Week 4 - Head, Ear, Eyes

Question 1

What are the red flags for headaches?

Answer 1

Red Flags
recent onset (< 6 months); onset after 50 years; acute onset like a thunderclap or the “worst headache of
your life”; markedly elevated blood pressure; presence of rash or signs of infection; presence of cancer,
HIV, or pregnancy; vomiting; recent head trauma; or persisting neurologic deficits.

Question 2

What are the characteristics of headaches caused by

migraine, cluster headache, subarachnoid hemorrhage, and brain tumor?

Answer 2

Migraine: unilateral, episodic, tends to peak over several hours, prodromal symptoms (aura, photophobia), nausea, vomiting

Cluster: unilateral, retro-orbital, onset upon waking usually late night, accompanied by lacrimation, rhinorrhea

Subarachnoid hemmorhage: worst headache of my life, suddent onset, motor weakness

Brain tumor: dull pain, worse early morning, aggravated by head movement, cough

Question 3

Describe tension headaches, meningitis, analgesic headache

Answer 3

Tension: stress related, frontal, pressure-like, afternoon-evening time when you’re tired

Meningitis: dull pain, fever, neck stiffness, seizure

Analgesic: daily headache, caused by daily consumption of painkillers

Question 4

What are myopia and hyperopia?

Answer 4

Myopia is nearsightedness and hyperopia is farsightedness

Question 5

What are the causes of sudden unilateral visual loss both painless and painful?

Answer 5

Painless sudden, unilateral loss of vision may be caused by vitreous hemorrhage from diabetes or trauma,
macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.

Painful sudden, unilateral loss of vision may be due to problems in the cornea and anterior chamber,
which may be due to corneal ulcer, uveitis, traumatic hyphema, acute glaucoma, and optic neuritis from
MS.

Question 6

What are the causes of sudden bilateral visual loss both painless and painful?

Answer 6

Painless sudden, bilateral loss of vision may be caused by medications such as cholinergics,
anticholinergics, and steroids.

Painful sudden, bilateral loss of vision may be due to chemical or radiation exposure.

Question 7

What are the causes of gradual bilateral visual loss?

Answer 7

Cataracts or macular degeneration.

Question 8

What are the causes of flashing lights in the vision? What should you do in this case?

Answer 8

This suggest detachment of vitreous from the retina. Prompt eye consultation is indicated.

Question 9

What are the possible causes of diplopia?

Answer 9

Brainstem or cerebellar lesions, weakness or paralysis of one or more extraocular muscles, cornea or lens
problems (if only in one eye).

Question 10

Define two types of hearing loss. How does noisy environment affect each type?

Answer 10

Conductive (noisy environments help ability to hear) and sensorineural (noisy environments hamper
ability to hear).

Question 11

What medications can cause hearing loss?

Answer 11

Aminoglycosides, aspirin, NSAIDs, quinine, furosemide

Question 12

Which condition causes discharge through perforated eardrum?

Answer 12

May be due to acute or chronic otitis media.

Question 13

What is tinnitus? What are the features of Meniere’s disease? What are the possible causes of
dizziness? What are the causes of vertigo?

Answer 13

Tinnitus is a perceived sound that has no external stimulus, commonly a musical ringing or a rushing or
roaring noise.

Tinnitus associated with hearing loss and vertigo are features of Meniere’s disease.

Causes of dizziness include orthostatic hypotension; heart failure; inner ear (vestibular) problems;
sensory disorders; joint and muscle problems; neurological conditions; medications; anxiety disorders;
anemia; hypoglycemia; ear infections; overheating; and dehydration.

Causes of vertigo include benign paroxysmal positional vertigo (BPPV); inflammation in the inner ear;
Meniere’s disease; vestibular migraine; and acoustic neuroma.

Question 14

What are the cause of red and scaly scalp, and enlarged skull? What may the cause of excessive facial hair in women be?

Answer 14

Red and scaly scalp may indicate seborrheic dermatitis or psoriasis.

Enlarged skull may signify hydrocephalus or Paget’s disease.

Excessive facial hair in women (hirsutism) occurs in some women with polycystic ovary syndrome

Question 15

Define visual field. What are the near reactions when a person shifts gaze from a far object to a near one?

Answer 15

Visual field is the entire area seen by an eye when it looks at a central point.

The near reaction is pupillary constriction, convergence of the eyes, and accommodation of the ciliary
muscles when a person shifts their gaze from a far object to a near one.

Question 16

What are the six cardinal directions of gaze?

Answer 16

▪ medial (medial rectus);
▪ lateral (lateral rectus);
▪ superior/lateral (superior rectus);
▪ inferior/lateral (inferior rectus);
▪ superior/medial (inferior oblique); and
▪ inferior/medial (superior oblique).

Question 17

How will you test visual acuity? How will you test near vision? What is Presbyopia?

Answer 17

Visual acuity is tested with a Snellen eye chart with the patient 20’ from the chart.

Near vision is tested with special cards held 14” from the patient’s face.

Presbyopia is impaired near vision due to aging in middle-aged and older patients.

Question 18

How will you screen visual field? What are the causes of eyeball protrusion, eyebrow
scaliness, and upstarting palpebral fissure?

Answer 18

Visual fields by confrontation is used to test visual field by holding the patient’s gaze and bringing your
wiggling finger in from 2’ to each side until they can see them, then superior-lateral, then inferio-lateral.

Eyeball protrusion (exophthalmos) may be found in Graves’ disease or ocular tumors.

Eyebrow scaliness may be found in seborrheic dermatitis.

Upstarting palpebral fissure is found in Down syndrome.

Question 19

Define ptosis. What are its causes?

Answer 19

Ptosis is a drooping of the upper eyelid. Causes include myasthenia gravis, congenital issues, weakened
muscles, or damage to the oculomotor or sympathetic nerve supply.

Question 20

What are the causes of excessive tearing? How will you test nasolacrimal duct obstruction?

Answer 20

Excessive tearing may be from increased production (conjunctival inflammation, corneal irritation) or
impaired drainage of tears (ectropion, nasolacrimal duct obstruction).

Nasolabial duct obstruction is tested by having the patient look up and then pressing on the lower lid,
close to the medial canthus. A positive result is fluid is regurgitation upon pressure from the puncta into
the eye.

Question 21

What do large and small-sized pupils mean? What are the characteristics and causes Argyl Robertson pupils and Adie’s pupils?

Answer 21

Unequal pupils mean that the larger pupil cannot constrict properly. If both are large, it is due to
sympathetic(-like) reaction; if both are small, it is due to a parasympathetic(-like) reaction.

Argyll Robertson pupils are small, irregular pupils that accommodate, but do not react to light. This is
due to central nervous system syphilis.

Adie’s pupils are large, regular, and usually unilateral. Reaction to light is severely reduced and slowed,
or even absent. Near reaction, although very slow, is present. This is due to neurological disorder with
decreased deep tendon reflexes.

Question 22

How will you test for lid lag? How will you assess extraocular movements?

Answer 22

Test for lid lag by asking the patient to follow your finger as you move it slowly up and down along the
midline. Positive sign is if you can see white sclera above the iris, as they look down.

Extraocular movements are tested by asking the patient to follow your finger with their eyes only as you
move your finger in a wide H pattern.

Question 23

What are the contraindications of mydriatic eye drop? What is the significance of absent red reflex?

Answer 23

Contraindications of mydriatic eye drops include head injury and coma, or any suspicion of narrow-angle
glaucoma.

An absent red reflex signifies an opacity of the lens (cataract) or of the vitreous humor. Less commonly, a
detached retina or retinoblastoma may obscure this reflex (or an artificial eye).

Question 24

What is papilledema? What is its cause? What is the cause of enlarged cup?

Answer 24

Papilledema is a swelling of the optic disc and anterior bulging of the physiologic cup. It is caused by
increase intracranial pressure.

An enlarged cup suggests chronic open-angle glaucoma.

Question 25

What are the causes of red eye? What are the pain, vision and pupils in each?

Answer 25

Conjunctivitis
▪ Pain: mild discomfort
▪ Vision: not affected, except for mild blurring from discharge
▪ Pupils: not affected

Subconjuctival Hemorrhage
▪ Pain: absent
▪ Vision: not affected
▪ Pupils: not affected

Corneal Injury or Infection
▪ Pain: moderate to severe, superficial
▪ Vision: usually decreased
▪ Pupils: not affected unless iritis develops

Acute Iritis
▪ Pain: moderate, aching, deep
▪ Vision: decreased
▪ Pupils: may be small and, with time, irregular

Glaucoma
▪ Pain: severe, aching, deep
▪ Vision: decreased
▪ Pupils: dilated, fixed

Question 26

In which conditions is using eye drops to dilate the pupil contraindicated?

Answer 26

Head injury

Narrow angle glaucoma

Question 27

In which condition is the eye red but pain is absent, and vision and pupils are not affected?

Answer 27

Subconjunctival hemorrhage