Quiz 2 Flashcards
what measures visual acuity, what does it measure, and what CN
CN II (optic nerve)
measures central vision
Snellen chart- 20 feet away
***normal changes older adults
wrinkling, decreased turgor, less hair on the head (fine), more coarse hair on eyebrows/in nose, droopy eyebrows, loss angle of jaw definition, larger pores, decreased senses (smell, taste, hearing)
***HAs
tension= frontal, band-like, dull throb
migraine= unilateral, pulsating, throbbing, n/v, photophobia
sinus HA
cluster= unilateral, behind an eye, severe burning, tearing or nasal drainage
what do the fractions mean in visual acuity testing
numerator= distances of the patient from the chart (20 feet away)
denominator= distance average eye can read the line
smaller the fraction, worse the vision
legal blindness= vision can’t be corrected to better than 20/200
ex: 20/200 means the patient can read at 20 feet what the average person can read at 200 feet
***how to test near vision
Each eye separately w/ handheld card like Rosenbaum Pocket Vision Screener
35cm/14 inch from eyes
how to test peripheral vision, what do abnormalities indicate
through confrontation test
sit 1m/3ft away, NP and pt cover opposite eyes and NP holds up # of fingers in each visual field
only significant if abnormal. Can indicate: stroke, retinal detachment, optic neuropathy, pituitary tumor, compression at optic chiasm, central retinal vascular occlusion
how to perform external eye exam
systematic manner, begin with appendages (eyebrows/surrounding tissue) and move inward
only inspect upper tarsal conjunctivae if concerned about foreign body
cobblestoning on conjuctivae
allergic or infectious conjunctivitis
cornea assessment
shine light, should be no blood vessels
sensitivity controlled by CN V tested with cotton tip to cornea & pt should blink (also tests CN VII facial nerve)
decreased corneal sensitivity= DM, HSV, herpes zoster, conquence of trigeminal neuralgia or ocular surgery
corneal arcus= lipids around cornea= lipid disorder < 40 y/o, common in > 60 y/o
miosis vs mydriasis
miosis= pupil constriction < 2mm. ex Opioid use
mydriasis= pupil dilation > 6mm. ex stimulant use
how to test for afferent pupillary defect and what it means
swinging flashlight test; second pupil should only slightly dilate when light crossing over then should constrict like opposite eye
if second pupil continues to dilate, afferent pupillary defect present AKA Marcus-Gunn pupil
testing for accommodation
pupils dilate w/ distant object (10cm) constrict as moves closer and eyes will converge together
*only of dx importance if defect in pupillary response to light
failure to respond to light but retaining constriction w/ accommodation seen in DM or syphilis
extraocular eye movements
controlled by CN III (oculomotor) IV (trochlear) VI (abducens) and 6 muscles
***strabismus
corneal light reflex test (look at light with both eyes then object) if fail do cover-uncover test
strabismus= cross eyed, eyes don’t line up
and referral to ophthalmologist
exotropic= outward away from nose
esotropic= inward toward nose
may have poor or double vision
**opthalmoscopic/fundoscopic exam
**how to stand and where to look: To exam the patient’s RIGHT eye, hold the ophthalmoscope in your RIGHT hand and use your RIGHT eye to look through the instrument.
inspects optic disc, arteries, veins, retina
needs pupil dilation so dim room; hold 12 inches away then move to 6 inches
red reflex first= light illuminates retina. Absence can mean cataract or hemorrhage
should NOT see discrete areas of light/dark pigment
may see venous pulsations
disc margin sharp well defined yellow to creamy pink color varies w/ race
move closer to eye, vessels seen 3-5 cm away
myopic (constriction)= use minus/red lens
hyperopic= use plus lens
normal disc margin w/ ophth. exam
well define and sharp, yellow to creamy pink but darker in darker skinned people
***retinal abnormalities
myelinated retinal nerve fibers= white area continuous w/ optic disc; no physiologic significance
papilledema= loss of definition of optic margin. Caused by increased ICP
glaucomatous optic nerve head cupping= raised disc margins w/ lowered central area; intraocular pressure, peripheral visual fields are constricted
From review:
**cotton wool spots= ill-defined yellow areas caused by infarction of nerve layer of retina; Vascular disease from HTN or DM
- arterial narrowing
- **Retinal arteriovenous nicking (AV nicking; hypertension/hypertensive retinopathy and cardiovascular diseases such as stroke)
-copper wiring
-disc edema
hemorrhages in retina
disc margin= poorly controlled or undx glaucoma
dot hemorrhages= microaneurysms in diabetic retinopathy
HTN retinopathy
mild= retinal arteriolar narrowing, arteriovenous nicking, opacity (copper wiring) of arteriolar wall; mod risk of stroke, coronary heart disease, death
mod= hemorrhage, cotton wool spots, hard exudates, microaneurysms; strong risk stroke cognitive decline, death
malignant/severe= above signs plus optic disc edema/papilledema; strong risk of death, NEEDS rapid BP lowering
**psuedostrabismus
**BABIES, Asian or native american
false appearance of strabismus caused by flattened nasal bridge or epicanthal folds in babies. Disappears by age 1.
Corneal light reflex can distinguish. *Asymmetric light reflex indicates true strabismus
visual acuity for child
use LEA or HOTV at 4 y/o
stand 10 feet away up to 5 y/o and 10 or 20ft 6 y/o and older
test both eyes first
visual acuity should be:
36-47 months old= 20/50 or better
48-59 months= 20/40
60 months (5 y/o) and up= 20/30
photoscreening is alternative for children 3-6 y/o
specialist if falls outside normal range OR if individual eyes have two-line difference
diabetic retinopathy (proliferative and non-proliferative)
PROLIFERATIVE
dot hemorrhages or microaneurysms and presence of hard and soft exudates
asx or blurred vision, distortion, visual acuity loss in more advanced
ophthalmoscope= balloon-like sacs on BV, blots of hemorrhages on retina, tiny yellow patched hard exudates, cotton-wool spots * (soft exudates)
NONPROLIFERATIVE
development new vessels d/t anoxic stimulation. Bleeding major cause blindness
asx or floaters, burred vision, progressive visual acuity loss, hemorrhage
***cataracts
opacity in lens
central with aging
blurry vision, faded colors, lights too bright, halo around lights, poor night vision/double vision, freq. prescription changes
old age, *** biggest= DM, smoking, obesity, sun exposure (UV light)
children’s ear predisposed to what and why
middle ear effusion
adenoids occlude eustachian tube interfered w/ aeration of middle ear
sensorineural hearing loss
occurs first w/ high frequency sounds (speech and localization of sounds)
***otoscope eval adult and over age of 3
head toward opposite shoulder, auricle upward and back
should see: min cerumen, pink color, hairs in outer third, no odor/lesions/discharge/foreign body
normal TM
translucent, pearly gray, visible landmarks, no perforations. Conical contour with concavity at umbo
bulging TM
more conical, loss body landmarks, distorted light reflex
Hearing eval
CN VIII
whispered voice=occlude non tested ear, stand behind to side arms length exhale full and say 3-6 letters and numbers. Should repeat > 50%. Very good to detect in age 50-70 y/o
Weber and Rinne tests
***Weber test
***Conductive and sensorineural hearing test
assesses unilateral hearing loss
place base vibrating tuning fork midline on head- can hear equally or one ear better?
if unequal, repeat occluding each ear. Should hear BEST in occluded ear
shouldn’t have lateralization
conductive hearing loss= sound heard better in affected ear
sensorineural hearing loss= sound lateralizes to better ear
***rinne test
**Strike fork ONCE Put on mastoid bone (hear for lesser amount of time) bring up to ear and hear air conduction should hear for longer
**looks at JUST conductive hearing loss
distinguish if hears better by ear or bone conduction
air conduction SHOULD be heard longer than bone 2:1 aka heard twice as long (rinne positive)
***cocaine use signs in nose
rhinorrhea, hyperemia, edema nasal mucosa, white powder on hairs
long term= scabs, decrease smell/taste, septum perforation, chronic congestion, nosebleeds, chronic sniffling
allergy signs in nose
bluish gray or pale pink turbinates, swollen boggy
***otoscope eval in infant
pull auricle down and back
TM not conical until > 3 months so diffuse light reflex, limited mobility, dullness, opacity of pink/red TM
hearing test in children
whisper behind them, meaningful words (ex spongebob) they should turn toward. No rinne/weber until can follow instructions 3-4 y/o
***cobblestoning
conjunctiva= conjunctivitis
back of throat= PND, erythema with it
***Tonsil grading
0 to 4+
surgically removed to touching each other > 75% of oropharynx
***ruptured TM
sharp pain, bloody or yellow discharge, tinnitus, hearing loss
***what sound made when laryngeal obstruction
stridor
***what age infant turn head to sounds
4-6 months
***diaphragmatic excursion
purpose= looking for symmetry and how far lungs can expand so looking for difference in size
normal 5-6 cm
increased= concerned about pleural effusion
*** normal respiratory to HR ratio
1:4
***percussion of lungs
patient sitting up with arms on something or folded leaning forward to increase surface size of lung fields
dull sounds= pneumonia or pleural effusion (not air filled) or a mass
