MED 1.3 HEENT

1.3 9 June 2014

HEENT Medicine Faculty “What a slut time is. She screws everybody.” — John Green, The Fault in Our Stars

― Paulo Coelho TOPIC OUTLINE I.

II.

III.

IV. V.

VI. VII. VIII. IX. X.

XI. XII.

The Head A. Common or Concerning Symptoms B. The Head Examination C. Face Abnormalities in Different Diseases The Eye A. The Eye Examination B. Visual Field Defects C. Observation of External Structures D. Abnormalities of the Eyes Testing Extra-Ocular Movement A. Strabismus or Squint B. Nystagmus C. Lid Lag Test for Convergence Inspection Using the Diagnostic Instruments: Ophthalmoscope A. Using the Ophthalmoscope (*Bates) B. Inspection of Other Retinal Structures Using the Ophthalmoscope (*Bates) C. Optic Disc Abnormalities Notes on Ophthalmologic Examination Red Eyes Ear Examination A. External Examination B. Use of Otoscope Nose Examination Assessment of Frontal & Maxillary Sinuses A. Techniques in the Examination of the Sinuses B. Infection of the Nasal Cavity C. Foreign Bodies in the Nose D. Nose Bleeding Examination of the Mouth & Pharynx A. Techniques in the Examination of the Mouth B. Techniques in the Examination of the Pharynx Examination of the Neck A. Lymph Nodes B. Trachea C. Thyroid

THE HEAD COMMON OR CONCERNING SYMPTOMS

 Headache o Most common symptom (30% of the general population) o Careful evaluation for life-threatening causes: meningitis, subdural or intracranial hemorrhage, mass lesion, etc. o Elicit full description  Is the headache one-sided or bilateral?  Severe with sudden onset? Steady or throbbing?  Continuous or intermittent? o Most important attributes are severity and chronologic pattern  Severe and sudden onset – t/c subarachnoid hemorrhage or meningitis o Primary Headaches  No identifiable underlying cause  Migraine o Most frequent cause of headache (80%) o Unilateral  Tension o Bilateral, often arise in the temporal areas  Cluster o Unilateral, may be retro-orbital o Secondary Headaches  Arise from other condition  Change in vision: hyperopia, presbyopia, myopia, scotomas  Diplopia  Hearing loss  Vetigo  Nosebleed  Sore throat  Swollen glands  Goiter

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

THE HEAD EXAMINATION HAIR

 Note its quantity, distribution, and pattern loss  Check for loose flakes of dandruff o e.g. fine hair – hyperthyroidism coarse hair – hypothyroidism SCALP

 Look for scaliness, lumps, nevi, or other lesions o e.g. pigmented nevi, pillar cysts redness and scaling – seborrheic dermatitis, psoriasis SKULL

 Observe size and contour  Note deformities, depressions, lumps, or tenderness  Recognize irregularities in normal skull o e.g. enlarged skull – hydrocephalus, Paget’s disease tenderness/ step-offs – common after trauma SKIN

 Observe and note color, pigmentation, texture, thickness, hair distribution, and lesions o e.g. acne – in many adolescents hirsutism in women – polycystic ovary syndrome FACE

 General appearance of the face  Not patient’s facial expression and contours  Observe for asymmetry, involuntary movements, edema, and masses  Determine if face abnormality is a local, systemic, or neurological manifestation FACE ABNORMALITIES IN DIFFERENT DISEASES

Acromegaly  Enlargement of both bone and tissue due to increased growth hormone production  Head is elongated with bony prominence of the forehead, nose, and lower jaw  Soft tissue of the nose, lips, and ears are enlarged  Facial features generally coarsened  e.g. in pituitary adenoma Myxedema  May be caused by decreased thyroid hormone levels  Face is dull and puffy  Edema is generally pronounced around the eyes, and does not pit with pressure  Hair and eyebrows are dry, coarse, and thinned  Skin is dry  e.g. in severe hypothyroidism Nephrotic Syndrome  Face is edematous and pale  Swelling first appears in the morning around the eyes  Eyes may become slit-like when edema is severe

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Cushing’s Syndrome  Increased adrenal hormone causes round or “moon” face with red cheeks  Excessive hair growth in the mustache and sideburn areas Parotid Enlargement  Has swellings anterior to the ear lobes and above angle of jaws  Gradual unilateral enlargement suggests neoplasm  Acute enlargement is seen in mumps  Bilateral asymptomatic enlargement suggests obesity, DM, and cirrhosis Parkinson’s Disease  Decreased facial mobility and blunt expression  Mask-like face  Decreased blinking and characteristic stare  Facial skin is oily  Drooling may occur  Since neck and upper trunk tend to flex forward, patient seems to peer upward toward the observer THE EYE

 Start inquiry about eye and vision problems with open-ended questions o “How is you vision?” o “Have you had any trouble with your eyes?”  Ask if there is blurring of vision. If yes, is the onset sudden or gradual? If sudden and unilateral, is the visual loss painless or painful?  As if the patient wears glasses.  Ask about pain in or around the eyes, redness, and excessive tearing or watering.  Check for diplopia or double vision o Horizontal Diplopia  Images display side by side o Vertical Diplopia  Images are on top of each other

o First number indicates the distance of the patient from the chart, and the second, the distance at which a normal eye can read the line of letters  If the patient is unable to read any of the lines, a gross estimate of what they are capable of seeing should be determined (e.g. ability to detect light, motion, or number of fingers placed in front of them)  Acuity is only tested when there is a new specific, visual complaint PINHOLE TESTING  Determine if a problem with acuity is due to refractive error (thus correctable with glasses)  Patient is instructed to view the Snellen chart with the pinholes up, and then again with them in the down position  If deficit corrects with the pinholes in place, the acuity issue is related to a refractive error  Pinholes allow the passage of light which is perpendicular to the lens and thus does not need to be bent prior to being focused on the retina

VISUAL FIELDS

 Entire area seen by an eye when it looks at a central point  Center of the circle represents the focus of gaze; the circumference is 90° from the line of gaze  The fields extend farthest on the temporal sides, normally limited by the brows above, the cheeks below, and the nose medially  The normal visual field for each eye extends out from the patient in all directions, with an area of overlap directly in front

THE EYE EXAMINATION IMPORTANT AREAS OF EXAMINATION

     

Visual acuity Visual fields Conjunctiva and sclera Cornea, lens, pupils Extraocular movements Fundi (includes optic disc, retina, retinal vessels) VISUAL ACUITY

 First part of the eye exam is an assessment of acuity  Can be done with either a standard Snellen chart hanging on a wall, with the patient standing at a distance of 20ft or a specifically designed pocket card held at 14in  Each eye is tested independently (e.g. one is covered while the other is used to read)  Patient who use glasses should put them on, and the results are referred to as “best corrected vision”  If they have no complaints, rapidly skip down to the smaller characters  Record visual acuity expressed as 2 numbers (e.g. 20/20)  The numbers at the end of the line provide an indication of the patient’s acuity compared with normal subjects; the larger the denominator, the worse the acuity o e.g. 20/200 means that the patient can see at 20ft what a normal individual can at 200ft

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

 Field cuts – specific regions where the patient has lost their ability to see o Occurs when the transmitted visual impulse is interrupted at some point in its path from the retina to the visual cortex in the back of the brain  You would, in general, only include a visual field assessment if the patient complained of loss of sight; in particular “blind spots” or “holes” in their vision Visual fields can be assessed as follows: 1. The examiner should be nose to nose with the patient, separated by approximately 8-12in. 2. Each eye is checked separately. The examiner closes one eye and the patient closes the opposite. The open eyes should then be staring directly at one another. 3. The examiner should move their hand out towards the periphery of his/her visual field on the side where the eyes are open. The finger should be equidistant from both persons. 4. The examiner should then move the wiggling finger in towards them, along an imaginary line drawn between the two persons. The patient and examiner should detect the finger at more or less the same time. 5. The finger is then moved out to the diagonal corners of the field and moved inwards from each of these directions. Testing is then done starting at a point in front of the closed eyes

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6. The wiggling finger is moved towards the open eyes. 7. The other eye is then tested  Meaningful interpretation is predicated upon the examiner having normal fields, as they are using themselves for comparison. CONFRONTATION  Starts in the temporal fields because most defects involve these areas  Imagine the patient’s visual field encircling the front of the patient’s head. 1. Ask patient to look with both eyes into your eyes. 2. Place your hands about 2ft apart, lateral to the patient’s ear. 3. Ask the patient to point at your fingers as soon as they are seen. 4. Slowly move the wiggling fingers of both your hands along the imaginary circle and toward the line of gaze until the patient identifies them. 5. Repeat this pattern in the upper and lower temporal quadrants.  Usually, a person sees both sets of fingers at the same time. VISUAL FIELD DEFECTS

1. Horizontal Defect  Occlusion of a branch of the central retinal artery may cause a horizontal (altitudinal) defect. Shown is the lower field defect associated with occlusion of the superior branch of this artery 2. Blind Right Eye (right optic nerve)  Optic nerve lesion, and of course of the eye itself, produces unilateral blindness 3. Bitemporal Hemianopsia (optic chiasm)  Lesion at the optic chiasm may involve only the fibers that are crossing over to the opposite side; since these fibers originate in the nasal half of each retina, visual loss involves the temporal half of each field 4. Left Hemianopsia (right optic tract)  Optic tract lesion interrupts fibers originating on the same side of both eyes; visual loss in the eyes is therefore similar (homonymous) and involves half of each field (hemianopsia) 5. Homonymous Left Superior Quadrantic Defect (right optic radiation, partial)  Partial lesion of the optic radiation may involve only a portion of the nerve fibers, producing, for example, a homonymous quadrantic effect 6. Left Homonymous Hemianopsia (right optic radiation)  Complete Interruption of fibers in the optic radiation produces a visual defect similar to that produced by a lesion of the optic tract

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

If you suspect a temporal defect in the visual field 1. Ask the patient to cover the right eye, and with the left eye, to look into your eye which is directly opposite (right eye) 2. Slowly move your wiggling fingers from the defective are toward the better vision OBSERVATION OF EXTERNALL STRUCTURES

 Position and Alignment of the Eye o Ocular Symmetry  Occasionally, one of the muscles that control eye movement will be weak or foreshortened, causing one eye to appear deviated medially or laterally compared with the other o Eyelid Symmetry  Both eyelids should cover approximately the same amount of eyeball  Damage to the nerves controlling these structures can cause the upper or lower lid on one side to appear lower than the other (CN 3 and 7)  Eyebrows o Inspect eyebrows – quantity and distribution  e.g. scaliness – seborrheic dermatitis  Eyelids o Note position in relation to eyeballs o Inspect width of palpebral fissures, edema and color of lids, lesions, condition and direction of lashes, adequacy with which the eyelids close  e.g. red inflamed lids – blepharitis  Lacrimal Apparatus o Inspect for swelling o Look for tearing or dryness  e.g. excessive tearing – impaired drainage of tears  Sclera o Observe color and vascular pattern o Normal sclera is white and surrounds the iris and pupil  e.g. icteric sclera – liver or blood disorder, yellowish sclera in the case of hyperbilirubinemia; can easily be confused with a muddy-brown discoloration common among older African Americans  Conjunctiva o Thin transparent membrane covering of the sclera o Reflects back onto the underside of the eyelids o Normally, it’s invisible except for the fine blood vessels that run through it o Check for inflammation and vascular pattern o By applying pressure and pulling down and away on the skin below the lower lid, you can examine the conjunctival reflection  e.g. severe anemia – pale conjunctiva conjunctivitis – infected or inflamed; appear quite red subconjunctival hemorrhage – blood accumulate under the conjunctiva when small blood vessels rupture relatively due to trauma; generally self limited, and does not affect vision  Cornea o Inspect cornea of eye for opacities, clarity, foreign body, ulcers, erythema/exudate  Iris o With the light shining directly from the temporal side, look for a crescentric shadow on the medial side of the iris o If shadow is present, it could be an indication of glaucoma

 Pupils o Inspect size, shape, and symmetry o If the pupils are large (>5mm), small (<3 mm), or unequal, measure them  A card with black circles of varying sizes facilitates measurements

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 Pupillary inequality of <0.5mm (anisocoria) is visible in approximately 20% of normal people; if pupillary reactions are normal, anisocoria is considered benign o Test the pupillary reaction to light  Ask the patient to look into the distance, and shine a bright light obliquely into each pupil in turn (both the distant gaze and the oblique lighting help to prevent a near reaction). Look for: o Direct reaction – pupillary constriction in the same eye o Consensual reaction – pupillary constriction in the opposite eye o Always darken the room and use a bright light before deciding that a light reaction is absent o If the reaction to light is impaired or questionable, test the near reaction in normal room light  Testing one eye at a time makes it easier to concentrate on pupillary responses without the distraction of EOM  Hold your finger or pencil about 10cm from the patient’s eye  Ask the patient to look alternately at it and into the distance directly behind it  Watch for pupillary constriction with near effort ABNORMALITIES OF THE EYES

Ptosis  Drooping of the upper lid  Causes include myasthenia gravis, damage to the oculomotor nerve, and damage to the sympathetic nerve supply (Horner’s Syndrome)  A weakened muscle, relaxed tissues, and the weight of the herniated fat may cause senile ptosis  May also be congenital Retracted Lid  Wide-eyed stare suggests retracted eyelids – in this case, the upper lid  Note the rim of sclera between the upper lid and the iris  Often due to hyperthyroidism, but may be seen in normal people  Eye does not protrude forward unless exophthalmos coexists Exophthalmos  Eyeball protrudes forward  When bilateral, it suggests the infiltrative ophthalmopathy of Grave’s disease, a form of hyperthyroidism  Edema of the eyelids and conjunctival injection may be associated  Unilateral exophthalmos may be due to Grave’s disease or to a tumor inflammation in the orbit Epicanthus  A vertical fold of skin that lies over the medial canthus  Normal among many Asians  Also seen in Down’s Syndrome and in a few other congenital conditions  May falsely suggest a convergent strabismus

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

Herniated Fat  Puffy eyelids may be caused by fat  If pushes weakened fascia in the eyelids forward, producing bulges that involve the lower lids, the inner third of the upper ones, or both  Appear more often in the elderly, but may affect the young Periorbital Edema  Skin of the eyelids is loosely attached to underlying tissues, edema tends to accumulate there easily  Causes include allergies, local inflammation, cellulites, myxedema, and fluidretaining states such Ectropion  Margin of the lower lid is turned outward, exposing the palpebral conjunctiva  When the punctum of the lower lid turns outward, the eye no longer drains satisfactorily, and tearing occurs  More common in the elderly Entropion  Inward turning of the lid margin  The lower lashes, which are often visible when turned inward, irritate the conjunctiva and lower cornea  Asking the patient to squeeze the lids together, and then open them may reveal an entropion that is not obvious  More common in the elderly TESTING EXTRA-OCULAR MOVEMENT  Coordinated action of six muscles, the four rectus and two oblique, control the eye  You can test the function of each muscle and the nerve that supplies it by asking the patient to move the eye in the direction controlled by that muscle 1. Instruct the patient to follow your index finger with their eyes only (i.e. their head remains in one position) as you first move it to either the extreme right or left. 2. Then, once you have the patient looking out laterally, have them follow your finger as you move it first up, then down. 3. Now move your finger across to the other side and repeat. 4. Your path should trace out the letter H. 5. At the end, bring your finger directly in towards the patient's nose. This will cause the patient to look cross-eyed and the pupils should constrict, a response referred to as accommodation. 6. Tracing out this path allows you to test each of the extraocular muscles individually and avoids movements that are dependent on more than one muscle, as occurs if you have the patient look up or down while the pupil is oriented straight ahead. 7. Assessments of both extra-ocular movements and visual acuity are actually tests of cranial nerve (CN) function. o CNs 3, 4, and 6 – control movement o CN 2 – vision  Pause during upward and lateral gaze to detect nystagmus o a fine rhythmic oscillation of the eyes (seen in various neurologic conditions) o a few beats of nystagmus on extreme lateral gaze are normal o if you see it, bring your finger in to within the field of binocular vision and look again

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 There are six cardinal directions

A. Left 6th Nerve Paralysis

Fig6. Six Cardinal Directions of Gaze  CN 4 o Innervates the superior oblique muscle o Allows you to move either eyeball down or inward  CN 6 o Innervates the lateral rectus muscle o Allows you to move either eyeball laterally  CN 3 o Innervates the remaining extra-ocular muscles as well as the upper eye lid o Allows eyeball movement in all remaining directions as well as lifting of the upper lid o The dilation is due to disruption of the parasympathetic fibers which run along the outside of CN3  Disorders of eye movement can also be due to problems with the extraocular muscles themselves

Fig9. Left 6th Nerve Paralysis

In CN 6 Paralysis, the eyes are CONJUGATE in RIGHT lateral gaze but not in LEFT lateral gaze. B. Left 4th Nerve Paralysis

STRABISMUS OR SQUINT  Deviation of the eyes from their normally conjugate position  May be classified into 2 groups: 1. Non-paralytic Strabismus  the deviation is constant in all directions of gaze  caused by an imbalance in ocular muscle tone  has many causes, may be hereditary, and usually appears early in childhood  deviations are further classified according to direction: Convergent Strabismus (Esotropia)

Divergent Strabismus (Exotropia) Fig10. Left 4th Nerve Paralysis COVER-UNCOVER TEST  A cover-uncover test may be helpful. Here is what you see in the right monocular esotropia

NYSTAGMUS  a fine rhythmic oscillation of the eyes, analogous to a tremor in other parts of the body  possible causes: impairment of vision in early life, disorder of the labyrinth and the cerebellar system, drug toxicity  occurs normally when a person waches a rapidly moving object  a few beats of nystagmus on extreme lateral gaze are normal  may be present in all directions of gaze Stabilize patient's head

Ask the patient to follow your finger to a specific direction (i.e., to the right) Observe for fast oscillations toward the opposite direction (fast nystagmus) Observe for slow oscillations toward the same direction (slow nystagmus) Fig8. Cover-Uncover Test 2. Paralytic Strabismus  the deviation varies depending on the direction of gaze  usually caused by weakness or paralysis of one or more extraocular muscles  determine the direction of gaze that maximizes the deviation

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

Bring your finger within field of binocular vision and look again; record

Assess for nystagmus in other directions of gaze

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USING THE OPHTHALMOSCOPE (Bates)

LID LAG  observed as the eyes move from up to down  usually seen in hyperthyroidism – in lid lag of hyperthyroidism, a rim of sclera is visible above the iris with downward gaze  If you suspect lid lag, as the patient to follow your finger again as you move it slowly from up to down in the midline

Darken the room. Switch on the ophthalmoscope until you see the large round beam of light.

Ask the patient to follow your finger as you move it slowly from up to down in the midline

To better examine the sclera, conjunctiva, pupil, cornea or iris, start with the lens identified by a green 4 or 6.

Normal = lid should overlap the iris slightly Grasp the handle with your hand (R hand for R eye, L hand for L eye) such that your middle finger is resting on the lower, front aspect of the head of the opthalmoscope. This gives you mobility. (+) for lid lag if a rim of sclera is visible above the iris

PLEASE SEE TABLES ON STRABISMUS AND RED EYES 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  Clinical Notes: o Hyperthyroidism – Poor Convergence

Bring your right eye up to the viewing window. The patient's glasses should be taken off. It's OK to leave contacts in place.

Place your left hand on the patient's forehead and gently pull the top lid with your thumb.

Place your left hand on the patient's shoulder.

Try to keep both of your eyes open while doing the exam.

Fig7. Test for Convergence INSPECTION USING THE DIAGNOSTIC INSTRUMENTS: OPHTHALMOSCOPE

Start approximately 15 in from the patient and approach from about 15 or 20 degrees to the left of center/ laterally. Check to make sure you see through the aperture.

Shine the light beam on the pupil and look for the orange glow in the pupil—the RED REFLEX. Note any opacities interrupting the red reflex.

When you look through the viewing window, the outer structures of the eye should come into sharp focus. If not, slowly move closer or further from the patient until these structures become clear. Change the lens to get a better focus.

Place the thumb of your other hand on the patient's eyebrow to help you keep steady. Lower the brightness to make the exam more comfortable for the patient and to avoid HIPPUS (spasm of the pupil)

Inspect the optic disc and the retina.  The ophthalmoscope magnifies the normal retina about 15 times and the normal iris about 4 times. The optic disc actually measures about 1.5 mm.  The optic disc—a yellowish orange to creamy pink oval or round structure that may fill your field of gaze or even exceed.  Don’t DILATE the eyes – better posterior view of the retina  However, to better view PERIPHERAL structures, use mydriatic drops to dilate the pupils

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

Clinical Notes: o Absence of the red reflex: o Cataracts or Opacity of the Vitreous Humour o Detached Retina o Children: Retinoblastoma o The opthalmoscope magnifies the retina about 15 times and the iris about 4 times. o If the lens is surgically cut, its magnifying lens is lost. Retinal structures look much smaller while the fundus is much bigger.

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INSPECTION OF OTHER RETINAL STRUCTURES USING THE OPHTHALMOSCOPE (Bates) A. The Optic Disc

Lesions of the retina can be measured in terms of “disc diameters” from the optic disc.

Locate the optic disc. It is a round, yellowish orange structure. If you do not see it at first, follow a blood vessel centrally unti you do.

Bring the optic disc into sharp focus by adjusting the lens. Normal: Focused at 0 diopters Blurred: Rotate the lens disc to find the sharpest focus Myopia : Rotate COUNTERCLOCKWISE Hyperopia: Rotate CLOCKWISE

Inspect the optic disc. Note the following: • Sharpness/ Clarity of Disc Outline - Nasal Portion may be blurred which is normal • Color - Yellowish orange to creamy pink. • Size of central cup, if present ; yellowish white in color • Symmetry of the eyes and fundus.

Inspect the anterior structures.

Look for opacities in the vitreous or lens by rotating the lens disc progressively to diopters of around +10 or +12. OPTIC DISC ABNORMALITIES A. Papilledema:  Pinkish, hyperemic  Loss of venous pulsations  Disc vessels are more visible  Physiologic Cup not visible  Seen in intracranial mass, lesion or hemorrhage

*Detect Papilledema: Papilledema - swelling of optic disc and anterior bulging of the physiologic cup due to increased Intracranial Pressure. This often signals serious disorders of the brain. B. Glaucomatous Cupping  Enlarged physiologic cup extending to the edge of the disc  Retinal vessels sink and may be displaced laterally

C. Optic Atrophy

Follow the vessels peripherally in each of four directions, noting their relative sizes and the character of the arteriovenous. Distinguish arteries from veins. Identify any lesions of the surrounding retina and note their size, shape, color, and distribution.

As you search the retina, move your head and instrument as a unit, using the patient’s pupil as an imaginary fulcrum.

Inspect the fovea and surrounding macula by directing your light beam laterally or by asking 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 in young people.

  

Whitish in color Tiny disc vessels absent Optic neuritis, multiple sclerosis, temporal arteritis

SEE NEXT

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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GENERAL RED REFLEX FUNDUS

VASCULAR SUPPLY

OPTIC DISC (NASAL SIDE)

MARGINS MACULA (FOVEA CENTRALIS) | (CENTRAL SIDE)

NOTES ON OPHTHALMOLOGIC INSPECTION FROM LECTURE FROM BATES You can only see small portions at a time Compare both eyes for symmetry Seen as you approach the patient while looking through -the ophthalmoscope Normally yellow or pink  Should be compared with the fundus of the other eye for symmetry  In older adults, the fundi lose their youthful shine and light reflections  Inspect fundi for colloid bodies causing alterations in pigmentation called drusen Branch away from the optic disc  Note the presence of venous pulsations.  In a normal person, pulsations in the retinal veins as they emerge from the To distinguish arteries from veins: central portion of the disc may or may not be present. ARTERIES VEINS  In older adults, the arteries look narrowed, paler, straighter and less Color Light red Dark red brilliant. Size Smaller Larger Light Bright Inconspicuous or Reflex absent Has a clear border Note:  Optic cup  The sharpness or clarity of the disc outline. o Has blood vessels  The nasal portion of the disc margin may be somewhat blurred, a normal  Vein = dark red finding.  Artery = light red  The color of the disc, normally yellowish orange to creamy pink. o Check ratio of blood vessels  White or pigmented crescents may ring the disc, a normal finding. o Wide optic cup = Glaucoma  The size of the central physiologic cup, if present. It is usually yellowish white.  The cup-to-disc ratio is usually 1:2 or less o Increased cup:disc ratio seen in open angle glaucoma  Sharp  Well defined  Central Vision/Color  Difficult to examine – DO NOT focus light directly on the macula or the patient will feel pain

CLASSIFICATION

CONJUNCTIVITIS

SUBCONJUNCTIVAL HEMORRHAGE

CORNEAL INJURY OR INFECTION

ACUTE IRITIS

GLAUCOMA

ILLUSTRATION

PATTERN OF REDNESS

PAIN VISION OCULAR DISCHARGE PUPIL CORNEA

SIGNIFICANCE

Conjuctival infection: diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally Dr. Guzman: Redness from conjunctiva spreading in an upward direction

Leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area that fades over days to yellow and then disappears Dr. Guzman: due to rubbing of the eyes; usually not pathologic Mild discomfort rather Absent than pain Not affected except for Not affected temporary mild blurring Watery, mucoid, or Absent mucopurulent Not affected Not affected Clear

Clear

Bacterial, viral, and other infections; allergy; irritation

Often none. May result from trauma, bleeding disorders, or a sudden increase in venous pressure, as from cough.

Ciliary injection: dilation of deeper vessels that are visible as radiating vessels or a reddish violet flush around the limbus. Ciliary injection is an important sign of these three conditions but may not be apparent. The eye may be diffusely red instead. Other clues of these more serious disorders are pain, decreased vision, unequal pupils, and a less than perfectly clear cornea.

Moderate to severe, superficial Usually decreased

Moderate, aching, deep Decreased

Severe, aching, deep

Watery or purulent

Absent

Absent

Not affected unless iritis develops Changes depending on cause Abrasions, and other injuries; viral and bacterial infections

May be small and, with time, irregular Clear or slightly clouded Associated with many ocular and systemic disorders

Dilated, fixed

Decreased

Steamy, cloudy Acute increase in intraocular pressure-an emergency

EAR EXAMINATION External structures: Briefly examine the outer structures, paying particular attention to any skin changes suggestive of cancer (e.g basal cell, melanoma, squamous cell), a common asymptomatic abnormality affecting this sun exposed area. If the patient has pain, try to identify its precise location. Infection within the external canal, for example, may cause discharge from the ear as well as pain on manipulation of any of the external structures.

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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EXTERNAL EXAMINATION (Auricle and Mastoid) Size, Shape, Symmetry, Color, Position, Tenderness, Color

USE OF OTOSCOPE Speculum Position Patient Scope AURICLE Up and Back CANAL  Discharge  Scaling  Redness  Lesions  Foreign Bodies  Cerumen TYMPANIC  Landmarks MEMBRANE  Color  Contour  Perforations OTOSCOPE

The otoscope allows you to examine the external canal, the structure that connects the outside world with the middle ear, as well as the ear drum and a few inner ear structures. Proceed as follows: 1. Put the otoscopic head on your oto-opthalmoscopic grip. It should easily twist into position. 2. Turn on the light source. 3. Place one of the disposable specula on the end of the scope. 4. Grasp the scope so that the handle is either pointed directly downward or angled up and towards the patient's forehead. Either technique is acceptable. The scope should be in your right hand if you are examining the right ear. 5. Place the tip of the specula in the opening of the external canal. Do this under direct vision (i.e. not while looking through the scope). 6. Gently grasp the top of the left ear with your left hand and pull up and backwards. This straightens out the canal, allowing easier passage of the scope. 7. Look through the viewing window with either eye. Slowly advance the scope, heading a bit towards the patient's nose but without any up or down angle. Move in small increments. Try not to wiggle the scope too much as the external canal is quite sensitive. I find it helpful to extend the pinky and fourth fingers of my right hand and place them on the side of the patient's head, which has a stabilizing effect. 8. As you advance, pay attention to the appearance of the external canal. In the setting of infection, called otitis externa, the walls becomes red, swollen and may not accommodate the speculum. In the normal state there should be plenty of room. If wax, which appears brownish, irregular and mushy, obscures your view, stop and go to the other side. Do not try to extract it until/unless you have had specific training in this area! There are pharmacologic means of softening wax, which may then be easily irrigated from the canal.

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

EXTERNAL EXAMINATION (Auricle and Mastoid) OTOSCOPIC EXAMINATION TYMPANIC MEMBRANE COLOR When healthy, it has a grayish, translucent appearance. STRUCTURES The malleus, one of the bones of the middle BEHIND IT ear, touches the drum. The drum is draped over this bone, which is visible through its top half, angled down and backwards. The part that is closest to the top of the drum is called the lateral process, and is generally most prominent. The tip at the bottom-most aspect is the umbo. LIGHT REFLEX Light originating from your scope will be reflected off the surface of the drum, making a triangle that is visible below the malleous ACUTE OTITIS EXTERNA ANATOMY

CLINICAL NOTES INFECTIONS AND OTITIS MEDIA Pathogenic organisms can gain entrance to the middle ear by ascending through the auditory tube from the nasal part of the pharynx. Acute infection of the middle ear (otitis media) produces bulging and redness of the tympanic membrane. COMPLICATIONS OF OTITIS MEDIA Inadequate treatment of otitis media can result in the spread of the infection into the mastoid antrum and the mastoid air cells (acute mastoiditis). Acute mastoiditis may be followed by the further spread of the organisms beyond the confines of the middle ear. The meninges and the temporal lobe of the brain lie superiorly. A spread of the infection in this direction could produce a meningitis and a cerebral abscess in the temporal lobe. Beyond the medial wall of the middle ear lie the facial

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nerve and the internal ear. A spread of the infection in this direction can cause a facial nerve palsy and labyrinthitis with vertigo. The posterior wall of the mastoid antrum is related to the sigmoid venous sinus. If the infection spreads in this direction, a thrombosis in the sigmoid sinus may well take place. These various complications emphasize the importance of knowing the anatomy of this region. ACUTE OTITIS MEDIA ANATOMY

AUDITORY ACUITY  If the patient does not complain of hearing loss, this part of the exam is omitted.  A crude assessment can be performed by asking the patient to close their eyes while you place your fingers a few centimeters from either ear. Rub the fingertips of first one hand and then the other. Make note of any obvious differences in hearing.  Alternatively, you can stand behind the patient and whisper a few words in first one ear and then the other. Are they able to repeat the phrases back correctly?  Does this seem to be equal on either side?  These tests obviously are not very objective. Precise quantification requires sensitive equipment and is usually done by a trained audiologist. WEBER TEST (Test for Lateralization)  Grasp the 512 Hz tuning fork by its stem and get it to vibrate by either striking the tines against your hand or by "snapping" the ends between your thumb and middle finger.  Then place the stem towards the back of the patient's head, on an imaginary line equidistant from either ear. The bones of the skull will transmit this sound to the 8th nerve, which should then be appreciated in both ears equally. Remind the patient that they are trying to detect sound, not the buzzing vibratory sensation from the fork.  If there is a conductive deficit (e.g. wax in the external canal), the sound will be heard better in that ear. This is because impaired conduction has prevented any competing sounds from entering the ear via the normal route. You can create a transient conductive hearing loss by putting a finger in one ear. Sound transmitted from the tuning fork will then be heard louder on that side.  In the setting of a sensorineural abnormality (e.g. an acoustic neuroma, a tumor arising from the 8th CN), the sound will be best heard in the normal ear. If sound is heard better in one ear it is described as lateralizing to that side. Otherwise, the Weber test is said to be mid-line.

 Then place the tines of the still vibrating fork right next to, but not touching, the external canal. They should again be able to hear the sound. This is because, when everything is functioning normally, transmission of sound through air is always better than through bone.  This will not be the case if there is a conductive hearing loss (e.g. fluid associated with an infection in the middle ear), which causes bone conduction to be greater than or equal to air. BC> AC  If there is a sensorineural abnormality (e.g. medication induced toxicity to the 8th CN), air conduction should still be better than bone as they will both be equally affected by the deficit. AC>BC

NOSE EXAMINATION Anatomy and Physiology (from Bates):  Upper third is supported by bone, lower 2/3 supported by cartilage.  Flow of air:  Media wall: nasal septum (supported by bone and cartilage)

 Vestibule – only part lined by hair-bearing skin, not mucosa  Turbinates – curving bony structures that protrude into the nasal cavity (superior, middle, and inferior), below each is a meatus named accdng to the turbinate above it. ○ Functions: cleansing, humidification, temp control of inspired air ○ Inferior meatus: where the nasolacrimal duct drains ○ Middle meatus: where most of the paranasal sinuses drain

RINNE TEST  Strike the same tuning fork and place the stem on the mastoid bone, a bony prominence located just behind and below the ear. Bone conduction will allow the sound to be transmitted and appreciated.  Instruct the patient to let you know as soon as they can no longer hear the sound.

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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 Paranasal sinuses – air-filled cavities within the bones of the skull, line by mucous membrane (Only the maxillary and frontal sinuses are readily available for clinical exam)

TECHNIQUES IN EXAMINATION  Exam is generally omitted in the absence of symptoms  First check to see if the patient is able to breathe through either nostril effectively.  Push on one nostril until it is occluded and have them inhale. Then repeat on the other side. Air should move equally well through each nares.  To look in the nose, have the patient tilt their head a little back. Push up slightly on the tip of the nose with the thumb of your left hand. Place the end of the speculum (it's OK to use the same one from the ear exam) into the nares under direct vision. NOTE THE FOLLOWING:  The color of the mucosa. It can become quite reddened in the setting of infection.  The presence of any discharge as well as its color (clear with allergic reactions; yellowish with infection).  The middle and inferior turbinates, which are shelf-like projections along the lateral wall. Any polypoid growths, which may be associated with allergies and obstructive symptoms  The other nostril is examined in a similar manner.  Loss of smell (anosmia) is a relatively common problem, though often undiagnosed. In patients who make mention of this problem, olfaction can be crudely assessed using an alcohol pad sniff test as follows:  Ask the patient to close their eyes so that they don't get any visual cues.  Occlude each nostril sequentially, making sure that they can move air adequately thru both.  Occlude one nostril and then present an alcohol pad to the other side, asking the patient to inform you when they are able to detect its smell.

TECHNIQUES IN THE EXAMINATION OF THE SINUSES 1. Check for colored mucosal discharge o This is due to the fact that the maxillary sinuses drain into the nose via a passageway located under the middle turbinate. 2. Directly palpate and percuss the skin overlying the frontal and maxillary sinuses. o Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. o Then check on the maxillary sinuses by pressing the finger against the anterior wall of the maxilla below the inferior orbital margin o Local tenderness, together with symptoms such as pain, fever, and nasal discharge, suggest acute sinusitis 3. With the use of an otoscope: First dim the room lights. o Place the lighted otoscope directly on the infraorbital rim (bone just below the eye). o Ask the patient to open their mouth and look for red dim glow through the mucosa of the upper mouth. o In the setting of inflammation, the maxillary sinus becomes fluid filled and will not allow this transillumination. There are specially designed transilluminators that may work better for this task, but are not readily available. 4. Using a tongue depressor,: o Tap on the teeth which sit in the floor of the maxillary sinus. This may cause discomfort if the sinus is inflamed because the pain is referred to the jaw and teeth. Remember that the maxillary sinus is innervated by the infraorbital nerve. INFECTION OF THE NASAL CAVITY  Infection may spread via the nasal part of the pharynx and the auditory tube to the middle ear.  organisms may ascend to the meninges of the anterior cranial fossa, along the sheaths of the olfactory nerves through the cribriform plate, and produce meningitis.

ASSESSMENT OF FRONTAL AND MAXILLARY SINUSES Paranasal sinuses o are air-filled cavities within the bones of the skull. o are lined with mucous membrane. o Act as voice resonators and reduce the weight of the skull. o Only the frontal and maxillary sinuses are readily accessible to clinical examination. (indirectly)

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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FOREIGN BODIES IN THE NOSE  Foreign bodies in the nose are common in children.  The presence of the nasal septum and the existence of the folded, shelflike conchae make impaction and retention of balloons, peas, and small toys relatively easy. NOSE BLEEDING  Epistaxis, or bleeding from the nose, is a frequent condition.  Most common cause: nose picking  The bleeding may be arterial or venous, and most episodes occur on the anteroinferior portion of the septum. EXAMINATION OF THE MOUTH AND PHARYN Anatomy and Physiology (from Bates): Lips muscular folds that surround the entry to the mouth Gingiva (gums) firmly attached to the teeth and to the maxilla/mandible where they are seated Labial Connects each lip with the gingival frenulum Teeth composed of dentin, only the crown (enamelcovered) is exposed. Blood vessels and nerves enter the tooth via the apex and pass into the pulp canal and chamber (32 total, 16 in each jaw) Tongue dorsum covered by papillae, giving it a rough surface. Undersurface has no papillae Lingual frenulum – connects the tongue to floor of mouth Ducts of submandibular glands (Wharton’s ducts) are located at the base of the tongue; they lie on each side of the lingual frenulum

o

Inspect the teeth. Are any of them:  missing,  discolored,  misshapen  abnormally positioned  looseness 4. Roof of the Mouth o Inspect the color and architecture of the hard palate. 5. The Tongue and the Floor of the Mouth. o Ask the patient to put out his or her tongue. Inspect it for symmetry—a test of the hypoglossal nerve (CN XII). o Note the color and texture of the dorsum of the tongue. o Inspect the sides and under surface of the tongue and the floor of the mouth, areas where cancer often develops. o Palpate any lesions. Ask the patient to protrude the tongue. With your right hand, grasp the tip of the tongue with a square of gauze and gently pull it to the patient’s left. Inspect the side of the tongue, and then palpate it with your gloved left hand, feeling for any induration. Reverse the procedure for the other side. o Tongue cancer is a common oral cancer, especially in:  men older than 50 years  smokers  tobacco chewers  alcohol drinkers TECHNIQUES IN THE EXAMINATION OF THE PHARYNX  Ask the patient to say “ah” or yawn with the patient’s mouth open but the tongue not protruded so you can see the pharynx well. If not, press a tongue blade firmly down upon the midpoint of the arched tongue— far enough back to visualize the pharynx but not so far that you cause gagging.  Note the rise of the soft palate—a test of CN X (the vagal nerve).  In CN X paralysis:  soft palate fails to rise  uvula deviates to the opposite side. EXAMINATION OF THE NECK  May use the Sternocleidomastoid muscle as a landmark. LYMPH NODES  Nodes are normally round or ovoid smooth  Tonsillar node and supraclavicular nodes may be palpable.  Palpate the lymph nodes: (Bates’)  Using the pads of your index and middle fingers, move the skin over the underlying tissues in each area.  With neck flexed slightly forward  can usually examine both sides at once.  For the submental node, however, feel with one hand while bracing the top of the head with the other. Sequence of Lymph nodes palpation based from Bates’:

 Anterior and posterior pillars, soft palate, and uvula form an arch above and behind the tongue  Right and left tonsils are often small or absent, and are located in the tonsillar fossa in between the anterior and posterior pillars.  Buccal mucosa – lines the cheeks, where the parotid duct (Stensen’s duct) opens to (near the upper Second molar) TECHNIQUES IN THE EXAMINATION OF THE MOUTH  Ask the patient to remove his/her dentures.  Inspect the following: 1. Lips o Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness. 2. Oral mucosa o Ask the patient to open his/her mouth and, with a good light and the help of a tongue blade, inspect o the oral mucosa for:  color,  ulcers,  white patches  nodules  wavy white line on the adjacent buccal mucosa developed where the upper and lower teeth meet - related to irritation from sucking or chewing. 3. Gums and Teeth o Note the color of the gums, normally pink. o Brown patches may be present, especially but not exclusively in black people.

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Lymph Node

Location

1. Preauricular

In front of ear

2. Posterior Auricular

Superficial to the mastoid process

3. Occipital

4. Tonsillar

At the base of the skull posteriorly Below thw Angle of the mandible

Drainage

Tonsillar and posterior pharyngeal regions Structures in the floor of the mouth

5. Submandibular

Midway between the angle and the tip of the mandible.

6. Submental

In the midline a few centimeters behind the tip of the mandible (below the chin)

Teeth and Intra-oral cavity

7. Superficial/ Anterior Cervical

Superficial to the sternomastoid

8. Posterior Cervical

Posterior to SCM, Along the anterior edge of the trapezius

 Internal structures of the throat  Part of the posterior pharynx, tonsils, and thyroid gland Skin on the back of the head

9. Deep Cervical Chain

Deep to the sternocleidomastoid and often inaccessible to examination Deep in the angle formed by the clavicle and the sternomastoid

10. Supraclavicular

o

Ask the patient to sip some water and to extend the neck again and swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetry.

Palpation  Find your landmarks—the notched thyroid cartilage and the cricoid cartilage below it.  Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings  Place the fingers of both hands on the patient’s neck so that your index fingers are just below the cricoid cartilage.  Ask the patient to sip and swallow water as before. Feel for the thyroid isthmus rising up under your finger pads.  Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sternocleidomastoid. Find the lateral margin.  In a similar fashion, examine the left lobe.  The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb and feels somewhat rubbery.  Note the size, shape, and consistency of the gland and identify any nodules or tenderness.  If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit,a sound similar to a cardiac murmur but of noncardiac origin

Part of the thoracic cavity and Abdomen



Describe:  Tender  Solitary, multiple  Movable, non-movable  Size  Infected LN :  Firm  Tender  Enlarged  Warm  Malignancy:  Firm  Non-tender  Fixed  Increasing size over time  Stage 3 disease if present at cervical, axillary and inguinal areas.  Characteristics of LN:  Hard – Kneecap  Firm – Nose  Soft – mons pubis TRACHEA  Place your finger along one side of the trachea  Note the space between it and the sternocleidomastoid. The spaces should be symmetric for both sides. THYROID Inspection  Tip the patient’s head back a bit.  Using tangential lighting directed downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage for the gland.  Observe the patient swallowing:

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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