ENT, Ophthalmic exam Flashcards
superficial temporal artery
passes right above ear where it is readily palpable
parotid gland
superficial and lies behind of the mandible becoming visible and mandible when enlarged
submandibular glands
deep to mandible below tongue w/ duct visible w/in oral cavity
common or concerning symptoms of HEENT
headache change in vision resulting in hyperopia, presbyopia, myopia, or scotomatas double vision (diplopia) hearing loss, earache, or tinnitus vertigo
Upper eyelid
covers portion of iris but does not cover pupil. opening between eyelids is palpebral fissure
sclera
white buff colored at periphery
conjuctiva
clear mucous membrane w/ two easily visible components
bulbar conjunctiva- covers most of anterior eyeball adheres loosely to underlying tissue and meets cornea at limbus
palpebral conjunctiva- lines upper and lower eyelids two parts merge in folded recess that permits movement of eyeball
Conjunctival injection: diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally Mild discomfort rather than pain Vision is not affected except for temporary mild blurring due to discharge Watery, mucoid, or mucopurulent. Due to varied causes
Bacterial- crusted nasty stuff
Viral-
Allergic- bilateral in both eyes can see changes in conjunctiva cobblestone look
tarsal plates
w/in eye lid lie firm strips of connective tissue each plate contains parallel row of meibomian glands which open on lid margin.
levator palpebrae
muscle of upper eyelid
tear fluid
protects conjunctiva and cornea from drying and infection comes from lacrimal gland, conjunctiva glands, and meibomian glands
lacrimal gland
above eye drains medially through lacrimal punta and passes into lacrimal sac and onto nose through nasolacrimal duct atop small elevatoion of lower lid medially. sac rests inside bony orbit. and is not visible
Dacryocystitis swollen infected lacrimal sac.
Unlike in dry eye do not push on canthus to try and express fluids leading you to think of blocked lacrimal apparatus.
If blocked duct swollen not red and may be painful can push
cornea
transparent anterior portion of outer covering of eye
iris
: ciliary bodies control thickness of lens and allow for focusing, muscles of iris control size of pupil
ciliary body
muscles of this control thickness of lens allowing eye to focus on near or distant objects
produces clear liquid aqueous humor which helps control pressure inside eye and drains out through canal of schlem
fundus
posterior part of eye seen through otoscope.
optic nerve
enters eye posteriorly find it w/ opthalmoscope of optic disc where retinal arteries and veins converge. follow retinal vessels ventrally
fovea
lateral and slightly inferior to disc is darkened circular area surrounds small depression in retinal surface that marks point of central vsion
macula
surrounds fovea w/ no discernible margins no retinal vessels
retina
light sensitive membrane that covers fungus,
vitreous body
transparent mass of gelatinous material fills eyeball not usually visible through ophthalmoscope helps maintain shape of eye
seeing an image
light reflected from image must pass through pupil and be focused on sensor neurons in retina. image projected on retina upside down and reverse left to right. nerve impulses stimulated by light conducted through retina, optic nerve, and optic tract into brain.
snellen eye chart
have patient stand 20 ft. don’t wear reading but other contact or glasses. hold card over left eye and read smallest line possible on both eyes
first number equals distance of patient from chart second number distance at which normal eye can read line of letters
deter lesions in anterior and posterior pathway
static finger wiggle test
place hands 2 feet apart lateral to patients ears slowly move your wiggling finger of both hands along the imaginary surface of bowl toward central vision line have patient tell you when they see it. map out maximum extent of left and right monocular vision fields. if defect do boundaries to one eye at time look at opposite eye from defective toward center
kinetic red target test
move 5mm red topped pin along the boundary of each quadrant along a line bisecting the horizontal and vertical meridians have patient tell you when the pin first appears to be red. insect patients eye for position and alignment, width of palpebral fissures, edema and color, lesions, and condition and direction of eyelashes, adequacy of eyelid closure (when prominent, facial paralysis or when patient unconscious
inspecting eye
area over lacrimal gland and sac for swelling, look for excessive tearing or dryness.
sclera and conjunctiva ask patient to look up as you depress lower lids w/ your thumbs look for any nodules or swelling inspectiong color, vascular pattern looking at each side and down looking at sclera and bull conjunctive.
looking at pupils
inspect each cornea and lens for opacities shine penlight from eye toward light look for shadow on medial side of iris suggesting glaucoma inspect pupils. Go down 1-2mm. Check direct and consensual reaction
oblique lighting and distant gaze get pupillary reaction swing light to other light for consensual reaction in opposite eye.
look alternately at it and in distant look for constriction w/ near effort
Abnormal: When light goes into ABNORMAL eye both dilate slightly due to afferent nerve stimuli decreased so efferent also reduced, net dilation. Afferent pupillary defect
ocular alignment
arising from extra ocular muscles. 2 ft. shine light onto patients eye looking at it inspect reflections in corneas should be visible slightly nasally to center of pupil.
conjugate movement from eye in any direction, deviation from normal nystagmus (rhythmic oscillation of eyes), lid lag moving up and down
H in air to patients extreme right, upward, down, up to extreme left upward and down. horizontal, diagonal, vertical rotary nystagmus look for jerking movement of eyes as patient looks to far left right and up and down. lid lag or hyperthyroidism do it again up to down in midline looking for right lid of sclera above iris. convergence of eyes can only keep track up to 5-8 in.
opthalmoscope
small light to avoid hybus or spasm of ciliary muscle. 80% of full brightness minimizing pupillary constriction, 0 diopter look over shoulder using eye and hand of patients side.
15 in. away and 20 degrees lateral to patient line of vision onto pupil thumb of other hand on eyebrow. red reflex on orange glow of pupil opacity interrupting reflux toward pupil until ophthalmoscope is close to eye almost touching thumb. bring optic disc into sharper focus noting color of disc, size of central physiology cup, disc margin, cup to disc ratio 1:3 can be elevated in glaucoma. note symmetry of eyes and fundi normal optic disc yellowish orange to creamy pink or round or oval w/ well-demarcated margins. papillemeda swelling of optic disc and bulging of cup singles intercrnaial pressure of edema subarachnoid hemorrhage. retina, arteries and veins extend to periphery size and color of narrower lighter arteries surrounding retina for lesions size shape color and distribution. fovea and surrounding macula to direct lateral into light tiny reflection. repeat on left eye using opposite hadn’t and eye
ear
external ear (auricle- cartilage covered by skin curved outer ridge is helix parallel and anterior is anti helix fleshy part is lobule and ear canal- behind trigs curves inward 24 mm long surrounded by bone and thin hairless skin) captures sound waves for transmission into middle and inner ear middle ear (tympanic membrane ear drum, mastoid portion of temporal bone mastoid process palpable behind lobule inter ear (ear filled cavity that transmits sound by way of eardrum and three tiny bones ossicles, malleus, inca, and stapes . cochleae semicircular canals, and distal end of cochlea. assessed by testing auditory conduction
examining ear
inspect auricle and surrounding tissue for deformities lumps or skin lesions, if ear pain, discharge or inflammation present do tug test to test for otitis externa move auricle up and down press trigs and mastoid bone behind ear (mastoiditis)
otoscope
grab auricle in adult upward back and slightly away from head insert gently into ear canal downward and forward bracing hand
note cerumen, discharge, foreign bodies, redness of skin or swelling. pars flaccid and pars tensa, color and content of eardrum w/ cone of light should be pearly grey, translucent should be able to see through or pinkish.
If no cone of light pressure or fluid in middle ear cavity right ear is around 5 o’clock left ear is 7 o’clock if missing or moved pathology such as fluid, retraction of membrane note position of handle of malleus inspect short process of malleus, handle w/ gumbo at tip crosses obliquely from cone of light upward toward short process.
whispered voice test
one ear at a time 2 feet behind seated patient occlude non tested ear rub trigs to prevent transfer of sound exhale for quiet voice whisper thee numbers and letter until identify words if incorrect change it up and test again 3/6 numbers and letter correctly repeating it
weber test
base of vibrating tuning fork onto hear or forehead is it louder in one ear or same in both ears hear equally on both side.
rinne test
lightly vibrating tuning fork on mastoid behind ear and level w/ canal when indicates no longer hear near ear canal U of fork face forward maximizing sound heard longer though ear than bone do both
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Hearing loss
unilateral or bilateral? sudden (if sudden usually stroke or infection) or gradual onset? Other associated symptoms (earache, vertigo, tinnitus)? Difficult understanding people when they talk (sensorineural loss w/ noisy environments make hearing worse difficulty understanding speech. ) or in a noisy environment (conductive loss will be able to hear w/ noise)? presbycusis- degernating hair cells in ear lead to gradually progressive hearing loss, for high-frequency sounds and is a common age-related cause also associated w/ disease.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• earache
unilateral or bilateral? sudden or gradual onset? pain (otalgia)? pressure? itchy? discharge (otorrhea)? fever? headache? numbness? Pain in otitis externa (inflammation of external ear canal) and otitis media- inflammation and infection of middle ear deeper w/in ear. Pain may be referred from other structures in mouth, throat, or neck.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• tinnitus
perceived sound that has no external stimulus like a musical ringing, rushing, popping or roaring in one or both ears accompanies hearing loss) common increasing in frequency w/ age. when found w/ hearing loss and vertigo suspect Meniere disease
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• discharge
earache or trauma associates found in acute otitis externa and acute or chronic otitis media w/ perforation presenting w/ yellow-green discharge
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Vertigo
- sensation of true rotational movement of patient or surroundings (tilting) pointing to problem in labyrinth of inner ear, peripheral lesions of CN 8 or lesions in central pathway or nuclei in brain. Dizziness (room spinning) Dizziness is a non specific term that encompasses several disorders. A thorough history is necessary in order to identify the etiology. Vertigo is defined as a spinning sensation accompanied by nystagmus and ataxia, Presyncope is a feeling of faintness or lightheadedness, Disequilibrium is unsteadiness or imbalance, Psychiatric causes of dizziness include: anxiety and panic disorder, depression, Multifactorial or unknown etiology and light-headedness usually accompany foundin presncope, weakness, unsteadiness, and disequilibrium. important to check for nausea, vomiting, double vision, and gait disturbance looking at nystagmus. represents vestibular disease, from peripheral cuases in inner ear such as benign positional vertigo, labyrinthitis, vestibular neuri- tis, and Ménière disease. Ataxia, diplo- pia, and dysarthria signal central neurologic causes in the cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor; also consider migraine.32 Feeling light- headed, weak in the legs, or about to faint points to presyncope from arrhyth- mia, orthostatic hypotension, or vaso- vagal stimulation.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Nosebleed
• - (epistaxis) bleeding from nasal passages or in paranasal sinuses or naso pharynx and may go into throat ask where it comes from or was it coughed up (hemoptysis) or vomited (hematemesis). epitstaxis include trauma (nose-picking), inflammation, drying and crusting of nasal mucosa, tumors, and foreign bodies.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Sore throat
• - usually associated with URI
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• hoarseness
• - change in the voice quality, sounding husky, rough, harsh, or lower pithced than usual. Caused by disease of larynx, extralaryngeal lesions pressing on laryngeal nerves. Ask about allergies, acid reflux, smoking, alcohol use, inhalations, and frequency of talking. If acute, consider voice overuse, acute viral laryngitis, and possible neck trauma. If hoarseness lasts over 2 weeks, refer for laryngoscopy and consider causes such as hypothyroidism, reflux, vocal cord nod- ules, head and neck cancers including thyroid masses, and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis
Auricle
- external cartilage covered by skin and has firm elastic consistency
Antihelix
- external, parallel and anterior to helix is curved prominence
Cochlea-
inner ear containing semicircular canals, distal end of auditory nerve, vestibulococchlear nerve or CN8. moements of stapes virbate perilymph in labyrinth of semicircular canals and hair cells and endolymph in ducts of cochlea, producing electrical electrical nerve impulses transmitted by auditory nerve to brain. much of middle ear and all of inner ear inaccessible to direct examination.
Cone of light
middle ear umbo where eardrum meets tip of malleus light reflection fans downward and anteriorly
Ear canal-
external curves inward and is 24mm long. cartilage encases its outer 2/4s, skin is hairy and contains glands that produce cerumen (wax). inner third of canal is surrounded by bone and lined by thin, hairless skin.
Eustachian tube-
proximal end of Eustachian tube connects middle ear of nasopharynx.
Helix
- External cartilaginous surface on outer of ear, prominent curved outer ridge.
Incus
- middle ear part one of ossicles hammer shaped
Lobule
- external lower lobe of ear where you pierce someone’s ear. Inferiorly fleshy projection of earlobe
Malleus
- middle ear anvil shaped located behind tympanic membrane visble through it and angled obliquely and held other ossicles inward. have handle and short process of malleus.
Mastoid process-
behind ear canal is msdtoid process of temporal bone on external area. palpable behind lobule. can develop mastoiditis as a result of pain, swelling, and erythema behind ear begins w/ acute totiis left untreated or recent URI look behind ear swelling and erythema treat it aggressively go in surgically and must drain childs ear or hav eto remove mastoid ear cells
Ossicles-
middle ear making up the malleus, incus, and stapes transforming sound vibrations into mechanical waves for inner ear.
Stapes
- saddle shaped bone connected to cocchlea
Tragus-
External triangle shaped outcropping covering of nodular protrusion points backward over entrance to canal. external acoustic meatus, ear canal opens behind
Tympanic membrane-
lateral eardrum, marking medial limit of external ear. external ear captures sound waves for transmission into middle and inner ear.
Tympanic membrane-
lateral eardrum, marking medial limit of external ear. external ear captures sound waves for transmission into middle and inner ear.
- Compare and contrast conductive hearing loss and sensorineural hearing loss.
First part of hearing pathway, external to middle ear is conductive. Air conduction describes normal first phase in hearing pathway. AC more sensitive than bone conduction (BC).
sensorineural, second part of pathway involving chochlea and cochlear nerve. Labyrnth of three semicircular canals in the inner ear senses the position and movements of head and helps maintain balance. see weber and rinne test
conductive loss- Initiates from pathology in the external or middle ear
Interference with vibration transmission to sensory apparatus. Sick can hear it louder in that ear caused bu impaction, infection of external or middle perforated membrane, interference w/ vibratory trnasmition external or middle ear for conductive loss.
Common causes: Cerumen impaction
Otitis Externa
Otitis Media
Perforated TM
Tumors/Growths
sensorineural loss
Initiates from pathology in the inner ear, cochlear nerve or central brain connections w/ oval window and beyond vestibule, cochleae etc. .
Difficulty with higher frequency sounds
Hard to hear their own voice
Common causes:
Presbycusis (older person hearing loss)
Noise-induced (damaged internal structures of inner ear)
Meniere’s Disease (vertigo, hearing loss, pain in ear, and tinnittus.)
Ototoxic medications
Tumor/Growths
Systemic Disease
Sudden hearing loss (alarm symptom)
- Given a diagram or picture of the nose and sinuses, identify the following structures:
Ethmoid sinus, Frontal sinus, Maxillary sinus, Nares, Nasal septum, Nasopharynx, Sphenoid sinus, Turbinates (S/M/I)- curving bony structures covered by highly vascular mucous membrane, protrude into nasal cavity. temperature control warming up air before getting to lungs, cleansing
below each is a groove or meatus named according to turbinate above it. nasolacrimal duct drains into inferior metaus, most of paranasal sinuses drain into middle meatus w/ nonvisble opening usually visible. additional surface area provided by turbinates and overlying mucosa aids nasal cavities in principal functions: cleansing, humidification, and temperature control of inspired air. Vestibule- air enters nasal cavity through anterior naris on either side, passes into widened area of this and on through narrow nasal passage. lined with hair-bearing skin, not mucosa.
- Given a diagram or picture of the mouth and pharynx, identify the following structures:
Buccal mucosa Gingiva Hard palate Labial frenulum Lingual frenulum Papillae Parotid duct Soft palate Tonsils Uvula
- Discuss and demonstrate appropriate technique for an ear exam on a model patient to assess:
• External ear-
tug test Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa (inflammation of the ear canal Why we press tragus and pull on ear because ear can be tender. External ear infection (Someone in diabetic w/ decreased immune or immune problems could lead to serious infelction going to brain malignant otitis externia not a cancer just an infection and very aggressive bacterial infection. May see pussy type of charge from walls especially in someone who is immune compromised by psueodmonis bacteria. Staph aureus most common cause of this in public hot tubs or swimming), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear occurs in otitis media.
- Discuss and demonstrate appropriate technique for an ear exam on a model patient to assess:
• Ear canal-
use otoscope w/ largest speculum inserting into canal. Position the patient’s head so that you can see comfortably through the otoscope. Pull auricle upward, backward, and slightly away from the head. Holding the otoscope like a pen bracing hand against patient’s face handle between your thumb and fingers. Insert the speculum gently into the ear canal, directing it somewhat down and forward and through the hairs, if any. Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or swelling. Cerumen, which varies in color and consistency from yellow and flaky to brown and sticky or even to dark and hard, may wholly or partly obscure your view. In acute otitis externa the canal is often swollen, narrowed, moist, pale, and tender. It may be reddened. Cerumen fomred by cells in external auditory meatus hair is normal for protection not allow things to go into ear create waxy cerumen deterrent for insects and protection. The longer its been in there the darker it is and it has gotten out
- Discuss and demonstrate appropriate technique for an ear exam on a model patient to assess:
Tympanic membrane
• (including mobility)- Inspect the eardrum, noting its color and contour. The cone of light, should be easy to see, to orient you. Identify the handle of the malleus, noting its position, and inspect the short process of the malleus. Gently move the speculum so that you can see as much of the drum as possible, including the pars flaccida (pulling or bulding functions in helping to maintain pressure tighten or loosen) superiorly and the margins of the pars tensa. Look for any perforations. The anterior and inferior margins of the drum may be obscured by the curving wall of the ear canal. Mobility of the eardrum can be evaluated with a pneumatic otoscope. In chronic otitis externa, the skin of the canal is often thickened, red, and itchy. Look for the red bulging drum of acute purulent otitis media30 and for the amber drum of a serous effusion. An unusually prominent short process and a prominent handle that looks more horizontal suggest a retracted drum. A serous effusion, a thickened drum, or purulent otitis media may decrease mobility. If there is a perforation, there will be no mobility.
- Discuss and demonstrate appropriate technique for an ear exam on a model patient to assess:
Air and bone conduction (Weber and Rinne)-
• if patient fails whispered voice test. Test for lateralization (Weber test). Place the base of the lightly vibrat- ing tuning fork firmly on top of the patient’s head or on the midfore- hea 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. In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. Explanations include otosclerosis, otitis media, perforation of the eardrum, and cerumen. In unilateral sensorineural hearing loss, sound is heard in the good ear. Compare AC and BC (Rinne test). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal (Fig. 7-45). When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ask if the patient hears a vibration (Fig. 7-46). Here, the “U” of the fork should face forward, which maximizes sound transmission for the patient. Normally, the sound is heard longer through air than through bone (AC > BC). In conductive hearing loss, sound is heard through bone as long as or lon- ger than it is through air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air
- Discuss and demonstrate appropriate technique for a nose exam on a model patient to assess:
External surface-
Approximately the upper third of the nose is supported by bone, the lower two thirds by cartilage. Air enters the nasal cavity through the anterior naris on either side, then passes into the widened area known as the vestibule and on through the narrow nasal passage to the nasopharynx. Tenderness of the nasal tip or alae suggests local infection such as a furuncle, particularly if there is a small erythematous and swollen area. Pressure on tip of nose use a penlight to view each nasal vestibule noting asymmetry or deformity of nose. Note any nasal deviation.
- Discuss and demonstrate appropriate technique for a nose exam on a model patient to assess:
• Mucosa- covers septum and inner nose and is a mucous membrane well supplied w/ blood. covers the septum and turbinates. Note its color and any swelling, bleeding, or exudate. If exudate is present, note its character: clear, mucopurulent, or purulent. The nasal mucosa is normally somewhat redder than the oral mucosa. In viral rhinitis, the mucosa is red- dened and swollen; in allergic rhinitis, it may be pale, bluish, or red. Viral infection w/ fluid festering becoming second type of bacterial infection. Causing bulging red tympanic membrane can barely see bulbs may see bubbles or effusions, yellow and pussy blocking fluid
Upper respiratory runny nose will precede the ear infection. Cant get rid of fluid and infection can come from ear or upper respiratory
- Discuss and demonstrate appropriate technique for a nose exam on a model patient to assess:
Septum
• - medial wall of each nasal cavity supported by both bone and cartilage. Don’t touch not if deviated. Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient’s finger can reach) is a common source of epistaxis (nosebleed). Fresh blood or crusting may be seen. Causes of septal perforation include trauma, surgery, and intranasal use of cocaine or amphetamines, which also cause septal ulceration. Nasal polyps (are pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses, seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis. Malignant tumors of the nasal cavity occur rarely, associated with exposure to tobacco or chronically inhaled toxins.
7. Discuss and demonstrate appropriate technique for a nose exam on a model patient to assess: Sinus tenderness (frontal & maxillary) and transillumination
- Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses. Local tenderness, together with symptoms such as facial pain, pres- sure or fullness, purulent nasal dis- charge, nasal obstructions, and smell disorder, especially when present for >7 days, suggest acute bacterial rhonosinusitis involving the frontal or maxillary sinuses.
7. Discuss and demonstrate appropriate technique for a nose exam on a model patient to assess: Sinus tenderness (frontal & maxillary) and transillumination
- Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses. Local tenderness, together with symptoms such as facial pain, pres- sure or fullness, purulent nasal dis- charge, nasal obstructions, and smell disorder, especially when present for >7 days, suggest acute bacterial rhonosinusitis involving the frontal or maxillary sinuses.
- Discuss and demonstrate appropriate technique for a mouth exam on a model patient to assess:
Lips, oral mucosa, and gums-
lips are muscular folds that surround the entrance to the mouth. When opened, the gums (gingiva) and teeth are visible. mucosa up to gum may look different paler skin be white or pinkish, darker color skin brown. Frenulum attaches thing lower lip to gingiva same up top
Note the color, moisture, any lumps, ulcers, cracking or scaliness. Scalloped shape of the gingival margins and the pointed interdental papillae. gingiva is firmly attached to the teeth and to the maxilla and mandible in which they are seated. In lighter-skinned people, the gingiva is pale or coral pink and lightly stippled. In darker-skinned people, it may be diffusely or partly brown, as shown below. A midline mucosal fold, called a labial frenulum, connects each lip with the gingiva. A shallow gingival sulcus between the gum’s thin margin and each tooth is not readily visible (but is probed and measured by dentists). Adjacent to the gingiva is the alveolar mucosa, which merges with the labial mucosa of the lip. The buccal mucosa lines the cheeks. Each parotid duct, sometimes termed Stensen duct, opens onto the buccal mucosa near the upper second molar. Its location is frequently marked by its own small papilla. Oral mucosa inspect for color, ulcers, white patches, and nodules. Oral white reddened areas, nodules, or ulcerations. feel for any indulation. Men aged >50 years, smokers, and heavy users of chewing tobacco and alcohol are at highest risk for cancers of the tongue and oral cavity, usually squamous cell carcinomas on the side or base of the tongue. Any persistent nod- ule or ulcer, red or white, is suspect, especially if indurated. These discolored lesions represent erythroplakia and leu- koplakia and should be biopsied.72,73
Note the carcinoma on the left side of the tongue below. Inspection and pal- pation remain the standard for detec- tion of oral cancers
- Discuss and demonstrate appropriate technique for a mouth exam on a model patient to assess:
pharynx
With the patient’s mouth open but the tongue not pro- truded, ask the patient to say “ah” or yawn. This action helps you see the poste- rior pharynx well. You can also ask the patient to “open the back of your throat” since many adults have learned to inspect their own posterior pharynx while looking into a mirror. Alternatively, you can press a tongue blade firmly down on the midpoint of the arched tongue—back far enough to visualize the pharynx but not so far that you cause gagging. Simultaneously, ask for an “ah” or a yawn. Note the rise of the soft palate—a test of CN X (the vagal nerve). In CN X paralysis, the soft palate fails to rise and the uvula deviates to the opposite side (points “away from the lesion”). Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx. Note their color and symmetry and look for exudate, swelling, ulceration, or tonsillar enlargement. If possible, palpate any suspicious area for induration or tenderness. Tonsils have crypts, or deep infoldings of squamous epithelium, where whitish spots of normal exfoliating epithelium may sometimes be seen. Tonsillar exudates with a beefy red uvula are common in streptococcal pharyngitis, but warrant rapid anti- gen-detection testing or throat cul- ture for diagnosis.
- Discuss and demonstrate appropriate technique for a mouth exam on a model patient to assess:
teeth
Each tooth, composed chiefly of dentin, lies rooted in a bony socket with only its enamel-covered crown exposed. Small blood vessels and nerves enter the tooth through its apex and pass into the pulp canal and pulp chamber. Note that there are 32 adult teeth, conventionally numbered 1 to 16 right to left on the upper jaw and 17 to 32 left to right on the lower jaw. Bright red edematous mucosa under- neath a denture suggests denture sto- matitis (denture sore mouth). There may be ulcers or papillary granulation tissue. Inspect for any missing, discolored, misshapen or abnormal positioned teeth.
Tonsils- note the right tonsil protruding from the hollowed tonsillar fossa, or cavity, between the anterior and posterior pillars. In adults, tonsils are often small or absent, as in the empty left tonsillar fossa.
- Discuss and demonstrate appropriate technique for a mouth exam on a model patient to assess:
Hard and soft palate-
Above and behind the tongue rises an arch formed by the anterior and posterior pillars, the soft palate, and the uvula. A meshwork of small blood vessels may web the soft palate. The posterior pharynx is visible in the recess behind the soft palate and tongue.
- Discuss and demonstrate appropriate technique for a mouth exam on a model patient to assess:
Tongue-
The dorsum of the tongue is covered with papillae, giving it a rough sur- face. Some of these papillae look like red dots, which contrast with the thin white coat that often covers the tongue. This patient has an erythem- atous posterior pharynx. The undersurface of the tongue has no papillae. Note the midline lingual frenulum that connects the tongue to the floor of the mouth and the ducts of the submandibular gland (Wharton ducts) which pass forward and medially. They open on papillae that lie on each side of the lingual frenulum. The paired sublingual salivary glands lie just under the floor of the mouth mucosa. Symmetric sticking out of tongue.
Tongue frenulum, look in mouth thoroughly. Submandibular glands enter underneath tongue warntons duct under tongue next to frenulum. Papillae taste buds normal to be rough.
Acute otitis media-
chronic OM
infection of the middle ear may perforate and have yellow-green discharge. marked by middle ear fluid and inflammation. Often caused by obstruction of the Eustachian tube.
is a recurrent infection of the middle ear in the presence of a TM perforation. Occurs more commonly in children. Most often follows episodes of acute OM.
Bullous myringitis-
painful hemorrhagic vesicles appear on the tympanic membrane, the ear canal, or both. Symptoms include earache, blood-tinged discharge from the ear, and conductive hearing loss. Inflammation reaction is Extremely Painful Caused by viral or bacterial infection
Serous effusion-
amber drum a thickened drum, or purulent otitis media may decrease mobility. no cone of light everything looks like you cant see bones fluid cloudyness or bubbles (serous effusion)
If there is a perforation, there will be no mobility. Serous effusions are usually caused by viral upper respiratory infections (otitis media with serous effusion) or by sudden changes in atmospheric pressure as from flying or diving (otitic barotrauma). The eustachian tube cannot equalize the air pressure in the middle ear and outside air. Air is absorbed from the middle ear into the bloodstream, and serous fluid accumulates in the middle ear instead. Symptoms include fullness and popping sensations in the ear, mild conduction hearing loss, and, sometimes, pain.Amber fluid behind the eardrum is characteristic, as in this patient with otitic barotrauma. A fluid level, a line between air above and amber fluid below, can be seen on either side of the short process. Air bubbles (not always present) can be seen here within the amber fluid.
Tympanosclerosis
- a scarring process of the middle ear from otitis media that involves deposition of hyaline and calcium and phosphate crystals in the eardrum and middle ear. When severe it may entrap the ossicles and cause conductive hearing loss. In the inferior portion of this left eardrum, note the large, chalky white patch with irregular margins. It is typical of tympanosclerosis: a deposition of hyaline material within the layers of the tympanic membrane that sometimes follows a severe episode of otitis media. It does not usually impair hearing and is seldom clinically significant. Other abnormalities in this eardrum include a healed perforation (the large oval area in the upper posterior drum) and signs of a retracted drum. A retracted drum is pulled medially, away from the examiner’s eye, and the malleolar folds are tightened into sharp outlines. The short process often protrudes sharply, and the handle of the malleus, pulled inward at the umbo, looks foreshortened and more horizontal.
Exudative tonsillitis-
This red throat has a white exudate on the tonsils. This, together with fever and enlarged cervical nodes, increases the probability of group A streptococcal infection or infectious mononucleosis. Anterior cervical lymph nodes are usually enlarged in the former, posterior nodes in the latter.
Geographic tongue-
Map w/ smooth red island and pappplae missing generalized inflammatory reaction w/ cirrhosis and immune problem patches move arround and are migratory
In this benign condition, the dorsum shows scattered smooth red areas denuded of papillae. Together with the normal rough and coated areas, they give a maplike pattern that changes over time
Gingival hyperplasia
Inflammed gums, sweollen pushing teeth usually plague buildip causing and not good dental hygiene w/ bacteria getting in there irritating tissues
- Gums enlarged by hyperplasia are swollen into heaped-up masses that may even cover the teeth. The redness of inflammation may coexist, as in this example. Causes include phenytoin therapy (as in this case), puberty, pregnancy, and leukemia.
Leukoplakia-
A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa. May or may not be benign condition smoking, chewing tobacco, immune system issues will not scrape off benign and with redder or speckled areas could indicate cancer
The extensive example shown on this buccal mucosa resulted from frequent chewing of tobacco, a local irritant. This benign reactive process of the squamous epithelium may lead to cancer and should be biopsied. Another risk factor is human papillomavirus infection.
Oral carcinoma-
Squmaous most common inspect entire mouth underneath and sides of tongue
This ulcerated lesion is in a common location for carcinoma. Medially, note the red- dened area of mucosa, called erythroplakia, that is suspicious for malignancy and should be biopsied.
Pharyngitis-
Petechiae- bleeding from small capillaries from inflammation and irritation. redness is diffuse and intense. Each patient would probably complain of a sore throat, or at least a scratchy one. Causes are both viral and bacterial. If the patient has no fever, exudate, or enlargement of cervical lymph nodes, the chances of infection by either of two common causes—Group A streptococci and Epstein-Barr virus (infectious mononucleosis)—are reduced.
Thrush-
yeast infection from Candida species. Common in babies and elderly immune system problems fungal infection actually wills crape off
Shown here on the palate, it may appear elsewhere in the mouth (see p. 297). Thick, white plaques are somewhat adherent to the underlying mucosa. Predisposing factors include (1) prolonged treatment with antibiotics or corticosteroids and (2) AIDS
- Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with a chief complaint of:
• Change in vision- sudden or gradual (cataracts or macular degeneration)? Unilateral or both eyes? Painful or painless? Central or peripheral? Floaters? Lights? Specks?
o If sudden loss is unilateral and painless can be vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion (CRVO), or central retinal artery occlusion (CRAO).
o If painful usually in cornea and anterior chamber such as corneal ulcer, uveitis, traumatic hyphema, optic neuritis, and acute angle closure glaucoma (change in color and size of optic disc)
o If bilateral and painless, consider vascular etiologies such as giant-cell arteritis or nonphysiologic causes. If bilateral and painful, consider chemical or radiation exposures
o Slow central loss or gradual progressive in nuclear central cataract and macular degeneration (subretinal hemorrhage or exudates) vs. peripheral loss in advanced open-angle glaucoma (a lot more progressive not as sudden from loss of retinal ganglion cell axons pallor and increasing size of optic cup), one-sided loss w/ hemianopsia and quadrantic defects.
o Moving specs or strands suggest vitreous floaters; fixed defects, or scoto- mas, suggest lesions in the retina or visual pathways. Flashing lights with new vitreous floaters suggest detachment of the vitreous body from the retina.
o Diplopia- double vision are images side by sde (horizontal) on top of eachother (vertical) when one eye closed and which eye? is seen in lesions in the brainstem or cerebellum, and with weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of CN III or VI, or vertical diplopia from palsy of CN III or IV. Diplopia in one eye, with the other closed, suggests a problem in the cornea or lens. Trochlear damage, due to head trauma, congential causes, or central lesions, causes dysfunction of superior oblique muscle cuasing double vision.
o Red eye-pain in or around eyes, redness, and excessive tearing or watering. red painless eye in subcon- junctival hemorrhage, a red eye with a gritty sensation in viral conjunctivitis. A red painful eye is seen in hyphema, episcleritis, acute angle closure glau- coma, herpes keratitis, foreign body, fungal keratitis, and sarcoid uveitis.
amblyopia-
reduced vision in an otherwise normal eye. Amblyopia can lead to a “lazy eye,” with permanently reduced visual acuity if not corrected early. Can be from strabismus- where there is dysconjugate gaze or from the affected eye having markedly different refractive error.
Cover and uncover test. Bad eye should focus on object because strong eye not taking over for it. Weak eye deviates again when uncovered
Anisocoria
difference in pupillary diameter of 0.4mm or greater w/out known pathological cause common, benigin if equal in dim and bright light w/ brisk pupillary constriction
Conjugate
The normal conjugate movements of the eyes in each direction. Note any devi- ation from normal, or dysconjugate gaze.
exophthalmos-
Exophthalmos describes protrusion of the eyeball, a common feature of Graves ophthalmopathy, triggered by autoreactive T lymphocytes. In this disorder, there is a spectrum of eye changes, ranging from lid retraction to extraocular muscle dysfunction, dry eyes, ocular pain, and lacrimation. Changes do not always progress. In unilateral exophthalmos, consider Graves disease (though usually bilateral), trauma, orbital tumor, and granulomatous disorders
hyperopia-
farsightedness can see far away difficulty w/ close work
miosis-
constriction of pupils
mydriasis-
dilation of pupils
myopia-
near sightedness can see close up cant see distances
O.D.
O.S.
O.U.
O.D.- oculus dextrus both eyes
O.S.- oculus sinister left eye
O.U.- oculus uterque right eye
Presbyopia-
problem w/ accommodation due to age trouble w/ focusing lens can see better when card is farther wawy
scotoma-
areas of visual loss with surrounding normal vision
- Given a diagram or picture of an eye, a sagittal section of an eye, or a cross-section of the eye and a fundoscopic view, identify the following structures and their functions:
bulbar conjunctiva-
clear mucous membrane covering most of anterior eyeball adhering looely to underlying tissue meeting cornea at limbus. on inner surface of outer sclera that connects w/ lid
choroid-
nder the sclera contains connective tissue and blood vessels and covers the retina. vascular layer of the eye
cornea-
outermost see through part of eye
extraocular muscles-
coordinated action of four rectus and two oblique muscles controlling eye. Test function of each miscle and CN innervation by asking patient to move eye in direction controlled by that muscle in six cardinal directions.
fovea-
small depression lateral and inferior to disc in retinal surface marking point of central vision w/ a darkened circular area
Iris
Coloring part of eye
lateral canthus-
outer area of eyelids connecting
limbus- where
the bublar conjunctiva meets the eyelids
macula-
roughly circular surrounding fovea, but has no discernible margins
medial canthus-
inner area of eye corner
meibomian gland-
parallel row opening on the lid margin. fild of tear flid protects the conjunctiva and cornea from drying, inhibits microbial growth, and gives smooth optical surface of cornea.
optic nerve-
with its retinal vessels enters eyeball posteriorly, visible w/ opthalmoscope at optic disc.
palpebral conjunctiva- skin on undereye of eyelid where the opening between eyelids
physiologic cup-
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.
pupil-
areas of black on an eye that dilate accommodating the amount of light that enters rest of eye and lens. Pupil Reaction:
LIGHT
Direct light causes pupil to constrict Consensual causes opposite pupil to constrict
Follows same path as vision: retina, optic nerve, optic tract optic radiation this splits in midbrain at optic chasm to visual cortex. Motor impulses return to constrictor muscles of the iris via oculomotor nerve (CN III)
NEAR
Pupils constrict with near gaze mediatized by oculomotor nerve (CN III)
Along with this but not part of it eyes converge through medial rectus muscle and accommodation: lens changes concavity caused by ciliary muscle contraction not visible to us in iris when bring eye in focus in
Autonomic nerve supply:
Parasympathetic constriction
Sympathetic dilation
retina-
posterior surface contains the photoreceptors nerves attaching into optic nerve going back to brain. inner part of eye ocntianing rods and cones connecting to the optic nerve and see
Sclera
buff-colored surrounding eye at periphery not jaundice. muscles attach to sclera outer white covering white of eye
tarsal plate-
within the eyelids lie firm strips of connetive tissue
upper eyelid-
covers and protects top portion of eye
vitreous body-
not normally seen in an exam, transparent mass of gelatinous material fills eyeball behind lens and helps to maintain shape of eye
- Given a list of structures, identify and place in sequence the components of the lacrimal system, and the pathway of the flow of aqueous humor.
lacrimal gland small depression in w/in bony orbit, superior and lateral to eyeball. Tear fluid spread across eye and drains medially through two tiny holes called lacrimal puncta. Tears (film of fluid protecting conjunctiva and cornea from drying, inhibiting microbial growth, and give smooth optical surface to cornea) pass into lacrimal sac and into nose through nasolacrimal duct. Aqueous humor fills anterior and posterior chambers of eye produced by cilliary body, circulating from posterior chamber through pupil into anterior chamber draining through canal of Schlemm.
- Compare and contrast the direct and consensual pupillary responses.
A light beam shining onto one retina causes pupillary constriction in both that eye, termed the direct reaction to light, and in the contra- lateral eye, the consensual reaction to light. The initial sensory pathways are similar to those described for vision: retina, optic nerve (CN II), and optic tract, which diverges in the midbrain. Impulses back to the constrictor mus- cles of the iris of each eye are transmit- ted through the oculomotor nerve, CN III
- Describe the three components of the near reaction.
In the near reaction, when a person shifts gaze from a far object to a near object, the pupils constrict. This response, like the light reaction, is mediated by the oculomotor nerve (CN III). Coincident with this pupillary con- striction, but not part of it, are (1) convergence of the eyes, a medial rectus movement; and (2) accommodation, an increased convexity of the lenses caused by contraction of the ciliary muscles. In accommodation the change in shape of the lenses brings near objects into focus, but is not visible to the examiner. If reaction to light is impaired or questionable, test in both dim and normal. Good for testing Argyll Robertson and tonic (Adie) pupils). Testing one eye at time making it easier to concentrate on pupillary responses w/out distraction of EOM. Finger or pencil about 110cm from patient’s eye look alternately at it and into distance directly behind it. Watch for pupillary constriction w/ near effort an convergence of eyes. Third component of near reaction, accommodation of lens that brign near object into focus not visible. Compare normal light reaction and near reaction to benign anisocoria w/ constriction abnormalities of tonic pupil and oculomotor nerve (CN III) paralysis and dilation abnormalities of Horner and Argyll Robertson.
- Describe the methods used to test extraocular muscles, and discuss the significance of dysconjugate gaze, nystagmus, and lid lag.
Standing about 2 feet directly in front of the patient, shine a light into the patient’s eyes and ask the patient to look at it. Inspect the light reflection in the corneas. They should be visible slightly nasal to the center of the pupils. Asymmetry of the corneal reflections indicates a deviation from normal ocular alignment. A temporal light reflection on one cornea, for example, indicates a nasal deviation of that eye. A cover–uncover test may reveal a slight or latent muscle imbalance not otherwise seen; this is particularly useful in examining children. The normal conjugate movements of the eyes in each direction. Note any devi- ation from normal, or dysconjugate gaze. Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal. If you see this, bring your finger in to within the field of binocular vision and look again. Sustained nystagmus within the bin- ocular field of gaze is seen in congeni- tal disorders, labyrinthitis, cerebellar disorders, and drug toxicity. Lid lag as the eyes move from up to down. In the lid lag of hyperthyroidism, a rim of sclera is visible above the iris with downward gaze. Test six EOMs: Ask the patient to follow your finger or pencil as you sweep through the six cardinal directions of gaze. Making a wide H in the air, lead the patient’s gaze. In paralysis of the left CN VI, illustrated above, the eyes are conjugate in right lateral gaze but not in left lateral gaze. Pause during upward and lateral gaze to detect nystag- mus. Move your finger or pencil at a comfortable dis- tance from the patient. Because middle-aged or older adults may have difficulty focusing on near objects, increase this distance. Some patients move their heads to follow your finger. If necessary, hold the head in the proper midline position. If you suspect lid lag or hyperthyroidism, ask the patient to follow your finger again as you move it slowly from up to down in the midline. The upper eyelid should overlap the iris slightly throughout this movement. Note the rim of sclera from proptosis, an abnormal protrusion of the eye- balls in hyperthyroidism, leading to a characteristic “stare” on frontal gaze. If unilateral, consider an orbital tumor or retrobulbar hemorrhage from trauma. Finally, if the near reaction has not already been tested, test for convergence. Ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose. The converging eyes normally follow the object to within 5 cm to 8 cm of the nose. Convergence is poor in hyperthyroidism.
- Identify, explain, and demonstrate on a patient proper techniques to assess:
visual acuity-
Snellen eye chart. 20 feet away wearing corrective lenses, cover one eye and read smallest line of print. If cant read largest letter move closer until they can w/ the smallest line being where they can identify more than half letters. Visual acuity expressed as two numbers w/ the first indicating distance of patient from chart, and second, distance at which normal eye can read line of letters.
if cant read have them move closer, do a finger count, if still not might be light/dark perception.
Visual fields
area seen by an eye looking at central point Diagrammed as circle from patient view
Have central vision and lateral fields of light that overlap making 4D
90 degrees from line of gaze divided into quadrants
Blind spot each eye approx. 15-degree temporal of line of gaze at optic disc
Binocular vision only in overlap areas otherwise monocular
entire area seen by eye when it looks at a central point. conventionally diagrammed on circles from patient’s POV. center is focus w/ circumference 90O fro line of gaze. furthest on temporal side limited by brows, cheeks, and nose. there is an oval blind spot in normal field of each eye 15o temporal to line of gaze. Enlarged blind spot occurs in conditions affecting the optic nerve such as glaucoma, optic neuritis, and papilledema. Static finger wiggle test (arms length away from patient cover opposite eye while staring at open eye mimicking visual field of ipsalateral field of vision bring fingers into POV against yours) and kinetic red target test (move 5mm red-topped pin inward from beyond boundary of each quadrant along line bisecting horizontal and vertical meridians when does it appear.
conjunctiva and sclera-
have pt. look up as you depress both lower lids w/ thumbs, exposing sclera and conjunctiva noting color, vascular apttern of white scleral backround, note nodules or swelling. Resting fingers against cheek and brow opening wider looking at bulbar conjunctiva and everting upper lid.
cornea, lens, and pupils- use oblique lighting, inspect cornea of each eye for opacities noting any visile through pupil. Iris look at from temporal side looking for crescent shadow on medial side w/ casting crescent shadow indicative of narrow-angle glaucoma increase in IOP when aqueous drainage is blocked. pupils- size, shape, symmetry.
extraocular motions (EOM)-
H pattern looking for paralysis of CN 3, 4, &6 for the symptoms associated w/ each
fundi, including the optic disc, retina, retinal vessels, macula, and physiological cup-
locate the optic disc. contains the optic cup, Central Retinal Artery and Vein (larger) and The optic nerve attach in optic top surrounded by optic disc. The fovea is point of central vision surrounded by the macula which has indistinct edges. Look for the round yellowish-orange structure described above, or follow a blood vessel centrally until it enters the disc. The vessel size will help you. The vessel size becomes progressively larger at each branch point as you approach the disc. The sharpness or clarity of the disc outline. The nasal portion of the disc margin may be somewhat blurred, a normal finding. The color of the disc, normally yellowish orange to creamy pink. White or pigmented crescents may ring the disc, a normal finding.The size of the central physiologic cup, if present. It is usually yellowish white. The horizontal diameter is usually less than half the horizontal diameter of the disc. The comparative symmetry of the eyes and findings in the fundi. Inspect the retina, including arteries and veins as they extend to the periphery, arteriovenous crossings, the fovea, and the macula. Distinguish arteries from veins based on color size and light reflex. Inspect the fovea and surrounding macula. Direct your light beam laterally or ask the patient to look directly into the light. In younger people, the tiny bright reflection at the center of the fovea helps to orient you; shimmering light reflections in the macular area are common. Inspect the anterior structures. Look for opacities in the vitreous or lens. Rotate the lens disc progressively to diopters of around +10 or +12, so you can focus on the more anterior structures in the eye.
- Identify, explain, and correctly demonstrate on a patient special techniques for assessment of:
esotropia and exotropia (cover/uncover test) looking for deviations
functional impairment of the optic nerves moving in H pattern nasolacrimal duct obstruction- inspecting eye looking for excessive tearing or dryness of the eyes. Excessive tearing may be from increased production, caused by conjunctival inflammation or corneal irritation, or impaired drainage, caused by ectropion and nasolacrimal duct obstruction. Dryness from impaired secretion is seen in Sjögren syndrome.
- Discuss the following abnormalities of the eye and associated structures:
anisocoria
-difference in pupillary diameter of 0.4mm or greater w/out known pathological cause common, benigin if equal in dim and bright light w/ brisk pupillary constriction.
cataracts-
clouding of lens, variations in retinal pigmentation. Absence of a red reflex suggests an opacity of the lens (cataract) or, possi- bly, the vitreous (or even an artificial eye). Less commonly, a detached ret- ina or, in children, a retinoblastoma may obscure this reflex.
. Opacity of the lenses visible through the pupil. Risk factors are older age, smoking, diabetes, corticosteroid use. Nuclear Cataract. A nuclear cataract looks gray when seen by a flashlight
chalazion-
blocked meiboium gland. Unlike sty on the lid not on the margin of the lid. In lid not on edge.
A subacute nontender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed but, unlike a stye, usually points inside the lid rather than on the lid margin.
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 adults, especially African Americans. In young adults, suggests possible hyperlipoproteinemia. Usually benign.
ectropion-
Outward turning of the lower lid margin can lead to excess tearing. In ectropion, the lower lid margin turns 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 older adults.
entropion-
: Inward turning of the lower lid lashes and margin can lead to irritation. 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 less obvious.
esotropia
- inward deviation of eyes
exophthalmos-
Exophthalmos describes protrusion of the eyeball, a common feature of Graves ophthalmopathy, triggered by autoreactive T lymphocytes. In this disorder, there is a spectrum of eye changes, ranging from lid retraction to extraocular muscle dysfunction, dry eyes, ocular pain, and lacrimation. Changes do not always progress. In unilateral exophthalmos, consider Graves disease (though usually bilateral), trauma, orbital tumor, and granulomatous disorders
exotropia-
outward deviation of eye
papilledema-
Swelling of the optic disc and anterior bulging of the physiologic cup suggest papilledema which is associated with increased intracranial pressure. This pressure is transmitted to the optic nerve, causing stasis of axoplasmic flow, intra-axonal edema, and swelling of the optic nerve head. Papilledema signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions, so searching for this important disorder is a priority dur- ing all your funduscopic examinations
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.
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.
ptosis-
Ptosis is a drooping of the upper lid. Drooping of the upper eyelid can be due to oculomotor (sympathetic pathway through CN III) damage, Horner’s syndrome (anhydrosis- no sweating, (sympathetic nerve supply damage ptosis, miosis, anhidrosis)
Causes include myasthenia gravis, damage to the oculomotor nerve (CN III), and damage to the sympathetic nerve supply (Horner syndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.
sty-
: A painful, tender, red infection at the inner or outer margin of the eyelid, usually from Staphylococcus aureus (at the inner margin—from an obstructed meibomian gland; at the outer margin—from an obstructed eyelash follicle or tear gland). Staph infection of inner margin of eyelid from blocked meibomian gland or eyelash or duct constricted. A painful, tender, red infection at the inner or outer margin of the eyelid, usually from Staphylococcus aureus (at the inner margin—from an obstructed meibomian gland; at the outer margin—from an obstructed eyelash follicle or tear gland).
visual field defects-
causes of anterior pathway defects include glaucoma, optic neuropathy, optic neuritis, and glioma. posterior pathway defects include stroke and chiasmal tumors. As an example, when the patient’s left eye repeatedly does not see your fin- gers until they have crossed the line of gaze, a left homonymous hemianop- sia is present. It is diagrammed from the patient’s viewpoint
- Compare and contrast the findings of hypertensive and diabetic retinopathy.
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. Note the 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, 8, and 10 o’clock; a few more may be seen toward 10 o’clock. These two fundi show changes typical of severe hypertensive retinopathy, which is often accompanied by papilledema. 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.
Drusen: lipid deposits under the retina, increases risk of macular degeneration
Cotton Wool spot: Thought to occur due to ischemia from arteriole obstruction, thought to be nerve fiber infarct and arteriolar occlusion
Diabetic retinopathy: Note tiny red dots or microaneurysms. Note also the ring of hard exudates (white spots) located superotemporally. Retinal thickening or edema in the area of the hard exudates can impair visual acuity if it extends into the center of the macula. Detection requires specialized stereoscopic examination. 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. Note 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%. This is the same eye, but 2 years later and without treatment. Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity.Diabetic retinopathy
L top: Nonproliferative Retinopathy, Moderately Severe Note tiny red dots or microaneurysms. Note also the ring of hard exudates (white spots) located superotemporally.
L bottom: 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.
R top: 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.
R bottom: Proliferative Retinopathy, Advanced This is the same eye, but 2 years later and without treatment. Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity.
How does hearing work
Function- capture sounds transmitted to middle ear from forward vbration to the inner ear (fluid filled)
Vibratory sense transmit through bones to ovalatory membrane into the coclea w/ basement membrane having hair cells or cilia affected by virbatory sense generating action potential sending information through cochlear nerve then reaching tmeporal lobe
Myringotomy
vs.
tympanovstomy
If patient cant get them to fluid may put an incision in tympanic membrane to let it drain on its own or tympanostomy making incision putting tube in 6 or 8 years old tube will go downward and get bigger as it grows but before that a lot of time
aphthous ulcer
canker sore occurs on buccal mucosa or tongue not contagious not a herpes cold soar or from biting drink really hot w/ some kind of irritation.
lesion of CN XII hypoglossal
Deviated tongue ask them to stick tongue out can go to side or opposite side of lesion, push it and see if patient has strength through side of mouth.
Deviating away from side of lesion because of weakness
Gag reflex has two cranial nerves involved glossopharyngeal (9-sensory and vagus 10-motor
Yell while gagging
humor in eyes
posterior chamber behind the iris. Aqueous humor flows from ciliary bodies into posterior chamber then through the pupil into the anterior chamber out through canal of Schlemm helps control IOP comes and goes is secreted and made more of out through canal of schlem letting you focus through pupil into anterior allows for pressure
Vitreous gelatinous made in vitro w/ no turnover constant no replaceable fluid filling and maintaining the structure in posterior chamber maintaining it otherwise deflate
visual pathway
Reflected light enters pupil strikes photoreceptors on retina. Image upside down and reversed L to R. Nerve impulses travel through optic nerve (CN II) nasal side fibers cross over and down the curving optic tract to the optic radiation to the visual cortex in the occipital lobe
red eye
Some can be bad: acute glaucoma, uveitis, keratitis, Hyphema
Ask: contact lens, trauma, chemical exposure, anticoagulants, systemic disease
Alarm signs: Pain, foreign body sensation, decreased visual acuity, photophobia, diplopia, vomiting headache
