers, and alcohol drinkers Usually appears on the side or base of the tongue

Rinne Test

Compare air conduction (AC) and bone conduction (BC). - Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Here the "U" of the fork should face forward, thus maximizing its sound for the patient.

Hearing loss that improves in noisy environments suggests ________ loss

Conductive

BC= AC or BC>AC

Conductive hearing loss

What kind of hearing loss is present in a patient that is helped with noisy environments?

Conductive hearing loss - this results from problems in the inner ear, cochlear nerve, or its central connections in the brain

Contrast conductive vs sensorineural hearing loss.

Conductive: -External/middle ear -Noisy environments may help Sensorineural -Inner ear -Particular trouble understanding speech, often complaining that others mumble -Noisy environments make hearing worse p209

Excessive tearing from increased production of tears seen in:

Conjunctival inflammation, corneal irritation

Conjunctivitis (Pattern of Redness)

Conjunctival injection: diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally

What does conjunctival injection, discomfort, and watery, mucoid, or mucopurulent discharge suggest?

Conjunctivitis

Lingual Frennulum

Connects the tongue to the floor of the mouth

What is miosis?

Constriction of the pupil

Miosis

Constriction of the puplis

Diplopia in one eye with the other eye closed suggests...

Cornea/lens issue

What is a Corneal Scar and how does it differ from a Cataract?

Corneal Scar: A superficial grayish white opacity in the CORNEA, secondary to an old injury or to inflammation. Size and shape are variable. Do not confuse with the opaque LENS of a cataract, visible on a deeper plane and only through the PUPIL.

What is indicated with moderate to severe, superficial eye pain, with ciliary injection/diffusely red conjunctiva? Note, vision is usually decreased.

Corneal injury of infection

Painful unilateral vision loss

Corneal ulcer Uveitis Traumatic hyphema Acute glaucoma Optic neuritis

Soft Exudates: Cotton-Wool Patches

Cotton-wool patches are white or grayish, ovoid lesions with irregular "soft" borders. They are moderate in size but usually smaller than the disc. They result from infarcted nerve fibers. Seen in hypertension and many other conditions.

Tongue

Covered in papillae; under surface has none

Chelitis

Cracking redness on the side of the lips Most caused by dryness or sun exposure, also iron deficiency, nutrient deficiency, allergy, infection

Turbinates

Curving bony structures, covered by vascular mucous membrane; provide cleansing, humidification, and temperature control of inspired air

Dome-shaped lump forms a benign closed firm sac

Cutaneous cyst, sebacous cyst, epidermoid cyst of face or neck, pilar cyst on the scalpA

an unusually prominent short process of the malleus, and a prominent handle that looks more horizontal suggests

a retracted eardrum

Diplopia in one eye, with the other eye closed, suggests

a problem in the cornea or lens

ropy discharge is seen in what type of conjunctivitis

allergic

Seasonal onset of environmental triggers

allergic rhinitis

what conditions could indicate nasal polyps

allergic rhinitis ASA sensitivity asthma chronic sinus infections cystic fibrosis

Conditions conducive to nasal polyps include

allergic rhinitis, ASA sensitivity, asthma, chronic sinus infections, and cystic fibrosis

nasal polyp causes

allergic rhinitis, ASA sensitivity, asthma, chronic sinus infections, cystic fibrosis

Nasal polyps come from:

allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis

Conditions that cause nasal polyps

allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, cystic fibrosis.

in conductive losses, bone conduction exceeds _____

air conduction

Stensen's duct

aka parotid duct opens onto the buccal mucosa near the upper second molar

Tropias

always there! (manifest)

Macular degeneration (what type of vision occurs, describe types)

an important cause of poor central vision in older adults; dry atrophic (more common but less severe) and wet exudative (or neovascular)

Discharge of mucopurulent fluid from the puncta suggests

an obstructed nasolacrimal duct

absence of the red reflex suggests

an opacity of the lens (cataract) possibly the vitreous

Absence of a red reflex suggests

an opacity of the lens (cataract) or possibly of the vitreous, less commonly a detached retina or in children a retinoblastoma

What ear exam finding suggests a retracted ear drum?

an unusually prominent short process and a prominent handle that looks more horizontal

headache causing meds (overuse)

analgesics, ergotamin, triptans; consider medicaiton overuse in patiens with chronic daily headache taking symptomatic medications more than 2 days per week

Medication for overuse headache is indicated if

analgesics/ergotamines/triptans present >/= 15 days a month for three months and reverts to </= 15 days a month when the medication is discontinued

Review a few abnormalities of the oral mucosa

aphthous ulcer, gingivitus, black line of lead poisoning, erythroplakia and leukoplakia (persistent nodule or ulcer, red or white, especially if indurated SHOULD BE BIOPSIED)

sore tongue

apthous ulcers, nutritional deficiency; sore tongue may result from local lesions or systemic illness

earache questions

associated URI, discharge

"Raw Beef" Tongue

associated with B-12 deficiency

Hypoglossal Nerve Paresis (CN XII)

asymmetric

tonsillar nodes

at angle of mandible

Primary Headache-Tension

bilateral, can be generalized to the back of the head and upper neck or to the frontotemporal area; no nausea but sometimes photo/phono; 30 min to 7 days. pain can decrease but is omnipresent when having an episode.

enlarged blind spot occurs in ...

conditions affecting optic nerve such as glaucoma, optic neuritis, papilledema

An enlarged blind spot occurs in

conditions affecting the optic nerve such as glaucoma, optic neuritis, and papilledema

Rinne test=(BC=AC or BC>AC)

conductive hearing loss

noisy environments may help hearing with

conductive hearing loss

the bone-anchored hearing aid should be ipsilateral for

conductive loss

middle ear HL causes

congenital conditions, benign cholesteatomas, otosclerosis, tumors, TM perforation

Middle Ear Hearing Loss Causes

congenital conductions, benign cholesteatomas, otosclerosis, tumors, perforated TM

risk factors of hearing loss

congenital/familial hearing loss, syphilis, rubella, meningitis, hazardous noise exposure

inner ear HL causes

congenital/hereditary conditions, presbycusis, viral infections (rubella/cytomegalovirus), minieres disease, noise exposure, acoustic neuroma

red eyes

conjunctivitis, subconjunctival hemorrhage, corneal injury or infection, acute iritis, acute angle closure glaucoma

labial frenulum

connects each lip

miosis

constriciton of the pupils

miosis

constriction of pupils

miosis is

constriction of the pupil

chronic glaucoma suggests

contraction of field

thin grayish circle around cornea

corneal arcus

what is another cause of haloes

corneal edema

superficial opacity in the cornea from old injury

corneal scar

painful vision loss suggest

corneal ulcer uveitis traumatic hyphema acute glaucoma

5 Possible causes of unilateral vision loss (painful)

corneal ulcer, uveitis, hyphema, acute glaucoma, optic neuritis

If sudden unilateral vision loss is painFUL, consider

corneal ulcer, uveitis, traumatic hyphema, acute glaucoma

Symptoms of HTN

cotton wool spots, AV nicking, hard exudates

What are vassal maneuvers and how are they related to headaches?

coughing, sneezing may increase the pain from acute sinusitis or from mass lesion due to changing intracranial pressure

Hard Exudates

creamy or yellowish, often bright, lesions with well-defined "hard" borders. They are small and round but may coalesce into larger irregular spots. They often occur in clusters or in circular, linear, or star-shaped patterns. Causes include diabetes and hypertension.

iris bows forward, forming a very narrow angle with the cornea- shining light cast a:

crescentic shadow

The ear canal in the adult

curves inward and is approximately 24mm long

Moon face with red cheeks

cushing syndrome

flashing lights or new vitreous floaters suggest

detachment of vitreous from retina

Flashing lights or new vitreous floaters suggest

detachment of vitreous from retina and require prompt eye consultation

flashing lights or new vitreous floaters in vision

detatchment of vitreous from retina; prompt eye consultation is indicated

Pneumatic mobility

determines mobility of TM moves in response to pressure

one sided nasal congestion suggests

deviated nasal septum nasal polyp FB granuloma carcinoma

Is the nasal congestion only on one side? Consider..

deviated nasal septum, nasal polyp, foreign body, granuloma (Wegener's), or carcinoma

unilateral congestion pathology

deviated septum, nasal polyps, FB, granuloma, carcinoma

nasal congestion on one side

deviated septum, tumor, foreign body

the TM separates what

external ear from the middle ear

conductive phase of hearing pathway

external to middle ear, air and bone conduction (air is more sensitive)

Conductive hearing loss is due to problems in the ________ or ___________ ear

external, middle

a crescent shadow is indicative of

narrow angle glaucoma as

pale save like growths of inflamed tissue that can obstruct the air passage or sinuses

nasal polyps

the ET joins the middle ear with the

nasopharynx

exostoses

non-malignant overgrowths in ear canal, may obscure TM

Acute Iritis (ocular discharge)

none

exostoses

nonmalignant overgrowths in ear canal; may obscure eardrum

Exostoses

nontender nodular swellings covered by normal skin deep in the ear canal. these are nonmalignant overgrowths which may obscure the drum.

Exostoses

nontender nodular swellings covered by normal skin deep in the ear canals; nonmalignant overgrowths which may obscure the drum

Fordyce Spots (Fordyce Granules)

normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or on the lips.

Epistaxis is bleeding from the ___________

nose

Subconjunctival Hemorrhage (pupil)

not affected

Subconjunctival Hemorrhage (vision)

not affected

Corneal Injury or Infection (pupil)

not affected unless iritis develops

Physical Examination of the EYE: Step 5 Observe the Eyebrows

note quantity and distribution and any scaliness of underlying skin

tongue symmetry test what CN?

hypoglossal nerve CN XII

Sympathetic pathway for pupil dilation

hypothalamus--> brain stem--> cervical cord--> neck--> follows carotid artery--> branches into orbit

coarse hair accompanies

hypothyroidism

lateral sparseness of eyebrows indicates

hypothyroidism

if hoarseness lasts more than 2 weeks suggests

hypothyroidism reflux vocal cord nodules head and neck CA neuro disorder

hoarseness over 2 weeks pathology

hypothyroidism, GERD, vocal code nodules, head/neck ca, neurologic disorders (refer to laryngoscopy)

Myxedema Facies

hypothyroidism, dull puffy facies. edema is pronounced around the eyes, and does not put with pressure. hair and eyebrows are coarse, dry, and thinned.

Extraocular muscles associated with CN VI

lateral rectus (lateral middle)

hypertensive retinopathy

marked arteriolar-venous corssing changes are seen, especially along the inferior vessels. copper wiring of the arterioles is present. a cotton-wool spot is seen just superior to the disc. incidental disc drusen are also present but are unrelated to hypertension

normal fundus of a dark-skinned person

ring around the fovea has a normal light relfectoin. color of the funus is a grayish brown almost purplish cast which comes from pigment in the retina and the choroid that char obscures the choroidal vessels; no tessellation is visible

in CN X paralysis the soft palate fails to

rise and the uvula deviates to the opposite side

During an ophthalmic fundus exam if you or the patient is hyperopic then

rotate the lens disc clockwise to the plus diopters

During an ophthalmic fundus exam if you or the patient is myopic then

rotate the lens disc counterclockwise to the minus diopters

Lymph nodes are normally

round or ovoid and smooth, small, mobile, discrete, nontender

hearing loss questions

one or both ears, sudden/gradual, associated vertigo/earache, conductive vs sensorineural, meds, loud noise exposure

Cataract

one pupil is white/milky *ONLY THE PUPIL*

What is a thunderclap headache?

one with sudden onset occur in 70% of patients with subarachnoid hemorrhage

teeth

only enamel crown exposed, BV and nerves pass through

kayser-fleischer ring

opacities of the cornea and lens: a golden to brown ring sometimes shading to a green or blue from copper deposition in the periphery of the cornea found in wilson's disease. due to a rare autosomal recessive mutation of the ATO7B gene on chrom 13 causing abnormal copper transport, reduced biliary copper excretion, and abnormal accumulation of copper in the liver and tissues throughout the body. patients present with liver disease, renal failure, and neurological symptoms of tremor, dystonia, and psychiatric disorders ranging from behavior changes to depression and schizophrenia

corneal scar

opacities of the cornea and lens: a superficial grayish white opacity in the cornea seconadary to an old injury to an old injury or inflammation. size and shape are variable. do not confuse with the opaque lens of a cataract visible on a deeper plane and only through the pupil

corneal arcus

opacities of the cornea and lens: a thin grayish white arc or circle not quite at the edge of the cornea. accompanies normal aging but also seen in younger people, especially Af Am. in young people suggests possible hyperlipoproteinemia. usually benign

pterygium

opacities of the cornea and lens: a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea usually from the nasal side. reddening may occur. may interfere with vision as it encroaches on the pupil

cataracts

opacities of the cornea and lens: opacities of the lenses visible through the pupil. risk factor are older age, smoking, diabetes, and corticosteroid use nuclear cataract: looks gray when seen by a flashlight. of the pupil is widely dilated the gray opacity is surrounded by a black rim

peripheral contact

opacities of the cornea and lens: produces spokelike shadows that point-gray against black, as seen with a flashlight, or black against red with an ophthalmoscope. a dilated pupil shown her facilitated this observation

Corneal Ulcer

open sore in cornea outer layer caused by infection

palpebral fissure

opening between teh eyelids

death of optic nerve fibers leads to loss of tiny disc vessels

optic atrophy

defect in both eyes suggests

optic chiasm or tract damage

Defect in one eye suggests

optic nerve or retina damage

central defect in eyes suggests

optic neuritis or macula damage

Drugs that may induce nasal stuffiness

oral contraceptives, reserpine, guanethidine, alcohol, cocaine

drugs that might cause stuffiness

oral contraceptives, respirine, guanethidine, and alcohol

Unilateral Proptosis

orbital tumor or retrobulbar hemorrhage

Unilateral Protrusion of the eyeballs

orbital tumor or retrobulbar hemorrhage (from trauma)

what transmits sound impulses to CNVIII

organ of corti

Pain occurs in the external canal in what type of ear infection

otitis externa

pain in external ear suggests ______ _______

otitis externa

Movement of the auricle and tragus (the 'tug test') is painful in what type of ear infection

otitis externa (inflammation of the ear canal) but not in otitis media (inflammation of the middle ear)

Pain in ear

otitis externa, or otitis media if associated with upper respiratory infection; other otitis media symptoms: soft wax, inflammation debris, discharge through eardrum

Tenderness behind the ear may be present in

otitis media

What is indicated when a patient experiences pain with palpation of the mastoid process and generally behind the ear?

otitis media

pain in inner ear suggests ________ ________

otitis media

Respiratory infections are associated with what type of ear infection

otitis media (it may also be referred from other structures in the mouth, throat, or neck)

what are some reasons for CHL

otosclerosis OM TM perf cerumen

Unilateral Conductive Hearing Loss Reasoning

otosclerosis otitis media, perforation of eardrum, cerumen.

what is the limbus

outer edge of iris

most likely causes of sudden hoarseness

overuse of voice and acute infections

Otitis Media

pain in the inner and external ear accompanied by respiratory infections. Pain may also be referred from the mouth, throat, or neck. Unusually soft wax, debris from inflammation, or discharge through a perforated eardrum is present.

Otitis Externa

pain occurs in the external ear canal; pain can also be referred from other structures in the mouth, throat, or neck

bullous myringitis

painful hemorrhagic vesicles appear on the tympanic membrane, the ear canal, or both. earache, blood-tinged discharge from the ear and conductive hearing loss. caused by mycoplasma, viral, and bacterial otitis media

Nasal polyps are

pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses

in allergic rhinitis the mucosa is

pale, bluish or red

allergic rhinitis sxs

pale, bluish, red mucosa

description of nasal polyps

pale, semitranslucent masses that usually come from the middle meatus. ulcers may result from cocaine

gingiva normal color

pale/coral in lighter skin, diffuse/brown in darker skin

The opening between the eyelids is called the

palpebral fissure

hypothyroidism sxs

palpitations, involuntary weight loss, temperature intolerance

Eyes conjugate in right lateral gaze but not in left lateral gaze

paralysis of CN VI

decreased facial mobility, mask like appearance

parkinson's disease

Swelling in from of the ear lobe and above the angles of the jaw

parotid gland enlargement, acute enlargement seen in mumps

Homonymous left Superior Quadrantic Defect

partial lesion of optic radiation in the temporal lobe, may involve only a portion of nerve fibers.

sensorineural hearing loss

particular trouble understanding speech, often complaining that others mumble; noisy environments make hearing worse

who should be routinely screened for hearing

past hx of noise exposure 65+

static finger wiggle test

patient looks into your eyes

Groups at risk for impaired hearing

patients with a history of congenital or familial hearing loss, syphilis, rubella, meningitis, or exposure to hazardous noise levels at work or on the battlefield

Noisy environments may help these patients hear better

patients with conductive hearing loss

These patients have particular trouble understanding speech, often complaining that others mumble, noisy environments make hearing worse

patients with sensorineural loss

Physical Examination of the EAR (photo)

perform otoscopy Proper technique: gently pull the auricle up and back - while holding the otoscope, slowly insert the speculum with a downward and forward movement into the ear canal REPEAT IN OPPOSITE EAR EXTERNAL CANAL: look for cerumen (wax) build up or fluid in the canal TM: should be pink; see handle of malleus umbo and the cone of light; fluid is normal MOBILITY: - valsalva -pneumatic

if the whispered voice test for auditory acuity shows the following results: Four of the six possible numbers and letters are incorrect.... What do you do?

perform the Weber & Rinne tests Bates says to conduct further testing by audiometry. (Weber and Rinne tests are less accurate and precise.) p.237

smoke-like shadows that point with very dilate pupil

peripheral contact

enlarged tender lymph nodes go with

pharyngitis

Soft lumps on the scalp may indicate

pilar cysts (wens)

soft lumps on head

pilar cysts (wens) pigmented nevi

soft lump on scalp pathology

pilar cysts, pigmented nevi

3. Furunculosis

pimple of pus

harmless yellow triangular nodule that appears with aging

pinguecula

hirsutism in women

polycystic ovary disease

audible tinnitus

popping of TMJ or vascular noises from neck

bulbar

portion of conjunctiva reflected onto eyeball

enlargement of a supraclavicular node, especially on the left

possible metastasis from a thoracic or abdominal malignancy

enlargement of supraclavicular nodes, especially on left suggests

possible metastasis from a thoracic or an abdominal malignancy

retroorbital headache

possibly cluster headache

Lymph node superficial to the mastoid process

posterior auricular

occipital nodes

posterior base of skull

Lymph node along the anterior edge of the trapezius

posterior cervical

which chamber contains the vitreous humor

posterior chamber

where do light rays focus in hyperopia

posterior to the retina

lightheadedness, leg weakness, fainting pathology

pre-syncope from arrhythmia, orthostatic hypotension, vasovagal stimulation

Lymph node in front of ear

preauricular

red purple papules form in gingival interdental papillae

pregnancy tumor

Inner Ear Hearing Loss Causes

presbycusis, viral infections, Menieres disease, noise exposure, acoustic neuroma

aging vision or old mans vision

presbyopia

the nasopharynx allows for

pressure to equalize between the middle ear and throat

What is the difference between a primary and secondary headache?

primary = migraine, cluster, tension or chronic daily headaches secondary = arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life threatening

2 headache types

primary and secondary

gradual loss of vision as a result of the loss fo retina ganglion cell axons, initial loss of eripheral visual fields, and pallor and increasing size of optic cup which enlarges to more than havlf the diameter of the optic disc. What is this condition?

primary open-angle glaucoma; other risk factors include over 65 yrs, family history, African American descent, diabetes, myopia, and ocular hypertension

diplopia in one with the other closed suggests

problem in the cornea or lens

Diplopiain one eye with other closed

problem with cornea or lens

Diplopia in one eye with other closed

problem with cornea or lens -------------shingles can distort the cornea

likely vertigo causes

problem with labyrinth, lesions on CN VIII, central pathway lesions, brain nuclei

Conductive hearing loss results from

problems in the external or middle ear

Sensorineural hearing loss results from

problems in the inner ear, the cochlear nerve, or its central connections in the brain

migranes are often preceded by

prodrome headaches; sometimes pt. has aura with photophobia, scintillating scotomata, or reversible visual and sensory symptoms

headache red flags

progressive sxs, severe over 3 months, "thunderclap", new onset >50 yrs, aggravated/relieves with position change, precipitated with valsalva maneuver, associated fever/night sweats/weight loss, hx of cancer/HIV/preg, associated papilledema/neck stiffness/focal neuro deficits

retracted drum description

prominant short process looks horizontal

triangular of bulbar conjunctiva that grows across the outer surface of the cornea

pterygium

drooping of eyelid

ptosis

with young kids what do you do with the auricle on exam

pull it down and back

retracted drum

pulled medially away from the examiner's eye and the malleolar folds are tightened into sharp outlines. short proccess protrudes sharply and the handle of the malleus, pulled inward toward the umbo, loks foreshortened and horizontal

hypertensive retinopathy with macular star

punctate exudates are readily visible, some are scattered, others radiate from the fovea to the macular star. note the two small, soft exudates, about 1 disc diameter from the disc. find te flame shaped hemorrhages sweeping toward 7:00 and 8:00. these two fundi show changes typical of accelerated (malignant) hypertension and are often accompanied by papilledema

Miosis

pupil constriction

what is miosis

pupil constriction

what is mydrasis

pupil dilation

tonic pupil (adie's pupil)

pupil is large, regular and usually unilateral. reaction to light is severely reduced and slowed or even absent. near reaction, although very slow, is present. slow accomodation causes blurred vision. deep tendon reflexes are often decreased- causes anisocoria. in this is a large pupil and normal size. NO PTOSIS

anisoocoria

pupillary inequality of the less than 0.5 mm; considered benign if pupillary reactions are normal

anisocoria

pupillary size difference

what tone test is done for both air and bone conduction

pure tone

Acute Angle Closure Glaucoma (Pain)

severe, aching, deep

most important attribute for headache

severity and chronologic pattern

Trigeminal Neuralgia

sharp pain in the face because of the trigeminal nerve. even mild stimulation to the face can cause severe pain.

Test for a crescentic shadow

shine light at the side of the iris and look for a crescent shaped shadow on the other side, indicating that the iris is bowing out abnormally- think narrow angle glaucoma.

Floor of the nose (normal findings)

should be erythematous - note its color and any swelling, bleeding or exudate - note if clear mucopurulent-containg pus and mcus or purulent-yellow or yellow- brown

During otoscopic examination, what should you see?

should see the tympanic membrane should be pink color if red and inflammed or look like fluid behind it =bad should see the jumbo the cone of light the nadle of malleus and the lateral process of malleus posterior fold of the malleus and anterior fold

causes of chronic hoarseness

smoking, allergy, voice abuse, hypothyroidism, chornic infections such as TB, and tumors

thyroid gland pathology

soft - graves disease hard - hashimotos thyroiditis, malignancy

CN x paralysis sxs

soft palate fails to rise, uvula deviates to opposite end

Phoria

sometimes there (latent) 4 types: 1. esophoria 2. exophoria 3. hypotropia 4. hypertropia

unilateral SNHL with weber test

sound heard in good ear

unilateral CHL with weber test

sound heard in impaired ear

rinne test normal results

sound heard longer through air connection than bone connection

posterior pathway defects

stroke, chiasmal tumors

painful infection in the gland at the margin of the eyelid

sty

If a headache is sever and of sudden onset, consider ______ or ______.

subarachnoid hemorrhage meningitis

Headaches severe and sudden onset, consider

subarachnoid hemorrhage or meningitis

If headache is severe and of sudden onset, consider

subarachnoid hemorrhage or meningitis

Severe and sudden onset of headache

subaradchnoid hemorrhage or meningitis

Lymph node midway between the angle and the tip of the mandible; these nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie

submandibular

Lymph node in the midline a few centimeters behind the tip of the mandible

submental

Benign Positional Vertigo

sudden onset after rolling onto affected side, lasts less than a minute. no loss of hearing or tinnitus. sometimes there is nausea, vomiting, nystagmus

Attributes of subarachnoid hemorrhage (SAH)

sudden, thunderclap onset, with worst pain of their life. preceded by sentinel leaks (sudden or focal pain that may be severe). Can also be associated with nausea and vomiting.

absence of red reflex

suggests an opacity of the lens (cataract) or possibly of the vitreous, detached retina or retinoblastoma (children)

parotid glands

superficial and behind mandible, openings visible within oral cavity

Lymph node superficial to the sternomastoid

superficial cervical

superficial cervical nodes

superficial to SCM

posterior auricular nodes

superficial to mastoid process

what is the pars flaccida

superior aspect of the TM

Lymph node deep in the angle formed by the clavicle and the sternomastoid

supraclavicular

Secondary Headache- Errors of Refraction

sustained contraction of EOMs, occurs around and over eyes, could also be in occipital area. steady, aching pain, sandy sensation of eyes, red conjunctiva, occurs after long use of eyes resting helps

what is chemosis

swelling of the bulbar conjunctiva

Papilledema

swelling of the optic disc and anterior bulging of the physiologic cup. Indicative of: intracranial mass, lesion, hemorrhage, meningitis

papilledema

swelling of the optic disc and anterior bulging of the physiologic cup; often signals serious brain d/o (meningitis, subarach. Hemorrhage, trauma, mass lesions)

Papilledema describes

swelling of the optic disc and anterior bulging of the physiologic cup; often signals serious disorders of the brain such as meningitis, subarachnoid hemorrhage, trauma, mass lesions

rise in soft palate when saying "ah"

test for Cranial Nerve X; in CN X paralysis, the soft palate fails to rise and the uvula deviates to opposite side

Physical examination of the NOSE step 2

test potency bilaterally - ask the patient to inhale through each nostril separately while the opposite nostril is help shut

Testing for Near Reaction

testing accommodation hold something about 10cm from their eyes- have patient look off in the distance and then look at the object ** FAR AWAY: pupils should DILATE **BRING CLOSER: pupils should CONSTRUCT when looking at near object (this is mediated by the oculomotor nerve CNIII) Observing one eye at a time is helpful

Weber Test

tests for lateralization; in conductive sound is lateralized to bad ear, in sensorineural sound is lateralized to the good ear. Sensitivity is 55%, specificity is 79 for SN and 92 for Conduction.

The thyroid isthmus usually overlies

the 2nd, 3rd, and 4th tracheal rings

The thyroid isthmus spans

the 2nd, 3rd, and 4th tracheal rings just below the cricoid cartilage

the middle ear is internal to

the TM

looks gray with a flashlight and the pupil is very dilated

nuclear cataract

Slow central vision loss occurs in

nuclear cataract and macular degeneration

slow central vision loss

nuclear cataract, macular degeneration

slow central visual loss

nuclear cataract, macular degeneration

Sore smooth tongue

nutritional deficiency

Causes of angular cheilitis

nutritional deficiency or over closure of mouth in people with no teeth

the eyes are normal looking to the right, but not when looking to the left

o In paralysis of CN 6

Physical Examination of the Oropharynx step 13

observe breath odors

Physical Examination of the Oropharynx step 14

observe the voice - hoarseness - nasal quality - stridor

Lymph node at the base of the skull posteriorly

occipital

Horizontal Defect in the Eye

occlusion of a branch of the central retinal artery may cause this. ischemia of optic nerve can produce this as well.

Acoustic Neuroma

occurs from CN VIII. one side hearing is affected and tinnitus may be present.

Secondary Headache-Analgesic rebound

occurs from withdrawal of meds, can be very variable. location and severity varies.

can't see out of a certain quarter of the eye

quadrantic defects

Thunderclap headaches

reach maximal intensity over several minutes, occur in 70% of patients with subarachnoid hemorrhage, and are often preceded by a sentinel leak headache from a vascular leak into the subarachnoid space

AOM ear description

red bulging drum

What does acute purulent otitis media look like?

red bulging drum; amber drum of a serous effusion

in viral rhinitis the mucosa is

reddened and swollen

nasal mucosa coloration

reddened and swollen in viral rhinitis; pale, bluish, or red in allergic rhinitis

viral rhinitis sxs

reddened swollen mucosa

If hoarseness lasts more than 2 weeks..

refer for laryngoscopy and consider causes such as hypothyroidism, reflux, vocal cord nodules, head and neck cancers, and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis

Hoarseness that lasts more than 2 weeks

refer for laryngoscopy and consider hypothyroidism, reflux, vocal cord nodules, head and neck cancers, neurological disorders (Parkinson's, amyotrophic lateral sclerosis, MG).

when the light rays from a distance do not focus on the retina

refractive error

what is the most common cause of blurred vision

refractive errors

Squamous Cell Carcinoma

often on the top of the ear

nodular episcleritis

often self limiting in younger adults; also seen in RA and SLE

Glaucoma Risk Factors

older than 65 y/o, family history, African American descent, diabetes, myopia, ocular hypertension.

where does tongue cancer usually appear

on the side or the base of the tongue

Strabismus

one eye is lagging

oculomotor nerve (CNIII) paralysis

the dilated pupil is fixed to light and near effort. ptosis of the upper eyelid and lateral deviation of the eyes are almost always present

Oculomotor Nerve III Paralysis

the dilated pupil is fixed to light and near effort; ptosis of the upper eyelid and lateral deviation of the eye are almost always present

Primary Headache-Cluster

unilateral behind the eye or temple; lacrimation, rhinorhea, miosis, ptosis, edema, up to 3 hours. excruciatingly painful cannot function.

the semicircular canals contain

the end organs for vestibular function

What connects the middle ear to the nasopharynx

the eustachian tube

equal pupils and one blind eye

unilateral blindness does not cause anisocoria as long as the parasymp and symp innervation to both arises is normal. a light directed into the seeing eye produces a direct reaction in that eye and a consenual reaction in the blind eye. a light directed into the blind eye, however, causes no response in either eye

In ______________ hearing loss, sound is lateralized to (heard in) the impaired ear.

unilateral conductive

Weber test= sound is heard in (lateralized to impaired ear)

unilateral conductive hearing loss due to otosclerosis otitis media, cerumen, perforation of the eardrum

bone-anchored hearing air should be contralateral for

unilateral profound sensorineural loss

Weber test= sound is heard in good ear

unilateral sensorineural hearing

Primary Headache-Migraine

unilateral; nausea/vomiting and photophobia/phonophobia; 4-72 hours

What is a prodrome?

unusual feelings such as euphoria, craving for food, fatigue or dizziness that 60-70% of patients with migraines experience prior to onset

Evert the Upper Lid

using a Q-tip roll towards you rolling up the upper lid to evert it note color and any nodules or swelling

If sudden unilateral vision loss is painful, what should you consider?

usually causes are in the cornea and anterior chamber as in corneal ulcer, uveitis, traumatic hyphen, acute glaucoma (optic neuritis from multiple sclerosis may also be painful) immediately refer

Corneal Injury or Infection (vision)

usually decreased

perforated ear drum

usually from purulent infections of he middle ear. central perforations-do not extend the margin of the ear drum, marginal perforations do. reddening ring of granulation tissue surrounds perforation, indicating chronic infection. eardrum itself is scarred ad no landmarks are visible. discharge from middle ear may drain through the opening. ofen closes in the healing process. mem covering hole may be then and transparent

what is in the middle eye layer

vascular layer with choroid, ciliary body and iris

when doing the weber test where do you place the tuning fork

vertex of the head

Benign positional vertigo, labryinthitis, and Meniere's disease

vertigo representing vestibular disease

Central Vertigo

vertigo that occurs because of a CNS issue. often sudden, no LOH or tinnitus. usually occurs with other brainstem deficits like ataxia, crossed motor and sensory deficits; includes acoustic neuroma as a subset

4 Types of Dizziness

vertigo, lightheadedness, presyncope, disequilibrium. Vertigo is most common

Dizziness and Light-headedness are often non-specific and can signify a spectrum of conditions such as

vertigo, presyncope (from arrhythmia, orthostatic hypotension, or vasovagal stimulation), weakness, unsteadiness, and disequilibrium

the inner ear consist of

vestibule semicircular canals cochlea

nose exam is limited to

vestibule, anterior septum, lower/middle turbinates

weber test normal results

vibration heard midline or equal in both ears

Acute bacterial sinusitis is unlikely until..

viral URI symptoms persist >7 days; both purulent drainage and facial pain should be present for diagnosis

rhinorrhea pathology

viral infections, allergic rhinitis, vasomotor rhinitis

Common causes of rhinorrhea and accompanying nasal congestion

viral infections, allergic rhinits (hay fever), vasomotor (nonallergic) rhinitis * allergic often accompanied by itching

mucosa in viral rhinitis vs allergic rhinitis

viral: red and swollen allergic: pale, bluish, or red.

In the U.S. a patient is considered legally blind when

vision in the better eye, corrected by glasses, is 20/200 or less or a constricted field of vision 20 degrees or less in the better eye

Visual field tests include

visual fields by confrontation, static finger wiggle test, kinetic red target test

moving speck or strands in visual field

vitreous floaters

moving specks or strands

vitreous floaters

sudden unilateral vision loss is painless

vitreous hemorrhage macular degeneration retinal detachment retinal vein/artery occlusion

If sudden unilateral vision loss is painless, consider

vitreous hemorrhage from DM or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.

What should you consider if sudden unilateral visual loss is painless?

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion or central retinal artery occlusion

sudden, painless, unilateral vision loss

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, central artery occlusion

If sudden unilateral visual loss is painless consider

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion

unilateral visual loss is painless

vitreous hemorrhage from diabetes/trauma, macular degeneration, retinal detachment, retinal nein occlusion, central retinal artery occlusion

5 Possible causes of unilateral vision loss (painless)

vitreous hemorrhage, MD, retinal detachment, retinal vein occlusion, retinal artery occlusion

if hoarseness is acute what are the most likely causes

voice overuse acute viral laryngitis

Acure hoarseness

voice overuse and acute viral laryngitis

Acute hoarseness caused by

voice overuse and acute viral laryngitis

questions with voice hoarseness

voice quality changes, larynx disease or extra laryngeal lesions, environmental allergies/GERD/smoking/inhalation

Corneal Injury or Infection (Ocular Discharge)

watery or purulent

Scotomata

wavy lines in field of vision; could be a casue of damage to the brain, MD, part of aura in migraine

what ducts are the outlets of the submandibular glands

whartons

Consensual reaction

when a beam of light shown in one eye causes that pupil to contract, the other pupil will contract as well even if there is no light source, mediated by CN III

The near reaction

when a person shifts there gaze from a far object to a near one their pupils constrict, mediated by CN III. convergence of the eyes and accommodation (lens decreases in size and becomes thicker)

unequal pupils (anisocoria)

when anisocoria is greater in bright light than dim light, the large pupil cannot constrict properly. causes include blunt trauma to the eye, O-A glaucoma, and impaired parasymp nerve supply to the iris as in tonic pupil when anisocoria is greater in dim light, the smaller pupil cannot dilate properly as in Horner's syndrome, cause by an interruption of the sympathetic nerve supply

•Retinal structures than look much smaller than usual and you can see a much larger expanse of the fundus

when lens has been surgically removed

what is accommodation

when the accommodates for close vision by tightening the ciliary m.

what is trichiasis

when the eye lashes are stuck in the eye

what is an astigmatism

when the refractive errors in the horizontal and vertical axes differ

legal blindness

when vision in the better eye corrected by glasses is 20/200 or less, or a constricted field of vision (20 degrees or less in the better eye)

Hypopion

white blood cells inside of the eye from an infection

Arcus Cornealis (Arcus Senilis)

white, grey, or blue opaque ring around the corneal margin more common in older people

lid retraction and exophthalmos

wide-eye stare and common in Graves' disease

hirsutism occurs mostly in?

women with polycystic ovarian syndrome

Internal Anatomy of the NOSE

won't be able to see the meatus should be able to see the turbinates

yellow plaques that appear along the inner corners of the eye

xanthelasma

Fortifications

zig zac arcs of light

Conductive phase of hearing

the first part of the hearing pathway from the external ear through the middles ear

the tongue is anchored to the oral cavity at its base and to the floor by

the frenulum

5. Malignancy

the image shown is just one example

Nasolacrimal duct drains into what

the inferior meatus

What senses the position and movements of the head and helps to maintain balance

the labyrinth of three semicircular canals in the inner ear

left cranial nerve IV paralysis

the left eye cannot look down when turned inward. deviation is max in this direction

Tear fluid comes from

the meibomian glands, conjunctival glands, and lacrimal gland

Most of the paranasal sinuses drain into what

the middle meatus

the eustachian tube is a cartilaginous and bony passageway between

the nasopharynx and the middle ear

What does chronic otitis externa look like?

the skin of the canal is often thickened, red, and itchy

Tension headaches often arise in what area

the temporal areas

2nd most common cancer of the mouth

the tongue; usually on the side and then the base; lip is more common; any indurated red or white persistent nodule is suspect

The eardrum meets the tip of the malleus at

the umbo

Hyperopia

Farsightedness (Difficulty seeing close up)

an enlarged cup suggests

chronic open angle glaucoma

an enlarged physiologic cup indicates

chronic open angle glaucoma

An enlarge physiologic cup

chronic open-angle glaucoma

what does the ciliary body do

ciliary m. provides visual accommodation

pt has difficulty with seeing close

hyperopia

Firm strips of connective tissue within the eyelids are called

tarsal plates

new, persisting, progressively severe headaches

tumor, abscess, or mass lesion

when a patient c/o hearing loss what is the go to tool

tuning fork

What could absence of the red reflex suggest?

Cataracts cause opacity of the LENS so no red reflex.

presbyopia

aging vision

Pharyngitis

(see Bates p 284) - Reddened throats without exudate

Assessing for corneal reflex

(CN V: Trigeminal -- Sensory & Motor) have patient look straight ahead- touch the eye with a q-tip (after pulling out the edge of q-tip to a wisp) (only touch with the wisp) eye should blink

Tonic Pupil

(aka Adie's Pupil) pupil is large, regular, and usually unilateral, reaction to light is severely reduced and slowed, or even absent; near reaction although very slow is present; slow accommodation causes blurred vision; deep tendon reflexes are often decreased

Anatomy of the External Eye

*MEMORIZE*

When performing the Weber test (lateralization test), what is indicated when sound can only be heard in one ear? Which ear hears the sound with each condition?

1. Sensorineural hearing loss - sound heard in good ear 2. Conductive hearing loss - sound heard in bad ear

Name and describe 3 type of visual aura people with migraines may experience.

1. Spark photopsias (flashing of light) 2. Fortifications (zig-zag arcs of light) 3. Scotomata (area of visual loss with surrounding normal vision) Note: ~60-70% of patients with migraine have a symptom prodrome prior to onset. p207

What two conditions should you consider if a headache is severe and of sudden onset?

1. Subarachnoid hemorrhage 2. Meningitis p207

New and persisting, progressively severe headaches raise concerns of which 3 conditions?

1. Tumor 2. Abscess 3. Mass lesion p207

Sudden unilateral vision loss that is PAINLESS suggests which 5 conditions.

1. Vitreous hemorrhage from DM or trauma 2. Macular degeneration 3. Retinal detachement 4. Retinal vein occlusion 5. Central retinal artery occlusion p208

Physical Examination of the Oropharynx step 8

8. Inspect the pharynx With the patient's mouth open but the tongue not pro- truded, ask the patient to say "ah" or yawn. This action may let you see the pharynx well. If not, press a tongue blade firmly down upon the midpoint of the arched tongue—far enough back to visualize the pharynx but not so far that you cause gagging. Look for any discoloration or lesions on the tonsil anterior and posterior pillars -note color,symmetry - look for swelling - tonsil enlargement, exudate, ulceration etc. - palpate suspicious areas -tonsil should be pink like the pharynx Retropharyngeal wall- should be smooth shiny and pink, should have blood vessels and spots of lymphatic tissue

Physical Examination of the Oropharynx step 9

9. Determine function of CN IX and X IX: glossopharyngeal --> sensory & motor --- using a tongue depressor touch the posterior pharyngeal wall to elicit bilateral gag response X: Vagus --> sensory and motor - have patient say ahh and note the rise of the soft palate and uvula - if it doesn't rise and the uvula deviates to one side -paralysis of nerve x possible

Lid Retraction and Exophthalmos

A wide-eyed stare suggests retracted eyelids. Note the rim of sclera between the upper lid and the iris. Retracted lids and "lid lag" when eyes move from up to down markedly increase the likelihood of hyperthyroidism, especially when accompanied by a fine tremor, moist skin, and heart rate >90 beats per minute.41 Exophthalmos describes protrusion of the eyeball, a common feature of Graves' ophthalmopathy, triggered by autoreactive T lymphocytes. In this disorder, there are a spectrum of eye changes, ranging from lid retraction to extraocular muscle dysfunction, ocular pain, and lacrimation. Changes do not always progress. In unilateral exophthalmos, consider Graves' disease (usually bilateral), trauma, orbital tumor, and granulomatous disorders.

Keloid

A firm, nodular, hypertrophic mass of scar tissue extending beyond the area of injury. It may develop in any scarred area but is most common on the shoulders and upper chest. A keloid on a pierced earlobe may have troublesome cosmetic effects. Keloids are more common in darker-skinned people. Recurrence may follow treatment.

A 55 yof offers a c/o of dizziness for the past 24 hours. she feels faint and has been having diarrhea for the past two days. she takes a diuretic for HTN. didx?

A) Benign positional vertigo, orthostatic hypertention due to dehydration, Acute viral gastroenteritis, Labyrinthitis, Influenza

A 26 y/o female presents with a sore throat, fever, rash and weight loss He has a history of IV drug use and sharing needles. Which of the following are the most likely differential diagnoses?

A) HIV / acute retroviral syndrome, infectious mononucleosis, hepatitis, viral pharyngitis, streptococcal pharyngitis, secondary syphilis

A 44 y/o female presents to the clinic c/o an 11 kg weight gain over the last two months. She quit smoking three months ago. She is on amitriptyline for depression. She also admits to cold intolerance and constipation. Which of the following processes most likely explain her symptoms?

A) Smoking cessation, Hypothyroidism, Drug side effect, polycystic ovary syndrome.

Kaposi's Sarcoma

AID's defining lesion

Physical Examination of the EAR process PALPATION

AURICLES: auricle is the parts of the ear lying outside the head (AKA the pinna) - palpate and push for pressure ask if it hurts when you pull on pinna and push on tragus - NOTE CORRECT POSITION MASTOID REGION: palpate and check for pressure

when arterial walls lose transparency (become opaque) Concealment/AV nicking The vein appears to stop abruptly on either side of the artery The vein appears to taper down on either side of the artery Banking-The vein is twisted on the distal side of the artery and forms a dark, wide knuckle

AV crossings

CN VI

Abducens --- Motor controls the movement of a single muscle, the lateral rectus muscle of the eye

Corneal Injury or Infection (significance)

Abrasions, and other injuries; viral and bacterial infections

Lower two thirds of nose

Cartilage

A 42 y/o female presents to you your office c/o a 7 kg weight loss over the past two months. She has a fine tremor and her pulse is 112 bpm. Which of the following is the most complete differential diagnosis?

C) Hyperthyroidism, Cancer, HIV infection, Dieting/Diet drugs.

_______'s clinical prediction rule for streptococcal and Fusobacterium necrophorum pharyngitis

CENTORS; helps guide diagnosis and treatment of bacterial infection: fever history, tonsillar exudates, swollen tender anterior cervical adenopathy, and absence of cough

Central Retinal Artery Occlusion

CHERRY RED SPOT, Boxcar venules, Pale retina,

Pupils constricting with light controlled by

CN 3

Physical Examination of the EYE: Step 3 Test Extra Ocular Movements

CN IIII: Oculomotor --> Motor CN IV: Trigeminal --> Motor CN VI: Abducens --> Motor - cardinal fields of gaze - nystagmus - convergence -Stand in front of the patient and request that, without moving his/her head, follows your finger or a pencil in four directions (H or +) - End with bringing fingers to tip of nose (eyes should converge)

Soft palate fails to rise and uvula deviates to opposite side

CN X paralysis

asymmetric protrusion of the tongue suggests a lesion to CN

CN XII

Asymmetric protrusion of tongue

CN XII lesion

Monocular Diplopia

Can be an issue with the lens due to trauma. Light would be deflected if the lens is messed up, OR it could be an issue with the anterior chamber.

Aniscoria causes

Can be simple (normal difference in size of pupils, less than 0.04mm difference). Can also be Horner's Syndrome, oculomotor nerve paralysis, or tonic pupil.

Thrush on palate

Candidiasis- yeast infection, caused by prolonged antibiotic, corticosteriod use or AIDS

Aphthous ulcer

Canker sore; Small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors.

what is a columella

cartilage along the septum at the inferior base that divides the left and right nare

When is acute bacterial sinusitis likely?

When viral URI symptoms persist more than 7 days and both purulent drainage and facial pain should be present

Anterior Naris

Where air enters the nasal cavity

Centor scoring for strep throat

fever hx, tonsilar exudates, swollen/tender ant cervical andenopathy, absence of cough

Vestibule

Widened area just past anterior naris

Scotomas

Fixed lesions in the retina or visual pathways

How might detachment of the retina present?

Flashing lights or new vitreous floaters. Note: Prompt eye consultation is indicated. p208

Soft palate

Fleshy, flexible part toward the back of the roof of the mouth

Hypothyroidsm

Fatigue, lethargy Weight gain Cold intolerance Bradycardia; decreased SBP, increased DBP Dry, coarse skin Constipation Coarse hair

Kaposi's Sarcoma

Deep purple lesions; can be raised or flat

Flashing lights or new vitreous floaters suggest?

Detachment of vitreous from retina

What do flashing lights or new vitreous floaters in a patient's vision suggest?

Detachment of vitreous from retina Note: a prompt eye consultation is required for patients with flashing lights or new vitreous floaters in their vision.

Preretinal Hemorrhage

Develops when blood escapes into the potential space between the retina and vitreous.

Nasal congestion limited to one side suggests... (3)

Deviated septum, foreign body, tumor

Nasal congestion on one side suggests?

Deviated septum, nasal polyp, foreign body, granuloma (Wegener's) or carcinoma

Asymmetry of corneal reflex suggests:

Deviation from normal ocular alignment

Physical Examination of the EYE: Step 13 Prep the Ophthalmoscope

Dial to 0

What constitutes simple aniscoria?

Difference in pupil size of .04 mm or greater

If a patient's vision is not normal, what could be indicated if it is worse during close work or at distances?

Difficulty with close work --> hyperopia (farsightedness) or presbyopia (aging vision) Difficulty with distances --> myopia (nearsightedness)

Actinic chelitis

Diffuse or patchy dryness and variable thickening of the vermilion of the lower lip due to chronic sun exposure.

Mydriasis

Dilation of pupils

What is mydriasis?

Dilation of the pupil

Dull red and has gray exudates Airway may become obstructed

Diphtheria- caused by Corynebacterium

Chron's Disease

Disease that affects the entire immune system Involvement of oral mucosa more common in Crohn's than ulcerative colitis

Hirschberg Test (corneal light reflex)

Done 1st Shine light in the middle ~2 feet away The reflection should be at the same spot on the eye. If it is not, you may have a tropia or phoria.

Diplopia

Double vision

Upstarting palpebral fissures

Down Syndrome

Upstarting palepbral fissures seen in:

Downs syndrome

Rhinorrhea

Drainage from the nose and is often associated with nasal congestion, a sense pf stuffiness or obstruction

Drusen

Drusen are yellowish round spots that vary from tiny to small. The edges may be soft, as here, or hard

Why might valsalva maneuvers increase pain from acute sinusitis or mass lesions?

Due to changing ICP. p207

Otoscope exam of otitis externa

Ear canal is swollen, narrowed, moist, tender, and pale or reddened. If chronic, the skin may be thickened, red, and itchy

What are common symptoms associated with hearing loss?

Earache or vertigo

Koplik's Spots

Early sign of measles; small white specks that resemble salt on a red background

Excessive tearing due to impaired draininge of tears seen in:

Ectropion, Nasolacrimal duct obstruction

Papilledema (Process)

Elevated intracranial pressure causes intraaxonal edema along the optic nerve, leading to engorgement and swelling of the optic disc.

symptoms of strep

fever, pharyngeal exudates, anterior lymphadenopathy, especially in absence of a cough

Gingival Hyperplasia

Enlarged gums that are swollen and may even cover teeth; causes: phenytoin therapy, puberty, pregnancy, and leukemia

Metastasis from thoracic or abdominal malignancy

Enlargement of the supraclavicular node; especially on the left

Goiter

Enlargement of the thyroid gland to twice its normal size

What is a goiter?

Enlargement of the thyroid gland, typically twice its normal size

Entropion

Entropion, more common in the elderly, is an inward turning of the lid margin. The lower lashes, which are often invisible when turned inward, irritate the conjunctiva and lower cornea. Ask the patient to squeeze the lids together and then open them; then check for an entropion that is not obvious.

Describe how a migraine and tension HA presents?

Episodic and tend to peak over several hours

A Left Cranial Nerve VI Paralysis- left

Esotropia is maximum

1 inward eye

Esotropia:

Causes of Conductive Hearing Loss

Excess earwax, otosclerosis, otitis media.

Define hirsutism

Excessive facial hair

What causes drug-induced rhinitis?

Excessive use of decongestants or use of cocaine.

1 outward eye

Exotropia

Parts of ear

External ear- ends at tympanic membrane. Middle ear- air filled, contains ossicles and the end of the eustachian tube. Inner ear- the cochlea, semicircular canals, and the tip of the auditory nerve.

Common symptoms in the Centro's clinical prediction rule for streptococcal and Fusobacterium necrophorum pharyngitis include?

Fever history, tonsillar exudates, swollen tender anterior cervical adenopathy and absence of cough

What are common symptoms associated with earache?

Fever, sore throat, cough and concurrent URI

If a patient complains of an earache, what associated symptoms should you ask about?

Fever, sore throat, cough, and concurrent upper respiratory infection

Hutchinson sign

First sign of Herpes Zoster Ophthalmicus that appear as lesions on the tip of the nose

Hyperopia

Farsightedness Vision condition in which distant objects can be seen clearly, but close ones do not come into proper focus.

A 44 y/o female c/ dizziness with head movement to the left. She feels that the room is spinning around her head. Dix-Hallpike test produces nausea and nystagmus. What is the most likely diagnosis?

D) Benign positional vertigo, vestibular neuronitis, labyrnthitis, Meniere's disease

Optic Atrophy (Process)

Death of optic nerve fibers leads to loss of the tiny disc vessels.

Parkinson's Disease

Decreased facial mobility blunts expression. A masklike face may result, with decreased blinking and a characteristic stare. Since the neck and upper trunk tend to flex forward, the patient seems to peer upward toward the observer. Facial skin becomes oily, and drooling may occur

Rosenbaum Chart

For assessing near vision, hold 14" from eyes

Infectious Mononucleosis

Won't always see this Rash on the hard and soft palate

Soft palate issues are associated with what cranial nerve?

X (vagal); soft palate fails to rise and the uvula deviates to the good side

Jaundice

Yellow sclera

Hairy Tongue

Yellowish to brown and black elongated papillae; benign associated with: antibiotic therapy, candida, poor dental hygiene

can hearing loss be congenital?

Yes. from single gene mutations

Thrush

Yest infection from candida; thick white plaques

Cause of tinnitus

[Ringing in your ears] - tumors or aneurysms - Presbycusis: age-related hearing loss - noise-associated hearing loss - chronic otitis media - Meniere's disease - Otosclerosis (hardening in the ear) - Ototoxic drugs - Other

Weber Test

WEBER TEST -- checking to see which ear the sound lateralized to - Set the fork into light vibration by briskly stroking it between the thumb and index finger or by tapping it on your knuckles. -Test for lateralization (Weber test). Place the base of the lightly vibrating tuning fork firmly on top of the patient's head or on the mid-forehead. - Ask where the patient hears the sound: on one side or both sides? Normally the vibration is heard in the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly on the head. Restrict this test to patients with unilateral hearing loss since patients with normal hearing may lateralize, and patients with bilateral conductive or sensorineural deficits will not lateralize.

Conjunctivitis (Ocular Discharge)

Watery, mucoid, or mucopurulent

Testing conductive & sensorineural hearing loss

Weber & Rinne tests

Submandibular gland ducts

Wharton's Ducts Found at the base of the tongue

Unequal Pupils (Anisocoria)

When anisocoria is greater in bright light than in dim light, the larger pupil cannot constrict properly. Causes include blunt trauma to the eye, open-angle glaucoma

When is a person considered legally blind in the U.S.?

When his/her corrected vision is 20/200 or worse

Arteriovenous Crossing

When the arterial walls lose their transparency, changes appear in the arteriovenous crossings. Decreased transparency of the retina probably

The near reaction

When the person shifts their gaze from a far object to a near object, the pupils constrict. This is controlled by CN III.

Bacterial Pharyngitis Symptoms

fever, tonsillar exudates, swollen anterior lymph nodes, no cough.

Medical terms for farsightedness, aging vision, and nearsightedness

hyperopia; presbyopia; myopia

Asymmetry of teh corneal reflections indicates

a deviation from normal ocular alignment (dysconjugate gaze)

Meniere's Disease

a disease that causes hearing loss, tinnitus, and vertigo. comes from an issue with hte labyrinths of the inner ear or cranial nerve 8 (vertigo). first tinnitus, then vertigo then hearing loss, it is progressive and nonreversible. tinnitus bothers people mostly at night.

Poor convergence associated with...

hyperthyroidism

when left eye repeatedly does not see your fingers until they have crossed the line of gaze,

a left temporal hemianopsia is present; a left homonymous hemianopsia may thus be established

eardrum mobility may be decreased by

a serous effusion, a thickened drum, or purulent otitis media

near reaction to light

a test done on pupils if reaction to light is impaired or questionable; helpful in diagnosing Argyll Robertson and tonic (Adies's) pupils

a localized systolic or continuous bruit may be heard in

hyperthyroidism

increased pain with valsalva pathology

acute sinusitis or mass lesion (ICP changing)

exopthalmos

abnormal protrusion of the eyeball

proptosis

abnormal protrusion of the eyeball in hyperthyroidism: causes "lid lag"

ectropion

abnormalities of the eyelid: margin of lower lid is turned outward, exposing the palpebral conjunctiva. when punctum of the lower lid turns outward to eye no longer drains well, and tearing occurs. common in elderly

entropion

abnormalities of the eyelids: common in the elderly, inward turning of the lid margin. lower lashes irritate the conjunctiva and lower cornea

ptosis

abnormalities of the eyelids: drooping of the upper lid. causes include myasthenia gravis, damage to the oculomotor nerve, and damange to sympathetic nerve supply (Horner's syndrome). A weakened muscle, relaxes tissue, and weight of herniated fat may cause senile ptosis. may also be congenital

lid retraction and exopthalmos

abnormalities of the eyelids: wide-eyed stare. note the rim of sclera between the upper lid and the iris. retracted lids and "lid lag" when eyes move from up to down remarkably increase the likelihood of hyperthyroidism especially when accompanied by a fine tremor, moist skin, heart rate >90bpm exopthalmos describes protrusion of the eyeball a common feature of Grave's, triggered by autoreactive T lymphocytes, trauma, orbital tumor, and granulomatous disorders. Lid retraction EOM dysfuntion, pain and lacrimation

Headache from Sinusitis

above the eye or above maxillary sinus, aching pain with congestion, discharge, fever.

transillumination of the sinuses

absense of a glow on one or both sides suggest a thickened mucosa or secretions in the sinus, but it may also result from develpmentsal absence of one or both sinuses (frontal). See text for description of methods for transillumination of sinuses

Acute Angle Closure Glaucoma (ocular discharge)

absent

Subconjunctival Hemorrhage (Ocular discharge)

absent

Subconjunctival Hemorrhage (Pain)

absent

objects nearer than infinity are seen with the aid of ______ which increases the _______ power of the lens

accommodation refractive

small, irregular pupils

accomodate but do not react to light indicate argyll robertson pupils. seen in central nervous system syphilis

enlargement of bones and soft tissue

acromegaly

lip loses redness and becomes scaly and slightly everted

actinic cheilitis: caused by excessive exposure to sunlight and primarily affects the lower lip

What is indicated with severe, deep, and aching eye pain, with ciliary injection/diffusely red conjunctiva? Note, vision is decreased and the pupil is dilated and fixed.

acute angle-closure glaucoma

what is unlikely until viral sxs persist more than 7 days

acute bacterial sinusitis

Bacterial vs Viral sinusitis

acute bacterial sinusitis is unlikely unless respiratory infection symptoms have persisted for more than a week. Bacterial is accompanied by purulent (milky, colored) drainage from the nose and facial pain.

what type of glaucoma is common for haloes

acute glaucoma

ulcers in interdental papillae, fever, malaise, enlarged lymph nodes

acute necrotizing ulcerative gingivitis

Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum is present in

acute or chronic otitis media

Ear canal swollen, narrowed, moist, pale, and tender

acute otitis externa

the tragus will be painful is which type of ear infection

acute otitis externa

red bulging eardrum...

acute otitis media

local tenderness over sinuses together with sxs such as pain, fever and nasal dc suggest

acute sinusitis

Valsalva maneuvers increase pain in what two conditions because of the increased ICP?

acute sinusitis and mass lesion (some sort of large growth, can be an abscess, something benign, malignant, etc.)

Valsalva maneuvers may increase headache pain from

acute sinusitis or from mass lesion due to changing intracranial pressure

peripheral vision loss

adbance open-angle glaucoma

fine hair accompanies

hyperthyroidism

poor convergence is associated to what condition

hyperthyroidism

The U.S. Preventive Task Force recommends hearing screenings for who

adults 50 y.o. and older

peripheral visual field loss

advanced open angle glaucoma,

Peripheral vision loss occurs in

advanced open-angle glaucoma

Horner's Syndrome

affected pupil, although small, reacts briskly to light and near effort. ptosis of the eyelid is present, and the affected iris could be lighter in color. also could be inability to sweat on one side of the face (damage to sympathetic nerves on side of neck).

acute bacterial sinitus symptoms

after URI, pain bending forward or maxillary toothache, fever or local headache, tenderness over the sinuses

Risk factors for glaucoma

age >65 y.o., family history, African American descent, diabetes, myopia, and ocular hypertension (IOP >/=21 mm Hg)

presbyopia

aged vision (difficulty with close up)

serous effusion description

amber drum

what medications effect hearing loss

aminoglycosides ASA NSAIDs quinine furosemide

Medications that affect hearing include

aminoglycosides, ASA, NSAIDS, quinine, and furosemide

meds affecting HL

aminoglycosides, ASA, NSAIDs, furosemide

Medications that affect hearing:

aminoglycosides, aspirin, NSAIDS, quinine, and fureosemide

medications that affect hearing

aminoglycosides, aspirin, NSAIDs, quinine, furosemide

epistaxis causing drugs

anticoagulants, NSAIDs, coagulopathies

poor convergence occurs with

hyperthyroidism

What extend obliquely upward from the short process and separate the pars flaccid from the pars tensa

anterior and posterior malleolar folds (usually invisible unless the eardrum is retracted)

which chamber contains aqueous humor

anterior chamber

posterior cervical nodes

anterior edge of trapezius

airflow through nose

anterior naris -> vestibule -> nasopharynx

where do light rays focus in myopia

anterior to the retina; retinal structures in a myopic eye look larger than normal

Patients with visual field defects should be referred for further evaluation (identify causes of anterior pathway defects and posterior pathway defects)

anterior: glaucoma, optic neuropathy, optic neuritis, and glioma posterior: stroke and chiasmal tumors

secondary headaches

arise from other conditions-some may endanger patient's life

Secondary headaches:

arise from underlying structural, systemic, or infectious conditions such as meningitis or subarachnoid hemorrhage and may be life-threatening

Feeling light headed, weak in legs, or about to faint points or presyncope from:

arrhythmia, orthostatic hypotension or vasovagal stimulation

what are the two ways lesions responsible for sensorineural loss can be identified

auditory brainstem-evoked responses MRI

opacity of the lens visible through the pupil

cataracts

gradual BL visual loss

cataracts macular degeneration

Gradual bilateral vision loss usually arises from

cataracts or macular degeneration

If onset of bilateral vision loss is gradual what should you consider?

cataracts or macular degeneration

gradual bilateral visual loss

cataracts or macular degeneration

gradual bilateral vision loss

cataracts, macular degeneration

Vitreous Floaters

cause moving specks or strands to appear in the visual field. If these are fixed in place, it suggests lesions in the retina or visual pathway.

red inflamed eyelid margin with crusting

blepharitis

red inflamed eyelids in

blepharitis, often with crusting

Condition associated with poor convergence

hyperthyroidism.

Chondroma

benign cartilagenous tumor

torus palatines

benign midline lump in mouth

Torus palatinus

benign midline lump on the roof of the mouth

Peripheral vertigo types

benign positional vertigo and vestibular neuromitis (labryinthitis): hearing normal and no tinnitus

what drugs may induce nasal stuffiness

birth control reserpine guanethidine alcohol cocaine

epitaxis

bleeding disorders may contribute; must be differentiated from hemoptysis or hematemesis

epistaxis

bleeding from the nostril;bleeding disorders may contribute; must be differentiated from hemoptysis or hematemesis

in sensorineural losses air conduction exceeds ______

bone conduction

what type of hearing aid should someone with conductive loss or unilateral profound sensorineural loss have

bone-anchored hearing aid

Torus Palatinus

bony growth on hard palate, harmless

hyperopia (farsightedness) and presbyopia

both are indicated by difficulty with close work

Ectropion

bottom eyelid is turned outward away from the eyeball

Bulbar vs palpebral conjunctiva

bulbar covers most of the anterior eyeball, palpebral lines the eyelids

What is the number one most common sign of otitis media?

bulging TM

dysconjugate gaze

caused by an imbalance in ocular muscle tone. imbalance has many causes, may be hereditary, and usually appears in early childhood. gaze deviations are classified according to direction. use the cover uncover test

serous effusion

caused by viral URI (otitis mdia with serous infection) or by sudden changes in atmospheric pressure from flying or diving. eustachian tube cannot equalize the pressure in the middle ear and outside air. air is absorbed from the inner ear into the blood stream and serous fluid accumulated there instead.popping sensation in ear. amber fluid behind the eardrum, fluid level line seen on can be seen on either side of he short process, air bubbles can sometimes be seen in fluid

unilateral visual loss is painful

causes are from cornea and anterior chamber like corneal ulcer, uveitis, traumatic hyphema, acute glaucoma,

painful unilateral vision loss

causes are usually in corna or anterior chamber: cornal ulcer, uveitis, traumatic hyphema, acute glaucoma, optic neuritis from MS

rhinorrhea

causes include viral infections, allergic rhinitis, and vasomotor rhinitis; itching favors allergic cause

ear tug test

causes pain in otitis externa, but not in otitis media; OM may present with tenderness behind external ear

If sudden unilateral visual loss is painful consider

causes that are usually in the cornea and anterior chamber as in corneal ulcer, uveitis, traumatic hyphen, and acute glaucoma, optic neuritis from MS may also be painful

Xanthelasmas

cholesterol deposits around the eye

Scaly plaque or an ulcer with or without a crust

carcinoma of the lip

misidentification of lymph nodes

carotid artery; styloid process of mandible; you should be able to roll a node in two directions: up and down, and side to side

great vessels of neck

carotid, IJ vein (deep), EJ vein (superficial)

Attributes of brain tumors

can be associated with nausea and vomiting. Here the pain is new, persisting, and progressively getting worse.

rhinitis medicamentosa

can be caused by excessive use of decongestants; a worsening of rhinorrhea symptoms

Drug toxicity

can cause vertigo: from loop diuretics, amino glycosides, salicylates, alcohol

Epistaxis

can originate in paranasal sinuses or nasopharynx; bleeding from posterior may actually go down the throat instead. could present with hematemesis

Acute Otitis Externa

canal is swollen, narrowed, moist, pale, and tender. It may also be reddened. Be sure to put them on drops and culture some of fluid, STAPH AUREUS IS BIG

where does the anterior chamber drain

canal of schlemm

COE ear description

canal skin thickened, red, itchy

AOE ear description

canal swollen, narrow, moist, pale, tender, reddened

white oval ulcer surrounded by halo of reddened mucosa under the tongue

canker sores=Aphthous ulcer

Ataxia, diplopia, and dysarthria

central neurologic causes in the cerebellum or brain stem such as: cerebral vascular disease or posterior fossa tumor

Ataxia, diplopia and dysarthria (difficult or unclear articulation of speech) + dizziness/vertigo signal/indicate

central neurologic causes in the cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor, also consider migraine

vertigo with ataxia, diplopia, disarthria pathology

cerebellum/brainstem causes, CVD or posterior fossa tumor

painless nodule involving a blocked meibomiam gland

chalazion

tympanosclerosis

chalky white patch with irregular margins. deposition of hyaline material within the layers of the tympanic membrane that sometimes follow a severe episode of otitis media. usualy impair hearing and is clinical insig.

Corneal Injury or Infection (cornea)

changes depending on cause

Rhinophyma

characterised by prominent pores and a fibrous thickening of the nose, sometimes with papules

thyroid function questions

check for enlarged thyroid/goiter, temperature intolerance/sweating, palpitations/weight change

If bilateral vision loss is painful, what should you consider?

chemical or radiation exposure

painful bilateral visual loss

chemical or radiation exposure

Sudden bilateral vision loss (painful)

chemical or radiation exposures

what does speech discrimination measure

clarity of words

functions of nasal cavities

cleansing, humidification, temperature control

Conjunctivitis (Cornea)

clear

Subconjunctival Hemorrhage (cornea)

clear

Physical Finding consistent with acromegaly?

coarsening of facial features

cochlear implants are surgically implanted into the

cochlea

what structure contains the organ of corti

cochlea

sensorineural phase of hearing pathway

cochlea to cochlear nerve

Inner ear includes the

cochlea, labyrinth, the semicircular canals, organ of Corti, and the distal end of the auditory nerve (CN VIII)

inner ear contains

cochlea, semicircular canals, distal end of auditory nerve

what type of hearing device is used for severe to profound sensory loss

cochlear implant

open angle glaucoma

common form of glaucoma; normal spatial pattern between iris and cornea is preserved and the iris is fully lit

Leukoplakia

common on the sides of the tongue

acute otitis media with purulent effusion

commonly caused by bacterial infection from S pneumoniae and H influenzae. stmpyoms: earache, fever, and hearing loss. ear drum reddens and loses its landmarks. red is most obvious near the umbo. spontaneous rupture (perforation) of the drum may follow with discharge of purulent material into the ear canal. hearing loss is a conductive type

Nausea and vomiting occur with what

commonly with migraines, but also with brain tumors and subarachnoid hemorrhage

Causes of drug-induced rhinitis

excessive use of decongestants or use of cocaine

Lymph node deep to the sternomastoid and often inaccessible to examination; hook your thumb and fingers around either side of the sternomastoid muscle to find them

deep cervical chain

Kaposis Sarcoma (AIDS)

deep purple lesions in the mouth

supraclavicular nodes

deep to angle of clavicle and SCM

drug induced rhinitis

excessive use of decongestants, cocaine

Tension headaches often arise where? What about cluster headaches?

tension - temporal areas cluster - retro orbital

Cluster headaches may arise in what area

retro-orbital

swelling and redness between lower eyelid and nose

dacryocystitits (lacrimal sac inflammation)

Parkinson's Facies

decreased facial mobility blunts expression. decreased blinking and a characteristic stare present. patient seems to peer upward towards observer. facial skin becomes oily and drooling may occur.

Acute Iritis (vision)

decreased; photophobia

Wilson's Disease

dark lining around the iris

Vitreous floaters may be seen as

dark specks or strands between the fundus and the lens

vitreous floaters may be seen as

dark specks or strands btwn the fundus and the lens

mouth inspection

decayed/loose teeth, gingivitis, peridontal disease, bleeding, pus, gum recession, bad breath

drug induced rhinitis occurs in excessive use of

decongestants cocaine

a serous effusion a thickened drum or purulent OM may

decrease mobility

Acute Angle Closure Glaucoma (vision)

decreased

bright red edematous mucosa underneath a denture suggests

denture sore mouth

What is suggested with bright red edematous mucosa underneath a denture?

denture sore mouth - may be ulcers or papillary granulation tissue

Nodular episclertitis is seen in

rheumatoid arthritis and lupus erythematosus

mydriasis is

dialation

tuning forks are useful in

differentiating conductive from sensorineural hearing losses

Acute Angle Closure Glaucoma (pupil)

dilated, fixed

mydriasis

dilation of pupils

mydriasis

dilation of the pupils

Causes of sensorineural hearing loss

disorders of the inner ear such as congenital and hereditary conditions, presbycusis, viral infections such as RUBELLA and CYTOMEGALOVIRUS, Meniere's disease, noise exposure, and acoustic neuroma

Diplopia

double vision. seen in lesions in the brainstem or cerebellum, or if there is weakness in one or more extraocular muscles. Diplopia in one eye with the other closed suggests a problem in the cornea or lens.

paranasal sinuses

drain to medial meatus

nasolacrimal duct

drains to interior meatus

what is undigested cellular debris

drusen

Wharton's ducts

ducts of the submandibular gland at the base of the tongue

drainage from the nose

rhinorrhea

acute otitis externa signs

ear canal is often swollen, narrowed, moist, pale, and tender, maybe red; skin is often thickened, red and itchy in chronic OE

Prodrome

early symptom that may indicate the start of a disease or condition before it happens. 60-70% of migraine patients experience this, and they can appear as a visual aura: -spark photopsias=flashes of light -fortifications=zig zag arcs of light -scotomata=area of visual loss with surrounding normal vision

Cutaneous Cyst

ebaceous cyst, a domeshaped lump in the dermis forms a benign closed firm sac attached to the epidermis.

outward turning of the lid, common in older people

ectropion

dull puffy face with dry skin

myxedema (hypothyroidism)

pharyngitis is commonly accompanied by

enlarged tender lymph nodes

goiter

enlarged thyroid

Acromegaly Facies

enlargement of both bone and soft tissues. head is elongated with bony prominence over forehead, nose, and lower jaw. nose, lips, and ears also enlarge.

inward turning of eyelid, common in older people

entropion

circular inflammation of scleral vessels

episcleritis

light in the seeing eye produces a pupil response in both eyes, but light in the blind eye produces no response in either pupils

equal pupil and one blind eye

Physical finding upon exam of otitis media

erythematous, bulging tympanic membrane

A Left Cranial Nerve VI Paralysis- straight

esotropia appears

Due to increased risk of ischemic stroke and cardiovascular disease, the World Health Association advises women with migraines over age 35 and women with migraines with aura avoid use of what

estrogen-progestin contraceptives

Hirsutism

excessive facial hair, seen in women with polycystic ovary syndrome

what is epiphora

excessive tearing of the eye

Paralysis of CN 6

eye does not pull laterally, it stays midline

a left cranial nerve III paralysis

eye is pulled outward by action of the CNVI. upward, downward and inward movement are impaired or lost. ptosis and pupilary dilation may be associated

Entropion

eye lid (usually lower) turns inward

paralysis of cranial nerve VI (effect on eyes)

eyes are conjugate in right lateral gaze but not in left lateral gaze

Nephrotic Syndrome Facies

face is edematous and pale. swelling appears around the eyes and in the morning. eyes may become slitlike when edema is severe. periorbital edema, puffy pale face, and lips may be swollen.

The cone of light normally

fans downward and anteriorly

Hyperopia is ________ and myopia is _______.

farsightedness nearsightedness

hyperopia

farsightedness (difficulty seeing up close)

hyperopia

farsightedness - cant see upclose so you give them convex lens

Xerostomia

feeling of oral dryness (xeros-dry, stoma-mouth)

hair pathology thyroid

fine hair - hyper, coarse brittle hair - hypo

Spark Photopsias

flashes of light

Detachment of vitreous from retina

flashing lights or new vitreous floaters present.

xanthelasma

flat raised irregularly shaped yellow lesions, represents depositions of lipids

daily hygiene measures

fluoride toothpastes, brushing/flossing, annual dental care

What muscles control the eye

four rectus (superior, inferior, medial, and lateral) and two oblique (superior and inferior)....lateral rectus (CN 6), superior oblique (CN 4), all the rest (CN 3)

Acoustic neuroma

from CN 8 compassion

what does acute glaucoma cause haloes

from corneal pressure

tenderness of the nasal tip or alae suggests local infections such as a

furuncle

tenderness on nasal tip pathology

furuncle, local infection

Meningitis Headache

generalized headache, rapid, associated with fever, stiff neck, changes in mental status. need immediate antibiotics to determine if bacterial or viral.

gum enlarged and swollen, masses that may cover teeth

gingival hyperplasia- caused by phenytoin therapy, puberty, pregnancy, and leukemia

most common cause of bleeding gums

gingivitis

swollen interdental papillae

gingivitis

lid lag

rim of sclera is visible above iris with downward gaze

what are the 3 leading causes of blindness

glaucoma diabetic retinopathy macular degeneration

enlarged blind spot is in what conditions

glaucoma, optic neuritis, and papilledema

Causes of anterior pathway defects include:

glaucoma, optic neuropahty, optic neuritis, and glioma

anterior pathways defects

glaucoma, optic neuropathey, optic neuritis and glioma

Causes of visual field defects

glaucoma, optic neuropathy, optic neuritis, and glioma.

Possible causes of visual field defects

glaucoma, optic neuropathy, optic neuritis, glioma, stroke and chiasmal tumors

In Primary Open Angle Glaucoma (POAG) there is

gradual loss of vision as a result of the loss of retinal ganglion cell axons, initial loss of peripheral visual fields, and pallor and increasing size of the optic cup, which enlarges to more than half the diameter of the optic disc; blindness occurs in 5% of those with the disease

Primary open angle glaucoma (POAG)

gradual loss of vision with an initial loss of peripheral visual fields

To straighten the ear canal in an adult

grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head

protrusion of eyes

graves disease or occular tumors

inward/outward deviation of eyes

graves disease or ocular tumors

Physical Examination of the EYE: Step 6 Describe the eyelids and Lashes

have patient open/close for lid lag note quantity and distribution

Palpable tenderness or step offs may be present:

head trauma

loss of spontaneous venous pulsations in eye may indicate pathologic conditions such as

head trauma, meningitis, or mass lesions; a sign of elevated intracranial pressure

common concerning symptoms HEENT

headache, vision changes, double vision, hearing loss/earache/tinnitus, vertigo, nosebleed, sore throat/hoarseness, swollen glands, goiter

Secondary headaches include

headaches arising from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life-threatening

Causes of conductive hearing loss

hearing disorders of the external and middle ear; EXTERNAL EAR CAUSES include (otitis externs, trauma, squamous cell carcinoma, benign bony growths such as exostoses or osteomas) MIDDLE EAR CAUSES include (congenital conditions, benign cholesteatomas, otosclerosis, tumors, and perforation of the tympanic membrane

Central vertigo

hearing normal and tinnitus not present

JVD pathology

heart failure

Jugular venous distention is common in what condition

heart failure

One-sided vision loss occurs in

hemianopsia and quadratic defects

one sided visual field loss

hemianopsia, quadrantic defects

Whispered Voice Test

high specificity and even higher sensitivity to detect significant hearing loss/

retrosternal goiter sxs

hoarseness, SOB, stridor, dysphagia (tracheal compression)

Retrosternal goiters can cause

hoarseness, SOB, stridor, or dysphagia from tracheal compression

smaller more widely spaced teeth are notched on their biting surfaces

hutchinson's teeth- congenital syphilis

Hearing loss risk factors

hx of congenital or familial hearing loss, syphilis, rubella, meningitis, or exposure to hazardous noise levels at work/on the battle field.

Possible dx of an enlarged skull

hydrocephalus or Paget's disease (excessive formation of bone)

An enlarged skull may signify

hydrocephalus or Paget's disease of bone

enlarged skull

hydrocephalus or Paget's disease of bone

enlarged skull pathology

hydrocephalus, page's disease of bone

medical term for farsigthedness

hyperopia

medication for overuse headache

if 15 days/mo for 3 months and revers to <15 days/mo when meds stopped

What is considered overdue of analgesics?

if present for greater than or equal to 15 days a month for 3 months

When is anisocoria benign?

if pupillary rxns are normal

in unilateral CHL sound is heard in the

impaired ear

Dryness of the eye may occur from

impaired secretion in Sjogren's syndrome

macular degeneration

important cause of poor central vision in the elderly; types: dry atrophic, wet exudative (neovascular); undigested cellular debris (drusen) may be seen

Secondary Headache- acute glaucoma

in and around one eye, steady aching pain after rapid onset. could have decreased vision, nausea and vomiting.

AC vs BC

in conductive hearing loss, sound is heard through bone as long as or longer tha it is through air (BC=AC or BC>AC). in sensorineural hearing loss, sound is heard longer through air (AC>BC)

Rinne Test

in conductive, sound is heard through bone as long or longer than trough air. Sensitivity 60-90, specificity 95-98

Infraclavicular lymph nodes

in front of clavicle. Drains upper limbs

pre auricular nodes

in front of ear

superficial temporal artery

in front of ear, palpable

one-sided loss

in hemianopsia and quadrantic defects

in unilateral sensorineural hearing loss sound is heard

in the good ear

Vertigo sensations point primarily to a problem where

in the labyrinths of the inner ear, peripheral lesions of CN VIII or lesions in its central pathways or nuclei in the brain

Weber test

in unilateral conductive hearing loss, sound is laterlaized to the impaired ear; in unilateral sensorineural hearing loss, sound is heard in the good ear

Excessive tearing may be from

increased production (caused by conjunctival inflammation and corneal irritation) or impaired drainage of tears (ectropion and nasolacrimal duct obstruction

excessive tearing

increased production (conjunctival inflammation and corneal irritation); impaired drainage (ectropion and nasolacrimal duct obstruction)

excessive tearing causes

increased production, impaired drainage, conjunctival inflammation, corneal irritation, ectropion, nasolacrimal duct obsturcion

Valsalva mobility

increases middle ear pressure and can push a retracted eardrum out of the middle ear if not adherent to middle ear structures - -forceful attempted exhalation with closed mouth and plugged nose-clear ears and sinuses when ambient pressure change test potency of the eustachian tube, adjusting middle ear pressure

having a crescentic shade

increases risk for acute narrow angle glaucoma

A temporal light reflection on one cornea

indicates a nasal deviation of that eye

2. Otitis externa

infection in the canal

1. Acute otitis media

infection of the inside of the ear

Dacrocystitis

infection of the tear duct

Vestibular Neuronitis (acute labyrinthitis)

infection of the vestibular nerve in the middle ear. presents with vertigo, without tinnitus or hearing loss. can also have nausea, vomiting, balance difficulties, and can last a couple of weeks.

External Ear Hearing Loss Causes

infection, trauma, SCC, benign bony growths such as exostoses or osteomas.

what is the pars tensa

inferior aspect of the TM

Tender nodes suggest

inflammation

tender nodes suggest

inflammation

tender nodules suggest ________- while hard or fixed nodules suggest

inflammation malignancy

Optic Neuritis

inflammation of optic nerve, associated with MS

what is keratitis

inflammation of the cornea

Blepharitis

inflammation of the eyelids

Hyperemia (Injection)

injection of the uvula, tonsil, and palate

Physical Examination of the EYE: Step 7 Observe Lacrimal Apparatus

look at the lacrimal for swelling excessive tearing or dryness. Palpate for swollen or hard lacrimals

Physical examination of the NOSE step 4

inspect the nares and internal nose - floor - septum - turbinates *Comfort people as much as possible - Always come from the outside (and pull out form the outside) - Looking straight back and also looking up *look for polyps, bleeding, or ulcers

Careful examination of the mouth includes

inspection for decayed or loose teeth, inflammation of the gingiva, and signs of periodontal disease (bleeding, pus, recession of the gums, and bad breath), mucous membranes, palate, oral floor, and tongue surface; urge patients to seek dental care at least annually

what might suggest hypothyroidism

intolerance to cold, prefernce for warm clothing and blankets, decreased sweating; the opposite symptoms as well as palpitations and involuntary weight loss suggest hyperthyroidism

Sensorineural phase of hearing

involves the cochlea and cochlear nerve

Women with migraines over 35 and women with migraines and aura are at a greater risk of _____ and _____ if they use estrogen-progestin contraceptives

ischemic stroke and cardiovascular disease

why is the middle ear called a sinus

it is a hole in the bone that drains into the nose

when swallowing, yawing or sneezing what happens with the tube

it opens briefly to equalize the middle ear pressure with atmospheric pressure

surgical removal of lens affects eye exam because:

its magnifying effect is lost (the lens). retinal structures look much smaller than usual, and you can see a much larger expanse of the fundus

When the lens has been removed surgically

its magnifying effete is lost; retinal structures then look much smaller than usual, and you can see a much larger expanse of the funds

The most important attributes of headache are

its severity and chronologic pattern

what is the ora serrata

junction between retina and ciliary body

Feel the lobes of the thyroid by placing fingers

just below the cricoid cartilage

left cranial nerve VI paralysis

look to the right (eyes are conjugate) looking straight ahead esotropia appears looking to the right?- esoptropia is a maximum

A Left Cranial Nerve VI Paralysis- right

looking to the right -eyes are conjugate

golden ring around corner from rare mutation

kayser-fleischer ring

which plexus is more anterior

kiesselbachs

what are the two plexuses in the nose

kiesselbachs woodruffs

in conductive losses the sound is ______ and in sensorineural losses it is ________

louder in the poorer healing ear lateralizes to the better side

vertigo results primarily from problems with

labyrinths of inner ear, peripheral lesions of CN VIII, or lesions in its central pathways or nuclei in the brain

Black line in gums

lead poisioning

black lines on gums

lead poisoning

Vitreous Hemorrhage

leakage of blood into areas around vitreous

cataracts are densities in the

lens

Diplopia

lesion in brainstem or cerebellum, weakness or paralysis of extraocular muscles (horizontal diplopia from palsy of CNIII or VI, or vertical diplopia from palsy of CNIII or IV)

fixed defects in vision (scotomas)

lesion in the retina or visual pathway

fixed defects or scotomas suggest

lesions in retina/visual pathway

Diplopia is seen in

lesions in the brainstem or cerebellum, or weakness or paralysis of one or more extra ocular muscles

Fixed defects or scotomas, suggest what

lesions in the retina or visual pathways

diplopia

lesions of brainstem/cerebellum; weakness/paralysis of extra-ocular muscles

Cell and Flare

like a snow globe, there are WBC floating around in the anterior chamber.

buccal mucosa

lines cheeks, parotid (stensens) duct opens onto mucosa by upper 2nd molar

what do the tarsal glands secrete

lipid material that lubricates edge of eyelids

Tenderness of the nasal tip or alas suggests

local infection such as a furuncle

tenderness of the nasal tip or alae

local infection, such as furuncle

Nodular Episcleritis

local redness in the sclera, caused by arthritis, lupus, zoster, sjogrens

acute sinusitis is suggested by

local tenderness of frontal and maxillary sinuses alon with pain, fever, and nasal discharge

What frontal/maxillary sinus findings suggest acute sinusitis?

local tenderness, together with symptoms such as pain, fever, and nasal discharge

Brain Tumor Headache

location varies with location of the tumor. aching, steady, variable with intensity tumor. may be aggravated by coughing, sneezing, or sudden movements of teh head. pain intermittent

sty

lumps and swellings in and around eyes: a painful tender red infection in a gland at the margin of the eyelid

chalazion

lumps and swellings in and around eyes: a subacute nontender usually painless nodule involded in a blocked meibomian gland. may become acutely inflamed but unlike a sty usually point inside the lid rather on the lid margin

inflammation of the lacrimal sac (dacryocystitis)

lumps and swellings in and around eyes: a swelling between the lower eyelid and nose. an acute inflammation (example) is painful red and tender. chronic inflammation is associated with obstruction of the nasolacrimal duct. tearing is prominent and pressure on the sac produces regurgitation of material through the puncta of the eyelids

pinguecula

lumps and swellings in and around eyes: harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. appears frequently with aging, first on nasal and then on the temporal side

episcleritis

lumps and swellings in and around eyes: localized ocular inflamm of the episcleral vessels. vessels appear movable over the slceral surface. may be nodule or show only redness and dilated vessels. Seen in RA, sjogren's syndrome and herpes zoster

xanthelasma

lumps and swellings in and around eyes: slightly raised, yellowish, well circumscribed plaques that appear along the nasal portions of one or both eyelids. may accompany lipid disorders

Submandibular nodes

lymph nodes at the middle of the jaw line (midway between the angle and the top of the mandible)

Gradual vision loss causes (2)

macular degeneration or cataracts

Hard or fixed lymph nodes suggest

malignancy

hardened nodes suggest

malignancy

Tracheal deviation may signify

masses in the neck, mediastinal mass, atelectasis, or a large pneumothorax

tracheal deviations may signify:

masses in the neck, problems in thorax such as a mediastinal mass, atelectasis, or a large pneumothorax

thunderclap headaches

max intensity over several minutes, 70% of SAH pts, proceeded by sentinel leak HA

which sinus is the largest

maxillary

thunderclap headaches

maximal intensity over several minutes occur in 70% of patients with subarachnoid hemorrhage.

Parotid Gland Enlargement Facies

may be associated with obesity, diabetes, cirrhosis, and other conditions. swelling occurs anterior to ear lobes and above angles of the jaw. gradual unilateral enlargement indicates neoplasm. acute enlargement is seen in mumps.

acute narrow angle glaucoma

may be caused by iris bowing abnormally foward, forming a very narrow angle with the cornea (causes a crescetic shadow when examined). acute narrow angle glaucoma is a sudden increase in intraocular pressure when drainage of the aqueaous humor is blocked.

vitreous floaters

may be seen as dark specs or strands between the fundus and the lens; cataracts are densities in the lens

Drug Toxicity Vertigo

may or may not be reversible, hearing may be impaired and tinnitus may be present. presents with nausea and vomiting and is associated with diuretics, amingoglycosides, salicylates, alcohol

Tympanogram

measures motion of the tympanic membrane, and if there is an effusion it won't move normally.

tooth names (from medial to lateral)

medial incisor, lateral incisor, canine (cuspid), premolars (bicuspids), 1st molar (6 year molar), 2nd molar (12-year molar), 3rd molar (wisdome tooth

what is convergence

medial tracking of eye when focus is shifted from far to near

Tear fluid drains

medially through two tiny holes called lacrimal puncta which then pass into the lacrimal sac and on into the nose through the nasolacrimal duct

Sudden bilateral vision loss (painless)

medications may be the cause (cholinergics, anticholinergics, steroids)

painless bilateral visual loss

medications such as cholinergics, anticholinergics and steroids

If vision loss is bilateral and painless what should you consider?

medications that change refraction such as cholinergic, anticholinergics and steroids may contribute

If sudden bilateral visual loss that is painless occurs, consider medications that may contribute:

medications that change refraction such as cholinergics, anticholinergics, and steroids

painless bilateral vision loss

medications that change refraction such as cholinergics, anticholinergics, and steroids

when tinnitus is associated with hearing loss and vertigo you should think

menieres

superclavicular node enlargement pathology

metastasis from thoracic or abdominal malignancy

Levator Palpebrae

muscle that raises the upper eyelid, innervated by cranial nerve 3

difficulty seeing far

myopia

what is the term for nearsightedness

myopia

the ____ part of the ear is an air-filled cavity in the temporal bone

middle

Torus Palatinus

midline bony growth in the hard palate that is fairly common in adults.

submental nodes

midline, behind tip of mandible

submandibular nodes

midway between angle and tip of mandible

heacache with nausea and vomiting

migrain, brain tumors, subarachnoid hemorrhage

Unilateral headache occurs in

migraine and cluster headaches

unilateral headaches occur in _______ and ______.

migraine and cluster headaches

What types of headaches are episodic and tend to peak over several hours

migraine and tension headaches

episodic, peak over several house headache pathology

migraine, tension HA

Primary Headaches:

migraine, tension, cluster, and chronic daily headaches

Primary headaches include

migraine, tension, cluster, and chronic daily headaches

primary headache types

migraine, tension, cluster, chronic daily

non ocular conditions of photophobia

migraines meningitis TBI

unilateral headaches

migrane and cluster headaches

tinnitus with vertigo and HL

mineires disease

midline thyroid structures

mobile hyoid bone, thyroid cartilage with superior notch, cricoid cartilage, tracheal rings, thyroid gland

Retinal Arteries in Hypertension

n hypertension, the arteries may show areas of focal or generalized narrowing. The light reflex is also narrowed. The arterial wall thickens and becomes less transparent

Obtaining Near Visual Acuity

near vision with a special hand-held chart helps identify the need for reading glasses have patients pick their own distance to read presbyopia (impaired near vision) *presbyopic person often sees better when the card is far away

myopia

nearsightedness

myopia

nearsightedness (cant see far)

myopia

nearsightedness - cant see far away so you give them concave lens

edema, puffy eyes often accompany pale skin

nephrotic syndrome (anasarca)

Attributes of tumor, abscess, or mass lesion

new and persisting and progressively severe headaches.

disorders of the cranial nerves

new onset of dysconjugate gaze in adult life is usually the result of cranial nerve injuries, lesions, or multiple sclerosis, syphilis, and others

Proliferative Retinopathy, With Neovascularization

new preretinal vessels arising on the disc and extending across the disc margins. Visual acuity is still normal, but the risk for visual loss is high. Photocoagulation reduces this risk by >50%

Tiny white ovoid granules that adhere to hairs may be:

nits (lice eggs)

Conjunctivitis (Pupil)

no affected

primary headaches

no identifiable underlying cause

Physical Findings of Glaucoma

no ocular discharge, pupil fixed and dilated, cornea steamy/cloudy

circular redness (episcleritis) seen in:

nodular episclertitis, rheumatoid arthritis, and lupus

Fresh blood or crusting on the nasal septum

septal perforation: from trauma, surgery, intranasal use of cocaine or amphetamines

amber drum...

serous effusion

Causes for decreased eardrum mobility

serous effusion, thickened earfrum, purulent otitis media

amber ear drum

serous effusions

normal results of whispered ear test

repeat initial sequence correctly or responds incorrectly 1st time but 3/6 letters correct on second

Conductive hearing loss

results from problems in the external or middle ear. noisy environments may actually be helpful.

Cause of sensorineural loss

results from problems in the inner ear, the cochlear nerve (acousto-vestibular nerve), or its central connections in the brain

Quadrantic defects

results in visual loss on one side of the eye (1/4 field)

what is in the inner layer of the eye

retina

fixed defects (scrotomas) suggest lesions in the

retina or visual pathway

Arterial wall = opaque No blood is visible within

retinal arteries with silver wiring

upper or lower field visual loss in one eye suggests

retinal detachment

Symptoms of Diabetic Retinopathy

retinal hemorrhages, microaneurysm, neovascularization, hard exudate

vagus nerve test CN X

say ah, rise of soft palate

what is in the external eye layer

sclera and cornea

Redness and scaling of the scalp may indicate

seborrheic dermatitis or psoriasis

redness and scaling in hair may indicate

seborrheic dermatitis, psoriasis

AC>BC

sensorineural hearing loss

Rinne test=(AC>BC)

sensorineural hearing loss; normal hearing

what is the macula

site of central vision and color perception

3 functional portions of the ear by function

skin sinus brain

Chronic Otitis Externa

skin of the ear canal is often thickened, red, and itchy

normal fundus of a light skinned person

slightly darker fovea is just discernable, no light reflex visible in the object. note the striped or tessellated character of the fundus . redder

Macular degeneration attributes

slow central loss of vision, painless, unilateral.

Acute Iritis (pupil)

small and irregular

Petechiae

small red spots caused by blood that escapes from capillaries into the tissues.

where is the posterior chamber

space behind the lens

in the mouth what is the vestibule

space btwn the buccal mucosa and the outer surface of the teeth and gums

visual aura with migraine

spark photopsias, fortifications, scotomata (1/3 of migraines)

Hippus

spasm of the pupil

nystagmus

spazing back and forth of the eyes

pts with sensorineural loss have trouble understanding

speech

what is the audiometric study for speech reception threshold

spondees

Acute Angle Closure Glaucoma (cornea)

steamy, cloudy

Sensorineural hearing loss

stems from problems in the inner ear, cochlear nerve, or central connections in the brain. These people have particular trouble understanding speech, often complainign that others mumble. Noisy environments make hearing harder

what are the ducts that are outlets of the parotid gland

stensens

Causes of posterior pathway defects include

stokre and chiasmal tumors

Tetracycline Exposure

teeth are poorly formed

where do tension headaches often arise?

temporal areas

Horner's Syndrome

the affected pupil though small, reacts briskly to light and near effort; ptosis of the eyelid is present, perhaps with loss of sweating on the forehead

horner's syndrome

the affected pupil, though small, reacts briskly to light and near effort. ptosis of the eyelid is present perhaps with lss of sweating on the forehead. In congenital horner's syndrome, the involed iris is lighter in color than its fellow (heterochromia). small pupil and normal size

when doing the weber test in conductive hearing loss the pt will hear in

the bad ear

What does acute otitis externa look like?

the canal is often swollen, narrowed, moist, pale, and tender, may be reddened

Aqueous humor drains out through

the canal of schlemm

Aqueous humor is produced by

the ciliary body

the middle ear is external to

the oval window of the cochlea

Name the two paired salivary glands that lie near the mandible

the parotid gland (superficial to and behind the mandible) and the submandibular gland (located deep to the mandible)

Exudative Pharyngitis

the white stuff! common in strep

Are spontaneous venous pulsations (SVPs) in the fundus exam normal?

these rhythmic variations in the caliber of the retinal veins as they cross the fundus are present in 90% of normal patients; loss of SVPs occurs with high ICP (above 190mm H2O) that change the pressure gradient b/w cerebral spinal fluid pressure and intraocular pulse pressure in the optic disc

in chronic OM the skin of the canal is often

thickened red and itchy

arcus senilis

thin gray white arc or circle caused by lipid deposits

Lid Lag is seen in...

thyroid problems (both eyes) neurologic disease bells palsy MG

tenderness of thyroid in

thyroiditis

perceived sound with no external stimulus

tinnitus

New and persisting, progressively severe headaches raise concerns of

tumor, abscess, or mass lesion

large, regular, but unilateral pupil: run to light is very slow or absent

tonic pupil (adie's pupil)

Lymph node at the angle of the mandible

tonsillar

These lymph nodes drain portions of the mouth and throat as well as the face

tonsillar, submandibular, and submental nodes

rounded bony growths on the inner surfaces of the mandible

tori mandibulares

what is a midline bony growth in the hard palate that is fairly common in adults

torus palatinus

midline bony growth in hard palaate

tous palatinus

Physical examination of the NOSE step 5 (final step)

transilluminate the sinuses - Frontal: under the eyebrow if clear should see light on forehead - Maxillary: shine down nose- look in mouth should see light

Normal Conjunctiva

translucent, flat, sclera visible beneath

Local causes of epistaxis include

trauma (esp nose picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies

local causes of epistaxis

trauma, inflammation, drying/crusting of nasal mucosa, tumors, FBs

septal perforation causes

trauma, surgery, intranasal use of cocaine/amphetamines

sensorineural HL symptoms

trouble understanding speech, complaints of mumbling, noisy environments make it worse

a feeling of being pulled suggests

true vertigo from an inner ear problem or a central or peripheral lesion of CN VIII

New and persisting, progressively severe headaches raise concerns of _____, ____ or _____.

tumor, abscess or mass lesion

new persisting progressively severe HA pathology

tumor, abscess, mass lesion

normal eardrum

tympanic membrane is pinkish gray. note malleus lying behind the upper part of the drum. above the short process lies the pars flaccida. the remainder of the drum is the pars tensa. from the umbo the bright cone of light fans anteriorly and downward. post. to the malleus, part of the incus is visible behind the drum. the small blood vessels along he handel of the malleus are normal

large, chalky white patch with irregular margins

typanosclerosis- seen with severe otitis media

WHen looking at the tympanic membrane, what normal landmark is seen?

umbo

in emmetropisa (normal state) objects at distance are seen clearly with the _______ eye

unaccommodated

secondary headache causes

underlying structural, systemic, infectious (meningitis, SAH) LIFE THREATENING

Drusen

undigested cellular debris in the back of the eye, they are soft and confluent with altered pigmentation

Aniscoria

unequal size of the pupils. unilateral blindness does not cause this as long as sympathetic and parasympathetic innervation to the irises is normal. A light directed in the good eye causes a consensual reaction in the blind eye, but light in the blind eye will not cause constriction in either eye. If pupillary reactions are normla, aniscoria is considered benign.

Xanthelasma

yellow raised plaques that appear along nasal portions of one or both eyelids. Seen in lipid disorder.

The color of the optic disc is normally

yellowish orange to creamy pink (white or pigmented crescents may ring the disc, a normal finding)

The size and color of the central physiologic cup if present is normally

yellowish white; horizontal diameter is usually less than 1/2 the horizontal diameter of the disc

Anatomy of the INNER EAR

you will not be able to see the internal structures (beyond the malleus)