Chapter 10 Head, Eyes, Ears, Nose, and Throat FINAL EXAM Flashcards
Facial muscles are innervated by what cranial nerves?
V (Trigeminal)
VII (Facial)
The opening between the eyelids is termed?
Palpebral fissure
Two thin, transparent mucous membranes termed _______ lie between the eyelids and the eyeball
Conjunctivae
1) Bulbar conjunctiva-covers the scleral surface of the eyeballs
2) Palpebral conjuunctiva-lines the eyelids and contains blood vessels, nerves, hair follicles, and sebaceous glands. One of the sebaceous glands, the meibomian gland, secretes an oily substance that lubricates the lids, prevents excessive evaporation of tears, & provides an airtight seal when the lids are closed
Tears, formed by the lacrimal glands, combine with sebaceous secretions to maintain?
A constant film over the cornea
In the inner (or medial) canthus small openings termed the ______ _______ drain tears from the eyeball surface through the lacrimal sac into the nasolacrimal ducts
Lacrimal puncta
The globe of the eye, also known as the “eyeball” is surrounded by three separate layers:
1) sclera
2) uvea
3) retina
Describe the sclera of the eye
tough, fibrous outer layer commonly referred to as the white of the eye. Merges w/cornea in front of the globe at the junction termed limbus. Cornea covers iris & pupil. It is transparent, avascular, and richly innervated with sensory nerves via the ophthalmic branch of the trigeminal nerve V. Constant wash of tears provides cornea w/oxygen supply and protects its surface from drying. An important corneal function is to allow light transmission through the lens to the retina
Describe the uvea of the eye
Middle layer, consists of the choroid posteriorly & the ciliary body and iris anteriorly
- choroid layer is highly vascular & supplies retina w/blood.
- iris=circular, muscular membrane that regulates pupil dilation & constriction via the oculomotor nerve III.
- central opening of iris, the pupil, allows light transmission to the retina through the transparent lens
- ciliary body is a thickened region of the choroid that has two functions: (1) adjusts shape of lens to accommodate vision @ varying distances, (2) produces transparent aqueous humor (fluid the helps maintain intraocular pressure & metabolism of the lens & posterior cornea). Aqueous humor fills the anterior chamber between the cornea & lens and flows between the lens and the iris
Describe the retina of the eye
Inner layer, an extension of CNS
- transparent layer has photoreceptor cells, rods & cones, scattered throughout its surface. These cells perceive images & colors in response to varying light stimuli
- rods=low levels of light
- cones=higher levels of light
- macula lutea densely packed peripherally w/rods
- fovea centralis (small depression in center of macula lutea on the posterior wall of the retina) concentrated w/cones NO rods
- perforating retina is optic disc, head of the optic nerve II. Contains NO rods or cones, causing a small blind spot located 15 degrees laterally from center of vision
- The central retinal artery and central vein bifurcate at the optic disc and feed into smaller branches throughout the retinal surface
Vision, the primary function of the eyes, occurs when?
Rods and cones in the retina perceive images and colors in response to varying stimuli
The lenses are constantly adjusting to stimuli at different distances through?
Accommodation
When the lenses bring an image into focus what happens?
Nerve impulses transmit the information from the retina along the optic nerve and optic tract, reaching the visual cortex (located in the occipital lobe of each cerebral hemisphere) for cognitive interpretation
Six extraocular muscles and three cranial nerves allow for eye movement in six directions
1) The medial, inferior, & superior rectus muslces and the inferior oblique muscles, guided by the oculomotor nerve (cranial nerve III), control upward outer, lower outer, upward inner, & medial eye movements
2) The superior oblique muscle controls lower medial movement, innervated by the trochlear nerve (cranial nerve IV)
3) The lateral rectus muscle controls lateral eye movement, innervated by the abducens nerve (cranial nerve VI)
The external ear is composed of the?
Auricle (pinna) and the external auditory ear canal
The auricle (pinna) is composed of?
Cartilage and skin
External ear: the helix is the prominent outer rim; the concha is the ?
Deep cavity in front of the external auditory meatus
The bottom portion of the ear is referred to as the?
Lobule
The auricle (pinna) is attached to?
The head by skin, extension cartilage to the external auditory canal cartilage, ligaments, & muscles (the anterior, superior, and posterior auricular muscles)
The auricle (pinna) serves three main functions
1) Collection and focus of sound waves
2) location of sound ( by turning the head until the sound is loudest)
3) protection of the external ear canal from water and particles
The adult’s external ear canal is an?
S-shaped pathway leading from the outer ear to the tympanic membrane (TM), commonly known as the eardrum
The lateral one third of the ear canal has a cartilaginous portion framework; the medial two thirds of the canal are surrounded by bone The skin covering the cartilaginous portion of the auditory canal has hair follicles surrounded by sebaceous glands that secrete?
Cerumen (earwax). The hair follicles and cerumen protect the middle ear & inner ear from particles & infection
The middle ear is an?
Air filled cavity separated from the external ear canal by the tympanic membrane (TM). The TM, composed of layers of skin, fibrous tissue, & mucous membrane, is shiny & pearl gray. It is translucent, permitting limited visualization of the middle ear cavity
- middle ear contains 3 tiny bones: malleus, incus, & stapes (ossicles)
- lying between the nasopharynx and the middle ear is the eustachain tube. It opens briefly during yawning, swallowing, or sneezing to equalize the pressure of the middle ear to the atmosphere
- function of middle ear: amplification of sound. Sound waves cause the TM to vibrate; this vibration is transmitted through the ossicles to inner ear. The amplification results from the ossicles and from the size (area) difference between the TM and the oval window, an oval shaped aperture in the wall of the middle ear leading to the inner ear
The inner ear is encased in a bony labyrinth that contains three primary structures:
1) The vestibule
2) Semicircular canals
3) cochlea
The vestibule (inner ear) & the semicircular canals (inner ear) contain?
Receptors responsible for balance & equilibrium
The coiled snail-shaped cochlea contains?
The organ of Corti, the structure responsible for hearing
- specialized hair cells on the organ of corti act as sound receptors
- sound waves that reach the cochlea cause movement of the hair cells, which in turn transmit the impulses along the cochlear nerve branch of the acoustic nerve (cranial nerve VIII) to the temporal lobe of the brain, where interpretation of sound occurs
The nose serves as a?
Passageway for inspired and expired air. It humidifies, filters, & warms air before it enters the lungs and conserves heat and moisture during exhalation. Other functions of the nose include identifying odors and giving resonance to laryngeal sounds
The upper third of the nose is encased in bone, and the lower two thirds are composed of cartilage. The floor of the nasal cavity is the?
Hard palate
The septal cartilage maintains the shape of the nose and separates the?
nares (nostrils), which maintain an open passage for air
The nasal cavity is lined with?
highly vascular mucous membranes containing cilia (nasal hairs) that trap airborne particles and prevent them from reaching the lungs.
Three turbinates (inferior, middle, & superior) line the lateral walls of the nasal cavity, providing a?
Large surface area of nasal mucosa for heat and water exchange as air passes through the nose
-space between the inferior & middle turbinates is the middle meatus, which is an outlet for drainage from the frontal, maxillary, and anterior ethmoid sinuses
The nasal lacrimal duct drains into the?
inferior meatus, & the posterior ethmoid sinus drains into the middle & superior meatus
Paranasal sinuses extend out of the nasal cavities through narrow openings into the skull bones to form four paired, air filled cavities
Sphenoid, frontal, ethmoid, and maxillary, that make the skull lighter
-they are lined with mucous membranes & cilia that move secretions along excretory pathways
Within the mouth are several structures, including the lips, tongue, teeth, gums, and salivary glands. The roof of the mouth consists of the?
Hard palate, near the front portion of the oral cavity, and a soft palate, toward the back of the pharynx
The tongue has hundreds of taste buds (papillae) on its dorsal surface. The taste buds distinguish
Sweet, sour, bitter, & salty tastes
-the ventral (bottom) surface of the tongue is smooth & highly vascular
Humans have two sets of teeth
deciduous teeth (baby teeth) and permanent teeth
- 32 permanent: 12 incisors, 8 premolars, 12 molars
- teeth tightly encased in mucous membrane-covered, fibrous gum tissue, & rooted in the alveolar ridges of the maxilla and mandible
Three pairs of salivary glands
The parotid, submandibular, sublingual, all release saliva through small opening (ducts) in response to presence of food
- lie anterior to ears, immediately above mandibular angle, & drain into oral cavity through Stensen’s ducts (parotid gland openings). These are visible adjacent to the upper second molars
- submandibular glands tucked under the mandible & lie approximately midway between the chin & posterior mandibular angle
- Wharton’s ducts, the openings for the submandibular glands, are visible on either side of the lingual frenulum under the tongue
- sublingual glands (smallest salivary glands), lie on floor of the mouth and drain through 10-12 tiny ducts that cannot be seen with the naked eye
The oropharynx includes the?
Structures at the back of the mouth that are visible on examination: the uvula, the anterior & posterior pillars, the tonsils, & the posterior pharyngeal wall
- uvula is suspended midline from soft palate, which extends out to either side to form the anterior pillar
- tonsils are masses of lymphoid tissue that are tucked between the anterior and posterior pillars. May be atrophied in adults to point of being barely visible
- posterior pharyngeal wall is visible when tongue is extended and depressed. It is highly vascular & may show color variations of red and pink because of the presence of small vessels and lymphoid tissue
- epiglottis, a cartilaginous structure that protects the laryngeal opening, sometimes projects into pharyngeal area and is visible as the tongue is depressed
Structures within the neck include the?
Cervical spine, sternocleidomastoid muscle, hyoid bone, larynx, trachea, esophagus, thyroid gland, lymph nodes, carotid arteries, and jugular veins
The neck is formed by the bones within the upper spine (cervical vertebrae), which are supported by?
ligaments & the sternocleidomastoid and trapezius muscles
-these structures allow for the extensive movement w/in the neck
The relationship of neck muscles to one another and to adjacent bones creates?
Anatomic landmarks called triangles
- the medial borders of the sternocleidomastoid muscles and the mandible form the anterior triangle. Inside this triangle lie the hyoid bone, thyroid and cricoid cartilage, larynx, trachea, esophagus, and anterior cervical lymph nodes
- hyoid bone is a U-shaped bone at the base of the mandible that anchors the tongue. Only bone in the body that does not articulate with another bone
- posterior triangle formed by trapezius and sternocleidomastoid muscles and the clavicle; it contains the posterior cervical lymph nodes
The larynx (voice box) lies just below the pharynx and just above the trachea. The larynx acts as a?
Passageway for air (into trachea) and allows for vocalization w/vocal cords
- largest component of larynx is thyroid cartilage (Adam’s apple) located in the anterior portion of the neck
- thyroid cartilage: tough, shield-shaped structure w/a notch in the center of its upper border that protrudes in the front of the neck, protecting the other structures w/in the larynx (epiglottis, vocal cords, upper aspect of the trachea)
The thyroid gland, largest endocrine gland in the body, produces two hormones
1) Thyroxine (T4) and triiodothyronine (T3), which regulate cellular metabolism
- mental & physical growth & development depend on thyroid hormones
- thyroid gland positioned in the anterior portion of neck, below larynx, situated on front & sides of trachea
- Right & left lobes of the thyroid gland are butterfly shaped, joined in the middle by the isthmus
- isthmus lies across trachea under the cricoid cartilage (uppermost ring of the tracheal cartilages) & tucks behind the sternocleidomastoid muscle
The carotid arteries and internal jugular veins lie?
Deep and parallel to the anterior aspect of the sternocleidomastoid muscle
-carotid pulses palpated along the medial edge of the sternocleidomastoid muscle in the lower third of the neck.
Lymph nodes are tiny oval clumps of lymphatic tissue, usually located in groups along blood vessels. Nodes located in subcutaneous connective tissue are called?
Superficial nodes; those beneath the fascia of muscles or within various body cavities are called deep nodes
- deep nodes are not accessible to inspection or palpation
- superficial nodes are accessible to palpation & can become enlarged and tender, providing early signs of inflammation
In the head, lymph nodes are categorized as?
Preauricular, postauricular, occiptial, parotid, retropharyngeal (tonsilar), submandibular, submental, sublingual
In the neck, lymph nodes are found in?
Chains & are named according to their relation to the sternocleidomastoid muscle & the anterior & posterior triangles of the neck.
-lymph nodes in neck include: anterior & posterior cervical chains, sternomastoid nodes, and the supraclavicular nodes
What is a risk factor for macular degeneration and autoimmune disorder?
HTN
Present health status: Do you take any medications? If so what do you take and how often?
- AEs of medications can cause symptoms associated with the head and neck regions. Taking ototoxic medications such as aminoglycosides (an antibiotic) increases one’s?
- long term corticosteroid use is a known risk factor for?
Risk for hearing loss
-long term corticosteroid use is a known risk factor for glaucoma and cataracts
Myringotomy is a common surgical procedure of the?
Ears among children
Family history: Does anyone in your family have conditions impacting hearing, vision, or thyroid?
Cataracts, glaucoma, presbycusis, Meniere’s disease, and hyperthyroidism are examples of conditions that have familial tendencies and may increase a patient’s risk. Hearing loss has also been tied to genetic mutations of the GJB2 gene
Personal and Psychosocial history: When were your last routine examinations (dental, vision, hearing)? Do you use any corrective devices (contact lenses, glasses, hearing aids, dentures)?
These questions help to understand a patient’s health promotion practices. Routine dental examinations and examination of the eyes and ears are recommended
Personal and Psychosocial history: Do you use nicotine products or drink alcohol? If so how often and how much?
These questions help understand a patient’s potential risks for problems involving the head, eyes, and mouth. Chronic alcohol intake and smoking are risk factors for many problems, including cataracts, glaucoma, and cancers of the oropharynx
Cluster headaches occur?
More than once a day and last for less than an hour to about 2 hours. They may follow this pattern for a couple of months and then disappear for months to years
Migraine headaches may occur?
At periodic intervals and may last from a few hours to 1-3 days
Sinus headaches may cause?
Tenderness over frontal or maxillary sinuses
Tension headaches tend to be located in the?
Front or back of the head
Migraine and cluster headaches are usually?
Unilateral (only one side of an organ)
Cluster headaches produce?
Pain over the eye, temple, forehead, and cheek
Tension headaches are described as?
Viselike
Migraine headaches produce?
Throbbing pain
Cluster headaches cause?
A burning or stabbing feeling behind one eye
Migraines may be accompanied by?
Visual disturbances, N/V
Cluster headaches may occur with?
Nasal stuffiness or discharge, red teary eyes, or drooping eyelids
Possible triggers for headaches include?
Stress, fatigue, exercise, food, and alcohol
Conditions that precipitate headaches include?
HTN, hypothyroidism, and vasculitis
Migraines are frequently associated with?
Menstrual periods
Rest can help relieve what type of headaches?
Migraine
Movement helps relieve what types of headaches?
Cluster
Dizziness is a feeling of?
Faintness experienced within the patient
Vertigo is a?
Sensation that the environment is whirling around external to the patient
The perception of movement distinguishes?
Dizziness from vertigo. Nearly all patients who self-report a sensation of motion have vertigo
Headache triggering foods
- alcohol: sulfites
- avocado
- bacon: nitrites
- bananas
- canned figs
- chicken livers
- chocolate
- citrus fruits: lemon, lime, orange, grapefruit
- herring
- hot dogs
- meats, processed: bolonga, salami, pepperoni
- monosodium glutamate (chinese food)
- nuts
- onions
- sunflower seeds
- tea & coffee (caffeinated or decaffeinated)
- yogurt
Presyncope
Feeling of faintness and impending loss of consciousness-often a cardiovascular symptom
Disequilibrium
Feeling of falling-often a locomotor problem
Vertigo
Sensation of movement, usually rotational motion such as whirling or spinning. Subjective vertigo is the sensation that one’s body is rotating in space; objective vertigo is the sensation that objects are spinning around the body. Vertigo is the cardinal symptom of vestibular dysfunction
Light-headedness
Vague description of dizziness that does not fit any of the other classifications-usually idiopathic or psychogenic
A sudden onset of visual symptoms may indicate?
A detached retina and requires emergency referral
Difficulty with vision: Involvement of both eyes tends to indicate a?
Systemic problem
Difficulty with vision: Involvement of one eye is a?
Local problem
Symptoms commonly associated with visual difficulty
Headaches, dizziness, and nausea
Risk factors for cataracts
- age: between 65 & 74; 70% of adults had opague areas, 18% had cataracts; between 75-84 yrs, 90% of adults had opague areas, 50% had cataracts
- gender: women greater than men
- ethnicity: African Americans higher risk
- smokers: smoking 20 or more cigarettes daily have twice the risk
- alcohol: chronic drinkers of alcohol increased risk
- light exposure: exposure to low-level ultraviolet B or occupational exposure such as arc welding increases risk
- medication: corticosteroids taken on regular long term basis have higher risk
- chronic disease: diabetes mellitus increases risk
Risk factors for Glaucoma
- age: risk increases each year over age 50
- family history: those w/history of glaucoma in a first degree relative have 3x risk
- ethnicity: African Americans more likely to develop open-angle glaucoma than Caucasians. Asians and Alaska Natives have an increased risk for closed-angle glaucoma
- medication: corticosteroids (inhaled steroids) taken on regular, long term basis
- chronic disease: diabetes mellitus & HTN
Hearing loss associated with aging
Presbycusis occurs gradually and increases with advancing age, particularly with high frequencies
Risk factors for hearing loss
- Age: after 50
- Environmental noise (repeated exposure to loud noise >80 dB)
- Ototoxic medications (aminoglycosides, salicylates, furosemide)
- Family history (sensorineural hearing loss)
- Autoimmune disorders (sensorineural hearing loss)
- History of congenital hearing loss
Other symptoms associated with hearing loss
Fevers, headaches, visual changes
Ear pain can be related to an?
Infection in the mouth, sinuses, or throat
Pain caused by an ear infection involving the external ear or ear canal?
Increases with movement of the ear
Ear pain caused by otitis media?
Does not change with manipulation of the ear
Ear discharge may be a sign of?
Bacterial otitis media
Bacterial infection discharge description
Thick or purulent green-yellow, malordorous discharge
Discharge associated with a foreign body or chronic sinusits
A foul smelling discharge, especially unilateral discharge
Discharge associated with allergies
Profuse watery discharge
Discharge from neoplasm, trauma, or an opportunistic infection such as a fungal disease
Bloody discharge
A nose bleed (epistaxis) may occur secondary to?
Trauma, chronic sinusitis, malignancy, or a bleeding disorder; it may also result from cocaine abuse
Associated symptoms consistent with allergic rhinitis include?
Itching, swelling, discharge from the eyes, postnasal drip, and cough
Associated symptoms for individuals with infections
Fatigue, fever, and pain
If the patient uses nasal spray other than normal saline, alert him or her that?
It should only be used for only 3-5 days to avoid causing rebound congestion
Common associated symptoms of sore throat include?
Fever & fatigue
Possible symptoms of oral cancer include
Bleeding, lumps, and thickened ares in the mouth
-enlarged lymph nodes might be associated with cancer or an infection
Painful ulcerations may impair?
Adequate nutritional intake
Risk factors for oropharyngeal cancer
- age: increased after 40, peak incidence between 64-74
- gender: 2:1 male to female incidence
- race: African Americans higher incidence
- tobacco: 90% of individuals who develop oral cancer are tobacco users
- alcohol: 75-80% of individuals who develop oral cancer consume excessive amounts of alcohol
- exposure to sunlight: 30% of those who have cancer on the lip have an outdoor occupation with prolonged exposure to sun
- history of previously diagnosed cancer
- immunosuppression
Normocephalic
The term designating that the skull is symmetric and appropriately proportioned for the size of the body
Microcephaly is?
An abnormally small head
Macrocephaly is?
An abnormally large head
Symptoms of temporal arteritis
Tender, edematous, or hardened temporal arteries
-a bruit (a low-pitched blowing sound) heard during auscultation indicates a vascular abnormality
A person is considered legally blind when the best corrected visual acuity is?
20/200
Assess near vision for people over?
40 or those who think they are having difficulty reading
-procedure: have them cover one eye, hold a Jaeger or Rosenbaum card or newspaper about 14 inches from the eyes, and read the smallest line possible. Repeat on other eye
With age there is a loss of elasticity of the lens of the eye; this finding is termed?
Presbyopia (abnormal finding)
Normal values for peripheral vision (confrontation test)
Normal values are 50 degrees superiorly, 70 degrees inferiorly, 90 degrees temporally, and 60 degrees nasally
Normal findings: Blinking is typically?
Frequent and bilateral with involuntary movements, averaging 15-20 blinks per minute
The lid of either eye covering part of the pupil is known as?
Ptosis (abnormal finding)
Sclera is visible between the upper lid and iris in?
Hyperthyroid exophthalmos (abnormal finding)
Closure of the lid that is incomplete or accomplished only with pain or difficulty may occur with?
Infections
Edema of the eye lid may occur with?
Trauma or infection
Inward deformity of the eyelid and lashes. This is a finding seen in?
Enophthalmos
The palpebral fissures are horizontal in non-Asians, whereas Asians normally have an?
Upward slant to the palpebral fissures
In caucasian patients the eyeball does not protrude beyond the supraorbital ridge of the frontal bone. In African American patients it may?
protrude slightly beyond the supraorbital ridge
The sclera appears white except in?
Darker patients, in whom it is normally a darker shade. Tiny black dots of pigmentation may be present near the limbus in dark-skinned individuals.
-light skinned individuals there may be a slight yellow cast
Normal eye finding: The bulbar conjunctiva should be?
Pink and clear; tiny red vessels are often noted
Red conjunctiva, particularly with purulent drainage, may indicate?
Conjunctivitis
A sharply defined area of blood adjacent to normal-appearing conjunctiva may indicate?
Subconjunctival hemorrhage
Hirschberg test
The corneal light reflex for symmetry
When an imbalance is found in the corneal light reflex, perform the?
Cover-uncover test
twinkle test (corneal light reflex) abnormal finding: If light reflections appear at different spots in each eye it may indicate?
Weak extraocular muscles
Yellow sclera may indicate?
Jaundice caused by liver disease or obstruction of the common bile duct
Redness within the sclera suggests?
Inflammation or hemorrhage
A blue tone to the sclera may be caused by?
Osteogenesis imperfecta
White opaque ring encircling the limbus, termed?
Corneal arcus, seen in many patients over 60 & individuals with hyperlipidemia
Patients who have had an iridectomy or iridectomy to correct glaucoma have?
A section of the iris missing
Coloboma is a congenital defect of the?
Iris
Blunt trauma to the eye can cause a?
Iridodialysis, a circumferential tearing of the iris from the sclera
The pupil diameter is normally between
2 and 6 mm
When should the pupils constrict and dilate?
The pupils should dilate when visualizing a distant object and constrict when focusing on a near object
Failure of either one or both eyes to constrict to light in speed or magnitude indicates?
Dysfunction of the oculomotor nerve (cranial nerve III)
Abnormality: Miosis (pupilary constriction; usually less than 2 mm in diameter) contributing factors
Miotic eyedrops such as pilocarpine given for glaucoma
Mydriasis (pupillary dilation; usually more than 6 mm in diameter) contributing factors
Mydriatic or cycloplegic drops such as atropine; midbrain (reflex arc) lesions or hypoxia; oculomotor (cranial nerve III) damage; acute-angle glaucoma (slight dilation)
Anisocoria (unequal size of pupils) contributing factos
Congenital (20% of normal people have minor or noticeable differences in pupil size, but reflexes are normal) or caused by local eye medications (constrictors or dilators), amblyopia, or unilateral sympathetic or parasympathetic pupillary pathway destruction
Normal findings for 6 cardinal fields of gaze
Mild nystagmus at extreme lateral gaze may be noticed
Cover/uncover test abnormal findings
An eye that moves to focus after being uncovered indicates strabismus
An eyeball that is very firm and resists palpation may occur in?
Glaucoma
Lacrimal puncta that are clogged with mucus or particles cause?
Inflammation (dacryocystitis)
Excessive tearing (epiphora) may be caused by?
Blockage of the nasolacrimal duct
Edema of the brainstem might impair the function of cranial nerves?
V trigeminal & VII facial and may occur after head injury, cerebral hemorrhage, or tumor
Chamber depth is assessed in patients with a risk for?
Acute angle glaucoma
A narrow anterior chamber may indicate?
Glaucoma
Ophthalmoscopic examination: Red numbers (minus or negative compensate for? Black numbers (plus or positive) compensate for?
Red-myopia (nearsighted)
Black-hyperopia (farsighted)
Red light reflex abnormal finding: Dark shadows or black dots may indicate?
Opacities that occur with cataracts or may be caused by hemorrhage in the vitreous humor
Cataracts prevent inspection of the optic disc because?
The light cannot penetrate the opacity of the lens
Color of optic disc should be?
Creamy yellow to pink, lighter than the retina, possible with tiny blood vessels visible on the surface
Abnormal findings for optic disc: Blurred margin may indicate?
Papilledema, which is caused by increased intracranial pressure relayed along the optic nerve
Arteries are light red and may have a narrow band of light in the center. By contrast, veins are?
Larger than arteries and have no light reflex. They are darker, and venous pulsations may be visible
Abnormal artery (eye) findings: arteries should not be?
Pale or opaque
Abnormal findings: Indentations or pinched appearances where veins and arteries cross occur with hypertension and are termed?
Arteriovenous nicking
The macula may be difficult to see if the patient’s pupil has?
Not been dilated chemically
Drusen bodies are deposits that form within the later under the retina and appear as?
Small, discrete spots in the retina. They become yellow as the spots enlarge. When drusen bodies increase in size or number, they may contribute to macular degeneration
The ears should be between __ & ___ cm in length
4-10
A small painless nodule, called a ____ _____, is a normal deviation and may be noted at the helix of the hear
Darwin Tubercle
Low set ears are seen in persons with?
Congenital diseases such as Down syndrome
If the ears are smaller than 4cm in length they are referred to as?
Microtia ears
If the ears are larger than 10 cm in length, they are referred to as?
Macrotia ears
A bloody or clear discharge from the ear accompanied by a history of head injury may indicate?
A skull fracture
A purulent or crusty discharge from the ear usually indicates?
Infection or the presence of a foreign body
How does Carcinoma of the ear appear?
Progressive ulcer or a patch of crusty skin (squamous cell) or a waxy bump or flat lesion (basal cell)
Ear abnormal findings: tenderness of the mastoid area may indicate?
Mastoiditis
Ear abnormal findings: Pain when the helix of the ear is pulled may indicate an?
Inflammation within the auditory canal
Cerumen is almost always in the canal. Note the characteristics of the cerumen. The color may be?
Black, brown, dark red, creamy, or brown-gray. The texture ranges from moist to dry and flaky to hard. There should be no odor, edema, or erythmema
Erythemia and edema of the auditory canal may be an indication of?
Otitis externa. The infection may cause the canal to become occluded
Abnormal external ear findings: Purulent discharge may occur secondary to?
Otitis externa or with rupture of the tympanic membrane associated with acute otitis media
Abnormal external ear findings: Clear fluid or frank bloody drainage following a head injury may indicate?
A basilar skull fracture
White and dark-skinned races have cerumen that is?
Moist, sticky, and dark
Asians, Native Americans, and Alaskan Natives have cerumen that is generally?
Sparse, dry, flaky, and lighter
Most of the tympanic membrane is taut and is known as the?
Pars tensa; a smaller less taut part is the pars flaccida, and the dense fibrous ring around the membrane is the annulus
The cone of light is seen at the __o’clock location in the right ear and the __o’clock location in the left ear
5 oclock right ear
7 oclock left ear
Abnormal appearance of TM: Yellow/amber
Serous fluid in the middle ear, which may indicate otitis media with effusion
Abnormal appearance of TM: Redness
Infection in the middle ear such as acute purulent otitis media
Abnormal appearance of TM: Chalky white
Infection in the middle ear such as otitis media
Abnormal appearance of TM: Blue or deep red
Blood behind the TM, which may have occurred secondary to injury
Abnormal appearance of TM: Red streaks
Injected/increased vascularization may be caused by allergy
Abnormal appearance of TM: Dullness
Fibrosis or scarring of the TM secondary to repeated infections
Abnormal appearance of TM: White flecks/plaques
Healed inflammation of the TM
Bulging of the TM with no mobility indicates?
Pus or fluid behind the TM
Retraction of the TM with no mobility with negative pressure indicates?
Obstruction of the eustachian tube
Increased mobility of only one part of the TM indicates?
An area of healed TM perforation
Patients with a high-frequency hearing loss may not be able to hear?
Finger rubbing test
Weber test with tuning fork abnormal findings: Lateralization of sound to the affected ear suggests?
Lateralization of sound to the unaffected ear suggests?
affected ear: conductive hearing loss
unaffected ear: sensorineural hearing loss
Abnormal findings for rinne test (tuning fork)
When sound is heard longer by bone conduction than air conduction in the affected ear=conductive hearing loss
-Patients w/sensorineural hearing loss have air conduction longer than bone conduction in the affected ear, but it will be less than a 2:1 ratio
A perforation in the nose if often associated with?
Cocaine use
Vermillion border
Border between the lips and the facial skin
Pale lips may indicate?
Anemia or shock
Cyanotic (bluish) lips and circumoral cyanosis (bluish tint surrounding the mouth) may indicate?
Hypoxemia or hypothermia
Dry, flaking, or cracked lips may be caused by?
Dehydration or exposure to dry air or wind
Cracks and erythema in the corners of the mouth may be caused by?
Vitamin B deficiencies
Lesions, plaques, vesicles, nodules, or ulcerations on the lips may be signs of?
Infection, irritation (such as lip biting), or skin cancer
Lips may be edematous because of an?
Allergic reactions
Brown spots in the crevices or between the teeth may indicate?
Caries
Malocclusion refers to a?
Misalignment of teeth
About 30% of Asian Americans, 15% of Native Americans, and 10% of Caucasians have a congenital absence of the third molar and thus have only 28 teeth as adults. This pattern is rare in African Americans. Caucasians have the smallest teeth; African Americans tend to have larger teeth than Caucasians; Asians and Native Americans have the largest teeth
.
Darker-skinned persons often have darker oral pigmentation and may have a?
Patchy brown pigmentation of the gums. There may also be a dark melanotic line along the gingival margin
A split uvula occurs in up to?
10% of Asians and 18% of some Native Americans
Atrophy of the tongue on one side or deviation of the tongue may be a sign of a?
Neurologic disorder
A smooth or beefy-red-colored, edematous tongue with a slick appearance by indicate?
B Vitamin deficiency
A tongue with irregular patches with a map-like appearance is referred to as a?
Geographic tongue
The parotid gland opening (also known as Stensen’s duct) is on the?
Buccal mucosa adjacent to the upper second molar. It appears as a slightly elevated pinpoint red mark
Abnormal findings for buccal mucosa: Aphthous ulcers on the buccal mucosa appear as?
White, round, or oval ulcerative lesions with a red halo
Abnormal findings for buccal mucosa: Leukoplakia is a?
White patch or plaque found on the oral mucosa that cannot be scraped off
Abnormal findings for buccal mucosa: Erythroplakia is a?
Red patch found on the oral mucosa
Abnormal findings for buccal mucosa: An excessive dry mouth or excessive salivation may indicate?
Salivary gland blockage or may occur secondary to medications, dehydration, or stress
Abnormal findings for buccal mucosa: An acetone odor on the breath may indicate?
Ketoacidosis
Abnormal findings for buccal mucosa: A fetid odor may occur secondary to?
Gum disease, caries, poor dental care, or sinusitis
What cranial nerve is tested when patient says “ahh”
Cranial nerve X vagus
What cranial nerve is tested when the soft palate rises symmetrically?
Cranial nerve IX Glossopharyngeal
Enlarged, non inflammed tonsils are a normal variation among?
Adolescents
Abnormal findings: nodules observed on the palate may indicate a?
Tumor
Lesions associated with Kaposi sarcoma may be present on?
Both the hard and soft palates
Failure of the soft palate to rise bilaterally and uvula deviation during vocalization may indicate a?
Neurologic problem
Exudate or mucoid film on the posterior pharynx may be present secondary to?
Postnasal drip or infection
Abnormal findings: A grayish tinge to the membranes (oral) may occur with?
Allergies or diphtheria
Edematous, erythematous tonsils with or without exudate may indicate?
Infection
Tonsil enlargement is graded from?
1+ to 4+
Tonsil enlargement grading descriptions
1+, visible
2+, halfway between tonsillar pillars and uvula
3+, nearly touching the uvula
4+, touching one another
Marked movement of the teeth may be secondary to?
Peridontal disease or trauma
Gum tenderness with palpation or thickening may indicate that the?
Dentures do not fit well or the presence of lesions
Abnormal findings: tracheal displacement suggests?
Displacement by a mass in the chest
Abnormal findings ROM: Limited ROM or pain during movement may indicate?
Either a systemic infection with meningeal irritation, a musculoskeletal problem such as muscle spasm, or degenerative vertebral disks
How to assess cranial nerve XI spinal accessory
Shrug shoulders against resistance
A thyroid that is easily palpable before swallowing is enlarged, a common finding in?
Hyperthyroidism
- if thyroid gland is enlarged use the bell of the stethoscope to auscultate it for vascular sounds
- bruit indicates an abnormally large volume of blood flow and suggests a goiter
Regional lymph nodes include?
- Occipital
- Preauricular
- Postauricular
- anterior and posterior cervical chain
- parotid
- retropharyngeal (tonsilar)
- submental
- submandibular
- supraclavicular nodes
How to palpate the supraclavicular nodes?
Have patient hunch shoulders forward and flex the chin toward the side being examined. Place your fingers into the medial supraclavicular fossa
Migraine headaches main points
- 2nd most common in US
- can occur in childhood, adolescence, or early adult life
- young women most susceptible
- clinical findings: starts w/aura caused by vasospasm of intracranial arteries & described as throbbing unilateral distribution of pain
- accompanying s/s: depression, restlessness or irritability, photophobia, N/V
- may last up to 72 hours
Cluster headache main points
- most painful primary headaches
- most common from adolescence to middle age
- clinical findings: intense episodes of excruciating unilateral pain.
- may last from 30 min to 1 hour but may repeat daily for weeks at a time, followed by periods of remission, during which the person is free from attacks
- cluster period lasts from 6-12 weeks; remissions last for an average of 12 months or years
- burning, boring, stabbing pain behind one eye and may be accompanied by unilateral ptosis, ipsilateral lacrimation, and nasal stuffiness and drainage
- occur w/out warning, some report vague premonitory warning such as slight nausea
Tension headache mainpoints
- most common in adults 20 & 40 years of age
- clinical findings: bilateral and may be diffuse or confined to the frontal, temporal, parietal, or occipital area
- onset may be gradual & may last for several days
- may be accompanied by contraction of the skeletal muscles of the face, jaw, & neck
- tight band around head pain
Posttraumatic headach
- occurs secondary to head injury or concussion
- clinical findings: dull, generalized head pain
- accompanying symptoms: lack of ability to concentrate, giddiness, or dizziness
Hydrocephalus
- abnormal accumulation of cerebrospinal fluid (CSF) that may develop from infancy to adulthood
- in infants it’s usually a result of an obstruction of the drainage of CSP in the head
- in adults it may be caused by obstruction of CSF circulation or resorption
- clinical findings: in infants a gradual increase in intracranial pressure occurs, leading to an actual enlargement of the head, as the head enlarges, facial features appear small in proportion to the cranium; fontanels may bulge, & scalp veins dilate
- in adults signs of increased intracranial pressure (decreased mental status, HA) are noted because skull unable to expand
Chalazion
A nodule of the meibomian gland in the eyelid. May be tender if infected & often follows hordeolum or chronic inflammation such as conjunctivitis, blepharitis, or meibomian cyst
-clinical findings: firm, non-tender nodule is observed in the eyelid
Hordeolum (Stye)
Acute infection originating in the sebaceous gland of the eyelid is termed a hordeolum
- usually caused by Staphylococcus aureus
- clinical findings: affected area usually painful, red, and edematous (marked by edema)
Conjunctivitis
An inflammation of the palpebral or bulbar conjunctiva
- caused by local infection of bacteria or virus and by an allergic reaction, systemic infection, or chemical irritation
- clinical findings: eye appears red, with thick, sticky discharge on the eyelids in the morning
Corneal abrasion or ulcer
Disruptions of the corneal epithelium and stroma create a corneal abrasion or ulcer.
- Caused by fungal, viral, or bacterial infections or desiccation (dryness) because of incomplete lid closure or poor lacrimal gland function. Also be caused by scratches, foreign bodies, or contact lenses that are poorly fitted or overworn
- clinical findings: intense pain, has a foreign body sensation, reports photophobia, tearing & redness observed
Strabismus
Abnormal ocular alignment in which visual axes do not meet at the desired point
- nonparalytic strabismus is caused by muscle weakness, focusing difficulties, unilateral refractive error, or anatomic differences in eyes
- Paralytic strabismus is a motor imbalance caused by paresis or paralysis of an extraocular muscle
- clinical findings: common types are esotropia & exotropia. Esotropia is an inward-turning eye and is the most common type in infants. Exotropia is an outward turning eye
Pterygium
Noncancerous growth w/in the conjunctiva
- cause unknown, often associated w/excessive exposure to sunlight & wind
- mostly seen among adults & older adults & rarely among children
- clinical findings: usually painless, it may cause inflammation or irritation or create a feeling of a foreign body in eye. Appears as an area of raised white tissue w/blood vessels on the inner or outer edge of the cornea
Cataract
Opacity of the crystalline lens. Mostly occurs from denaturation of lens protein caused by aging, can also be congenital or caused by trauma
- clinical findings: cloudy or blurred vision; glare from headlights, lamps, or sunlight; and diplopia, poor night vision & frequent changes in their glasses prescriptions.
- cloudy lens can be observed on inspection, the red reflex is absent because the light cannot penetrate the opacity of the lens
Diabetic Retinopathy
Visual alteration caused by diabetes mellitus. Caused by deterioration of the retinal vasculature as a consequence of hyperglycemia and is the leading cause of blindness in Americans.
- can be nonproliferative and proliferative
- clinical findings: decrease in vision. in nonproliferative: microaneurysm and hemorrhages are seen. Exudates may be seen around macula. Elaborate vessel formation
Glaucoma
Group of diseases characterized by an increase in intraocular pressure. Untreated it causes damage to the optic nerve & leads to blindness
- types of glaucoma: open-angle (most common), closed-angle, congenital, and glaucoma caused by drugs or other medical conditions (leads to open-angle or closed-angle)
- clinical findings: no specific symptoms accompany open-angle. May report gradual & painless loss of peripheral vision, eye may be very firm to palpation. Most reliable indicator is an intraocular pressure measurement
- closed-angle: sharp eye pain & see halo around lights
- clinical findings associated with congenital begin during infancy w/in the first few months of life and include cloudiness over the pupil, red-appearing eye, eye enlargement (compared to other eye) light sensitivity
Clinical findings for foreign body in the ear
Sense of fullness & decreased hearing. If it’s a live insect they may hear the insect move & have severe pain. Symptoms may include fever
Infection: Acute Otitis Media (AOM)
Infection of middle ear
- can occur at any age but common in childhood infections
- clinical findings: ear pain (otalgia)
- infants unable to verbally communicate may demonstrate irritability, fussiness, crying, lethargy, and pulling at the affected ear
- associated manifestations include; fever, vomiting (infants), & decreased hearing (older children & adults)
- on inspection in the early stage, the TM appears inflamed; red & may be bulging and immobile
- later stages may reveal discoloration (white or yellow drainage) & opacification to the TM
- purulent drainage from the ear canal w/a sudden relief of pain suggests perforation of the TM
Otitis Media with Effusion (OME)
Inflammation of the middle ear space resulting in accumulation of serous fluid in the middle ear
- clinical findings: clogged sensation & problems w/hearing & balance, clicking or popping sounds
- because OME is NOT associated with acute inflammation (as with AOM), fever and ear pain are absent
- on examination the TM is often retracted and is yellow or gray with limited mobility
Hearing loss: Conductive hearing loss
Caused by interference of air conduction to the middle ear. Can result from blockage of external auditory canal (cerumen impaction), problems w/TM (perforations, retraction pockets, tympanosclerosis), or problems w/in middle ear (otitis media w/effusion, otosclerosis, trauma, or cholesteatoma)
- clinical findings: decreased ability to hear, muffled tones
- During Weber test the patient reports sound heard in affected ear
- During Rinne test, patient hears bone conduction longer than air conduction
Sensorineural Hearing loss (SNHL)
Caused by structural changes, disorders of inner ear, problems w/auditory nerve
- accounts for over 90% of hearing loss cases
- Presbycusis, most common cause of SNHL, caused by atrophy & deterioration of cells in cochlea or atrophy, degeneration, and stiffening of cochlear motion
- clinical findings: presbycusis manifests as gradual & progressive bilateral deafness w/loss of high-pitched tones. Those w/presbycusis have difficulty filtering background noise, making listening difficult
- during Weber test there is sound in unaffected ear
- Rinne test=hears air conduction longer than bone conduction, but it will be less than a 2:1 ratio
Nose: Epistaxis
Bleeding from nose
- occurs in all age groups, mostly elderly
- most common condition of nose
- causes: forceful sneezing or coughing, trauma, picking nose, heavy exertion
- some occur spontaneously
- bleeding can be mild or heavy
- most located in the highly vascular Kiesselbach area located in the anterior aspect of the septum; however, bleeds from the posterior septum may also occur and tend to be more severe
Inflammation/Infection: Allergic Rhinitis
Inflammation of nasal mucosa
- chronic rhinitis affects millions of individuals and usually caused by an inhalant allergy, which may be seasonal allergy or a year round sensitivity to dust & molds
- strong family history associated with allergic rhinitis
- clinical findings: sneezing, nasal congestion, nasal drainage, itchy eyes, cough, fatigue
- turbinates often enlarged and may appear pale or darker red
Acute sinusitis
Infection of sinuses that typically occurs as a result of pooling of secretions w/in sinuses, often occurs after an upper respiratory infection
- these pooled secretions provide a medium for bacterial growth
- clinical findings: throbbing pain w/in affected sinus, tender on palpation, fever, thick purulent nasal discharge; & edematous, erythematous nasal mucosa
- if transillumination is performed, absence of a red glow is noted in the affected sinus
Mouth: Herpes Simplex
Cold sore
- highly contagious, common viral infection caused by herpes simplex virus type 1
- spread by direct contact
- recurrent infections occur following stimulus of sun exposure, cold temps, fever, or allergy
- lesions can occur in mouth
- clinical findings: prodromal burning, tingling, or pain sensation before outbreak. Lesions usually on lip-skin junction as groups of vesicular lesions w/an erythematous base
- lesions progress from vesicles, to pustules, and finally to crusts
- appear in the mouth as white ulcerations
Gingivitis
Inflammation of the gingivae (gums)
- can be acute, chronic, or recurrent
- most common cause is poor dental hygiene, leading to formation of bacterial plaque on the tooth surface at the gum line, resulting in inflammation
- clinical findings: Hyperplasia of gums, erythema, & bleeding w/manipulation, edema of gum tissue deepens the crevice between the gingivae and teeth, allowing for formation of gingival pockets where food particles collect, causing further inflammation
- periodontitis occurs when inflammation process causes erosion of the gum tissue and loosening of the teeth
Tonsillitis
Infection of the tonsils
- common bacterial pathogens include beta-hemolytic and other streptococci
- clinical findings: sore throat, pain w/swallowing (odynophagia), fever, chills, and tender cervical lymph nodes, ear pain
- tonsils appear enlarged and red and may be covered w/white or yellow exudates
Candidiasis (Thrush)
Opportunistic infection typically caused by Candida albicans
- commonly seen among individuals who are chronically debilitated, immunosuppressed, or a result of antibiotic therapy
- clinical findings: soft, white plaques on the tongue, buccal mucosa, or posterior pharynx
- if lesion is peeled off, a raw, bleeding, erythematous, eroded, or ulcerated surface results
Lesions: Aphthous Ulcer (Canker sore)
Common oral lesion w/unknown etiology that affects up to 66% of the population
- clinical findings: very painful & appear on the buccal mucosa, the lips, the tongue, or the palate as round or oval ulcerative lesions w/yellow-white center and an erythematous halo
- may last 2 weeks
Oral cancer
Can occur on lip or w/in the oral cavity and oropharynx
- 45,780 new cases diagnosed in 2015
- clinical findings: often subtle and asymptomatic in early stages; premalignant changes of the oral mucosa such as white or red patches (leukoplakia and erythroplakia) may be seen. Lesions progress to painless, nonhealing ulcers
- later stages signs and symptoms include enlarged, hard, nontender cervical chain or submental lymph nodes; noticeable mass; bleeding; loosening of teeth; difficulty wearing dentures; and difficulty swallowing
Hyperthyroidism
Excessive production and secretion of thyroid hormone.
- several diseases can cause this but Graves disease, a familial autoimmune disorder, is most common
- clinical findings: most body systems affected. S/S reflect increased metabolism and may include enlargement of the thyroid gland and exophthalmos. Auscultation of goiter may reveal bruit
Hypothyroidism
Common problem associated w/thyroid function, characterized by decreased production of thyroid hormone
- several etiologies linked to it, including autoimmune thyroiditis, decreased secretion of thyroid-releasing hormone (i.e. antithyroid drugs or surgical resection of thyroid tissue), atrophy of the thyroid gland, & iodine deficiency
- Clinical findings: overall decreased metabolism; slow motion with a depressed affect, goiter may be seen w/hypothyroidism because of increases in thyroid-stimulating hormone
Thyroid cancer
Common type of endocrine malignancy
-clinical findings: frequently does not cause symptoms; first discovered as a small nodule on thyroid gland. As tumor grows, changes in voice and problems w/swallowing or breathing may be experienced because of invasion of the tumor into the larynx, esophagus, and trachea
Lymphoma
Group of disorders characterized by malignant neoplasms of lymph tissue
- occur in adolescents, young adults, people over 50
- clinical findings: malignant lymphomas cause lymph nodes to be large, discrete, nontender, and firm to rubbery
- enlarged nodes usually are unilateral and localized; however, chronic lymphocytic leukemia causes generalized lymphadenopathy
- Hodgkin disease is a malignant lymphoma characterized by a painless, progressive enlargement of lymphoid tissue, usually first evident by the cervical lymph nodes, splenomegaly, and atypical macrophages
