Exam 2 Flashcards
7 attributes of a symptom
Location, Quality, Quantity or severity, Timing, Setting in which it occurs, Remitting or exacerbating factors, Associated manifestations
Common or Concerning Symptoms in Head/Neck
Headache, Change in vision, Double vision, Hearing loss, earache, tinnitus, Vertigo, Nosebleed, Sore throat/hoarseness, Swollen glands, Trauma
Questions to ask in head trauma
Is pt awake and oriented
Mechanism of injury
Time of injury
Loss of consciousness immediately postinjury, Subsequent level of alterness, Amnesia, Headache, Double or bluured vision, Bleeding from ears, nose, mouth, eyes
A concussion is
a disturbance in brain function caused by a direct or indirect force to the head
Symptoms that suspect presence of a concussion
Symptoms such as headache
Physical signs such as unsteadiness
Impaired brain function or confusion
Abnormal behavior
Sport concussion Assessment Tool -2
Designed for use by medical professionals for pre-season sports screening. Then retaken post-injury
Classic Migraine Headache
Unilateral in 70% Pulsating or throbbing Hours to days Predominately female Nausea/vomiting Missing meals, menses, BCP, stress, certain foods
Cluster Headache
Adulthood Unilateral 1/2 to 2 hours Intense burning, searing knife like Several nights then several days then gone Predominately males Increased tearing/nasal discharge
Tension Headaches
Adulthood Unilateral or bilateral Hours to days Anytime Bandlike, constricting No prodrome Stress, anger, teeth grinding
Medication Rebound
Diffuse Lasts hours Hours or days of last dose Dull or throbbing Daily analgesics Abrupt analgesic stop
Hyperthyroidism
Nervousness Weight Loss Excessive sweating heat intolerance Warm, smooth, moist skin Graves disease Tachycardia
Hypothyroidism
Fatigue, lethargy Modest weight gain Dry coarse skin, cold intolerance Swelling of face, hands, legs Bradycardia Impaired memory
Head Exam includes
Head inspection, Symmetry Hair (for bugs/lice) Scalp (lesions, growths, scapes) Face (cranial nerve 7) Palpation Bony irregularities Oral mucosa Facial sensation Carotid and temporal arteries
Measure the circumference of head every exam from
Birth to 24 months
Infant’s head is ___ of its body length and ___ of its body weight at birth
1/4
1/3
Bones are separated by membranous tissue spaces called
Sutures
The areas where sutures intersect are known as
Fontanelle
Anterior fontanelle closes about
18 months (range 9-24 m.)
Posterior fontanelle closes about
2 months
Bulging fontanelle is caused by
increased intracranial pressure (also seen with coughing, vomiting, crying)
Sunken fontanelle are caused by
Dehydration
Hydrocephalus
increased intracranial pressure from deficient spinal fluid circulation causes enlargement of the clavarium before the sutures are closed
Molding
repositioning of cranial bones to allow passage of baby through birth canal
Caput succedaneum
Subcutaneous edema over the presenting part of the head at delivery
It usually occurs over the occipitoparietal area and crosses suture lines
Transluminates
Cephalhematoma
Subperiosteal collection of blood Does not cross over suture lines. It is commonly found in the parietal region Does not transluminate Looks like horns
Plagiocephaly
Occurs when infant lies on one side constantly
Treated in most cases with parental education and different holding patterns, placing objects on interest opposite normal head rotation
Self resolves with age
Craniosynostosis
Premature closure of sutures, can cause asymmetry as well
Caused by early closure of fontanelles
Brachycephaly
premature closure of coronal suture
In neck, palpate for
masses, enlarged lymph nodes, cysts, position of thyroid
Congenital Muscular Torticolis
injury and possible bleed into sternocleidomastoid muscle at birth
Treatment with stretching exercises
Ear exam HPI/PROS
Difficulty understanding people when they talk/noisy environment?
Earache, Vertigo, Upper respiratory infections, Tinnitus, discharge
Nose exam HPI/PROS
rhinorrhea, seasonal problems, URI, meds/remedies tried, congestion only on one side, Epistaxis, check if anything is stuck up nose
Before insertion of the otoscope,
palpate tragus and pinna for pain - differentiates otitis externa from otitis media
Otoscopic Exam for adult
Pull pinna up, out and back
Otoscopic exam for child
pull pinna down, out and back
Inspect tympanic membrane for
color, light reflex, bone structure
Whisper Test
No equipment needed
Stand behind and to the side 1-2 feet away
Have patient put finger in ear not being tested
Exhale fully, then whisper 3 numbers or letters
Ask patient to repeat what they heard
Weber Test differentiates between what kinds of hearing loss?
Conductive and neurosensory
Weber Test
place vibrating fork in middle of patients vertex and ask where they hear the sound
Rinne Test helps determine
whether each ear detects sound better through air or bone
Rinne Test
place vibrating fork on pts mastoid process - ask to tell you when no longer hear sound (time in sec)
Immediately move fork so vibrating tines are about 2 cm from pts auditory canal - ask to tell you when can’t hear sound
Rinne Test normal
Normally hear sound through air longer than bone
Conductive hearing loss
External or middle ear disorder
Causes - foreign body, otitis media, perforated eardrum, otosclerosis
Sound lateralizes to impaired ear
Bone conduction longer than or equal to air conduction
Sensorineural Loss
Inner ear disorder involving the cochlear nerve
Causes - loud noise exposure, inner ear infections, trauma, acoustic neuroma, aging, familial disorders
Sound lateralizes to good ear
Air conduction longer than bone conduction
Conductive hearing loss Weber test
hear sound in impaired ear
Sensorineural hearing loss Weber test
hear sound in good ear
Conductive hearing loss Rinne test
Bone conduction longer than or equal to air conduction
Sensorineural hearing loss Rinne test
air conduction longer than bone conduction (appears normal)
Throat and mouth HPI/PROS
sore throat or pharyngitis, sore tongue, bleeding from gums, hoarsness, swollen glands, temperature intolerance (check thyroid), sweating, skin changes, tobacco use
Grading of tonsil enlargement
Scale of 1-4
Asymmetric protrusion of tongue suggests
Damage to CN 12, tongue goes toward same side of lesion
Deviateion of uvula to one side as it raises with phonation suggests
lesion to CN 10
Trachea in lung volume loss
Trachea pulled toward affected side
Trachea in thyroid enlargement or pleural effusion
Trachea pulled away from affected side
Tension pneumothorax
trachea deviates away from affected side
Collapsed lung
Trachea deviates toward affected side
If thyroid gland is enlarged listen for
bruits
Position of ear on infant
upper part of auricle joins scalp at or above level of line from canthus of eye
Sinuses at 1 year
Maxillary sinus
Sinuses at 6 years
Sphenoid, Ethmoid, and Maxillary sinuses
Sinuses at 10 years
Sphenoid, Frontal, Ethmoid, Maxillary sinuses
Antenatal teeth
Inspect infants for these, about 1 in 2000 babies born with them
Need to take out, loose and could be a choking risk for baby
Epstein’s pearls
pin head sized white or yellow, rounded elevations that are located along the midline of the hard palate near its posterior border or gums caused by retained secretions and disappear within a few weeks
Peak size of tonsils occurs between
2-6 years of age
Relatively larger in middle childhood than in infancy and adolescence
Teeth begin to erupt by
6-7 months - upper and lower central incisors
Four teeth added every four months after that
Full complement teeth are in by
2-3 years
Primary teeth usually begin to fall out at
5 years
Secondary teeth usually begin in the
6th to 7th year
Nasal foreign body causes
chronic unilateral rhinitis or congestion, foul smell or bad breath
Common in children from 9 mo. to 5 years
Cataracts
usually later in life, leading cause of blindness if not corrected
Leading cause of blindness in people over 65
Diabetes
Macular degeneration
central vision loss
Glaucoma
elevated pressure, peripheral vision lost first
Transient loss of vision
young patient may be due to migraine; in older adult an emboli problem
Flashes of light caused by
retinal detachment
Diplopia
double vision, one eye optical problem, 2 eyes alignment problem
Bulging eyes (exophthalmos) typically caused by
Thyroid disease
Eye Exam HPI & Pros
sudden or gradual problem, persistent or transitory, recent trauma, time spent on computer screens, new medications, past medical/surgical history, recent URI, one or both eyes, last eye exam
Thinning of eyebrows is one of first signs of
hypothyroidism
Snellen Eye chart tests
Visual Acuity
Use in well lit area, pt 20 ft away from chart
Cover one eye and read smallest line possible
Start left to right for one eye, then read it backwards for other eye
Visual acuity fraction
Numerator - distance from chart
Denominator - distance the average eye can read the chart
Rosenbaum chart tests
Near vision - hand held card; helps identify if need reading glasses or bifocals
Visual fields by Confrontation tests
Any defect in any quadrant of field of vision
Pt closes one eye, slowly bring your fingers into visual field halfway between you and pt at 45 degree angle
Pt says how many fingers they see when they see it through peripherals
Extra-ocular Muscles assessment
Stand 3 ft from pt and ask them to follow your fingers with eyes only
Draw large X, then a plus with index finger, and convergence (bring finger toward their nose)
Look for jerking or drifting of eyes
Nystagmus
jerking or drifting of the eyes
Accommodation or Near Reaction Testing
Checks if eyes will converge and pupils constrict
Stand to one side of pt and hold something close to their eyes - eyes should converge and pupils constrict
Then ask pt to look at the wall in front of them - eyes should diverge and pupils dilate
Pupillary Responses
measure each pupil size under normal conditions and with light shining in eye
Direct - constriction of pupil with light shining in that eye
Consensual - constriction of eye when shining light in opposite eye
Swinging light test
for functional impairment of optic nerves
Shine light in one eye, then rapidly swing to other eye
Should have slight dilation in second eye while light is crossing bridge of nose, but constrict equally to first when light enters pupil
Go back and forth several times - if pupil tires and continues to dilate rather than constrict, there is an afferent defect
Lateral Penlight Test
Estimate depth of the chamber of eye - look for glaucoma
Should be done before putting in mydriatic drops
Shine light from temporal side of head across front of eye parallel to plane of iris -
If nasal part of iris not lightened - shallow anterior chamber and risk of acute-angle glaucoma
Corneal light reflex
Tests ocular alignment by reflecting light of pt’s pupils
Shine light towards patient and observe where light reflects from
Normal - light reflects from center of pupils
Esotropia
Eye turned in
Corneal light reflected lateral to pupil
Exotropia
Eye turned out
Corneal light reflected medial to pupil
Cover Tests
Used to detect tropia Tests eye not being covered Cover one of pts eyes Observe movements in the uncovered eye Normal is no movement
Cover - Uncover Testing
Used to detect presence of a phoria
Tests covered eye (just as it is uncovered)
Cover and uncover eye - observe if covered eye moves
Normal test is no movement
Esophoria
Covered eye turns in (after cover uncover test)
Exophoria
Covered eye turns out (after cover uncover test)
Corneal Sensitivity
Testing cranial nerve V & VII
Ask pt to look up and away
Touch cornea with wisp of cotton
Intact CN V - afferent, senses touch, blink eye - motor (CN VII)
Stenson’s Duct
lateral to 2nd upper molar, opening of parotid duct
Wharton’s Ducts
opening on floor of mouth, opening of submandibular gland
Myopic
near sighted
Hyperopic
far-sighted
When using ophthalmoscope to look in pt’s right eye, what hand and eye should you use?
Right hand, right eye
What is the first thing you look for when using an opthalmoscope?
Red reflex -light strikes retina and bounces back
After seeing the red reflex with the ophthalmoscope, you move in on the eye and look for
blood vessels, optic disc, macula
Why is pediatric vision screening important?
Can affect visual acuity
Find diseases early - can treat and prevent blindness
Vision Screening in newborn - check anatomy by looking at
size of eyes, epicanthal folds, distance between eyes, and lids first
Then conjunctiva, sclera, iris, pupil
Epicanthal folds
Vertical fold of skin nasally that covers the lacrimal caruncle
Normal variants in Asian infants but may be a sign of genetic anomalies in others
Red reflex
orange to red light reflection from fundus
Should be equal in both eyes and fill pupil
Leukocoria
White reflex - could be caused by congenital cataract or retinoblastoma
Visual fixation is present at
birth
Visual fixation well developed by
6-9 wks
Visual following present by
3 months
Accomodation and Stereopsis present by
4 months
Visual screening in 6 - 12 months consists of
Red reflex & corneal light reflex
Inspection
Fixation & following
Poor fixation past 6 months is usually pathologic - requires ophthalmology referral
Visual screening in 3- 5 year old consists of
Red reflex
Inspection
Visual acuity
Cover-uncover test
Visual Acuity in newborns
20/400 - 20/800
Visual Acuity in 3 year olds and older
20/40 or better
Strabismus
misalignment of eyes Iris starts in: Eso - in (moves out to correct) Exo - out (moves in to correct) Hyper - up (moves down to correct) Hypo - down (moves up to correct)
Pseudostrabismus
Appearance of misalignment of eyes without actual strabismus present
Most common when there is a broad nasal bridge
Light reflection in same place on both eyes
Amblyopia
Loss of visual acuity due to active cortical suppression of vision of eye
Strabismus is one cause
Most effective screening is determination of visual acuity via noninvasive screening
Requirements for normal visual development
Clear retinal image
Equal image clarity
Proper eye alignment
Tropia
full time eye misdirection
more permanent
need surgery to correct
Phoria
eye moves because of disturbances in binocular vision
Can correct without surgery
