7Q - Physical Diagnosis Midterm

7/25/2019 7Q - Physical Diagnosis Midterm

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Physical Diagnosis Midterm

OPTHALMOLOGYOrbit1. GeneralInformation

a. Quadralateral cavity (roof, floor, medial and lateral wall)b. Pyramidal in shape also

. !tr"ct"res in each#all(always referring to right eye unless specified)a. !ray view re"uired is the Caldwell View(head is erect, Central #eam is $etween %&'*+

and &-)b. ill $e a$le to see #&/ the right and left *pices

$ald#ell %ie#! *re all of the f issures and openings symmetricala. 1f -.&.%. is enlarged

+ilation of &phthalmic eins (has widened the fissure)

/his is due to a Carotid Jugular Fistula(the communication from a high to low pressure

system ! rises the pressure in the veins)

$. nlarged &ptic %oramen

Optic Nerve Tumor

&. 'oof ofOrbita. %rontal -inus located on medial side of &r$itb. -uperior &r$ital # (*rtery, ein and erve) pass through notch of eyec. -uperior &r$ital nerve $ranches into the %rontal -inusd. 1f pain is elicited on palpation here, an infection is possi$le

e. /he %loor of the %rontal -inus is thin enough to transmit light through (/ransiluminate)

(. Medial)alla. 'ight asal %ossa$. thmoid -inus 3 *ir Cells

all is very thin Called the Lamina Pa*aracia

c. -phenoid -inus

+. Lateral)alla. /emporal %ossa$. 4iddle Cranial %ossa

,. -loor ! via 4id -agital sectiona. 1nfraor$ital grooveb. 1nfraor$ital canalc. 1nfraor$ital foramen

/hrough theses, passes the Infraorbital %/

d. *lveolar canals

Part of the 1nfraor$ital nerve etends through these canals into the /eeth

Primary disease of the teeth can clim$ up the canals and gain entrance into the or$it

e. *ntrum of Ma0illary sin"s

1nfection could get through from this area as well

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0amination6. ith patient in P'14*'8 9*: (eyes aimed straight forward)

Cornea should line up with imaginary line from -uperior &r$ital 4argin to the 1nferior &r$ital

4argin

(2 mm $eyond line or 5 mm $ehind the line is the normal range)

a. 0o*thalmos.

2 mm $eyond line Pro*tosisand 0o*thalmos! $oth refer to forward displacement of the eye due to pathology

Pse"do!0o*thalmos

ye loo;s t hold the eye into the or$it

as it should

0o*thalmos(%rom pathology)

1. ThyroidDisease

?sually yperthyroidism (Gra4es! Thyroto0icosis)

&r$it $ecomes very edematous (increase in ground su$stance,

which is hydrophilic

*lso $uildup of inflitrates(lymphocytes) #&/ leading to

edema

ashimoto>s /hyroiditis usually only occurs late in the disease

(ypothyroidism) ! $ut rare@@

Pro*tosis

1. Orbital$ell"litisa. %rom %rontal all

%rom %rontal -inusitis (infection through the wall of

%rontal -inus)

%rom =acrimal 9land infection

$. %rom =ateral all

%rom asal %ossa or thmoid -inus

c. %rom %loor

4aillary -inus 1nfection +ental 1nfection

. T"mor a. /umors cause a forward displacement only when it is of a

significant siAe$. /hus rely on visual a$normalities to identify this

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$. no*thalmos

5 mm $ehind line (sun;en $ac;)

C*?--B1. -atAtro*hy

Causes eye to recede $ac; into or$it

MOST COMMONLY SEEN!

. Dehydration

&. /lo#o"t fract"re

-ee notes

)ater5s 67ray

ead is hyperetended

Central $eam is directed $etween nose and the chin

Gives you a good view of the floor and the orbit

-indings #ith )ater5s %ie# in a patient with #=& &?/ %'*C/?'B

all appears to $e thic;era. +ou$le all &sseous +ensity$. anging +rop +ensity

(. Horner5s!yndromea. $a"ses of Horner8s !yndrome(due to anything that affects the -uperior Cervical 9anglion)

Pancost /umor

C!spine fracture

/a$es +orsalis

-yringomyelia

*pical /#

Cervical Cord tumor

b. !igns and!ym*toms *nhydrosis ! 1psilateral

=id Ptosis

4yosis ! pupillary constriction

+. D"ane5s!yndrome

-omething wrong with inner4ation #ith Abd"cens ner4e(C 1)

&'

Adhesionshave developed $etween the Periorbital tiss"eand the Lateral 'ect"s

a. !ignsand !ym*toms

hen 4edial 'ectus a+ducts, it pulls the or$it into the or$it $ecause =ateral 'ectus

is not opposing the motion

Oc"lar Adne0a

O'MALyelid

s

O'MAL

1n position of primary gaAe, there should $e & visi$le -C='* $etween the

-uperior or 1nferior =im$us (Corneal 3 -cleral untcion) also called LIM/AL

LI

/his means that eyes are in proper, normal position

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A/O'MALYLID!

A/O'MALITI!! (with patient loo;ing straight ahead 3 P'14*'8 9*:)1. Dalrym*le5s !ign

-cleral strip seen at -uperior Corneal3-cleral unction

C*?--B19 0o*thalmosor Pro*tosisE 4&-/ C&44&@9 -pasm of Le4ator Pal*ebrae !"*erioris

. %on Graefe8s !ign19 4al"ation Method :1

1f this patient goes into 2F gaAe (without moving head, have patient loo;

up to the ceiling ! Sursumduction)

Patient must pull $ac; upper eyelid to do this (lid retraction)

ow have patient come $ac; to position of 6F gaAe

1f eyelid stays s +isease (/hyroid +:)2. ophthalmic 9oiter

&. LidPtosisa. Paresis 3 Parlysis of Le4ator Pal*ebrae !"*eriorisb. Primary muscle diseases

c. -omething in the eyelid that is heavy -;in lesion

-;in tumor

9landular infection

d. *icanth"s Tarsalis

4edial eyelid is drooping

9ives the impression that the patient is


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AnatomyB1. Le4ator Pal*ebrae!"*erioris

1nnervated $y &culomotor nerve

1nserts on /arsal Plate

. Pal*ebral *ortionof Orbic"laris Oc"li

1nnervated $y %acial nerve

&. 1 Ga


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,. Pal*ebral $on@"ncti4a

et to lid

?. Inferior $on@"ncti4al -orni0

-ac formed $y the two Conunctiva

%illed with tear fluid

K. -ollicle! *ll %ollicles are e"uipped $y glands which can $ecome infected@@a% 0ternal Hordeol"m(-ty)

1nfection of the !ebaceo"s Glands of >eis

'eadily seen area of localiAed redness J swelling

Possi$ility of purulent eudate (eyes stuc; shut)

Possi$le #lephoritis infectionsB1. Locali


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=ower lid has lost its integrity (due to degeneration)

-ince the dam has fallen down, the /*' fluid is allowed to tric;le out

=eads to an *i*hora (when tear fluid cannot $e maintained within the %orni)

$. *i*hora 7Tear#level

ot good $ecause you need tear fluid to ;eep the eye wet at all times

1f it is significant enough, will cause,erop&t&almia

c. 6ero*hthalmia

+ry eye

. Pal*ebral In4ersion or ntro*ion

=ower lid is too close to the eye

ye lashes (Cilia) ru$ $ac; and forth the Corneal surface

=eads to Trichasis

Trichasis

Ac"te Trichasis *atient

)ill get a Corneal Erosion(that does &/ go down $elow

#owman>s 4em$rane)

pithelium will grow and fill in the hole

In !%' Trichasis *atient

6. Corneal -lcercan occur that erodes down to the -u$stantiaPropia6. Collagen $undles are arranged in layers in a very 9eometric

and 4aticulous manner2. pithelial cells will fill in the hole in pithelial layer

&', the fi$ers in the -u$stantia Propia will fill in

a *P*:*'+ and random pattern /here will then $e a spot in the Cornea where lig&t

doesn.t pass t&roug& properl#@@@

&. Pterygi"m

*n ac"uired pathology that continues to grow out over the corneal surface

ill eventually compromise the pupil

/riangular, vascular formation from the 4edial Canthus

?sually develops from the Conunctiva $eing $om$arded $y eitherB

C*?--Ba. 2%Lightb. Partic"latematter

-alt in salt water that hits -urfer>s eyes ! -urfer>s eye

+ust from ranching ! 'ancher>s eye

%armer>s eye

(. $on@"ncti4itisa. !igns and !ym*toms3

'edC Hy*eremic$on@"ncti4a !#ollen $on@"ncti4a


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1% 2%Light e0*os"re

2% 3acterial Con/unctivitis

4ost concerned with this@@@

*. P"r"lent e0"date (yellow and ic;y) 9onorrheal infection ! (N6)

/u$erculosis infection

i$rio Cholera infection

#. M"co*"r"lent 7 4&-/ are this type@@@

-taph. infection

-trep. infection

. 1nfluenAa

. Coli

Pneumococcus

4% %iral$on@"ncti4itis erpes -imple irus

erpes :oster irus

5% Allergic 'eaction

Lacrimal !ystems2**er Lacrimal !ystem1. -"nction3

Produces the tear fluid

+ucts drain /ear %luid from 9lands into the Superior Temporal Con/unctival Forni6

. TA' -ILM3

a. M"coidLayer 4ade from 9lands of enle

b. )atery Layer

=acrimal 9land

9lands of Oraus

9lands of olfring

c. Oily Layer

4ei$omian 9lands

9lands of :eis

eed the TA' -ILM for3 %illing in the imperfections of the Corneal =ayer

utrition of Cornea

#actericidal properties

/ear fluid is almost isotonic to plasma

&. Lacrimal Gland

Can $ecome infected

1f the gland is infected, it is called a acr#oadenitis

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Lo#er Lacrimal !ystem

+rains the tear fluid

=ids close from /4P&'*= to *-*= (li;e a


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b. Tem*oral !cleral !ectors

-hould $e of the same volume (to assess if eyes are crossed)

. Hirschberg5s Test ?se Pen light

-hine in $etween the two eyes

If eyes are OT $ross yed If there is a D%IAT Y

ill get Corneal light reflees

1n the C/' of the Pupils

Corneal 'efle is not in the center of one eye

/*/ is the eviant e#e!!

&. $o4er Test

Cover eye and see where on!occluded eye wanders

?ncover eye to see what happens in the &ccluded eye

1f you cover one eye, the $rain is no longer operating in that area (no longer has to ;ic; in it>s

%usional 4echanism) -ince %usional 4echanism is not re"uired, the


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=ots of complications can arise

$lassifications of Hetero*horia(-u$tle -tra$ismus)1. Hori


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. PartsBa. *nterior -cleral %oramenb. Posterior -cleral %oramen

&ptic nerve fi$ers eit here

&. !ide4ie#

a. O*tical>one ant there to $e Q?*= 'adii of Curvature

1f it is une"ual, Cornea will have a s -yndromeD) 'etinitis Pigmentosa7) *topic Patient

as some immunodeficiency (/ Cells, *#)

/end to have hay fever, *sthma, s;in diseases

b. -lattened


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1ris

hen$iliary /ody andIris are inflamedhen$horoid and'etina are inflamed3

(1mpossi$le for one to $e inflamed without theother)

6. Anterior24eitis

2. Iridocyclitis

1. Posterior24eitis

. $hroioretinitis

2. Beratitis 7 1nflammation of the Cornea

!TAG I

6. /remendous infiltration of inflammatory cells with +4*

dema produces a Lac#$luster Cornea

%ormal Cornea glistens& but this eye has %' more luster!!

2. 4ay also $e a Ciliar# Flus&

!TAG II

1. Pann"s-ormation

#lood vessels actually start to grow into the Cornea itself (into

#owman>s 4em$rane)

ill produce a Beratocon@"ncti4itisC leading to an ntro*ionCleading to a Trichiasis

/hings that discolor the eye (not to $e mista;en for discoloration)1. Hy*hema

#lood in the *nterior Cham$er

. Hy*o*yon

Purulent eudate in the *nterior Cham$er (pus)

!$L'A6. Drainage of AFe"o"s -l"id 7 1n orderB

*"ueous %luid is made at the Ciliary $ody (constantly) filling the P&-/'1&' C*4#' of the

eye

/ric;les out across the surface of the lens and comes into and fills the */'1&' C*4#' of

the 8

/hen goes to the %iltration angle (where Cornea meets the 1ris

/ra$ecular 4esh (which has holes caled the (aces of )ontana)

1nner Canals of -onderman

Canal o" Sc&lemm

fferent Canals to &uter surface of -clera

pi!-cleral veins

7ate o" production must E8-)L t&e rate o" drainage!!!

/o ensure this, there is a constant pressure gradient in the */'1&' C*4#' called the

(ntraocular pressure 9(O*:

GLA2$OMA

Common etiology is that the 1&P is too high@@

/his directs flow into the Posterior Cham$er of the ye affects the 'etinaand the O*tic Disc

0amination of Press"re of the yeball6. Pal*ation(have patient close the eye and press two fingers on their eyelid)

a. ormal pressure

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-hould feel li;e pushing on a hot water $ottle with two fingers

Pressing on one should raise the other

P'&C+?'B *s; patient to loo; down (+eosirsumduct the eye) ?pper eyelid always follows the =im$al line

ith eye having a partially closed upper eyelid, palpate the -C='*, &/ the Cornea.

. Tonometry

#ring instrument up to the eye and apply the pro$e of the instrument onto the surface of the

CorneaPO!T'IO' !$L'AL -O'AM1. 1' P&'/1& of -clera

-tretched across so that there are holes (li;e a screen)

/his portion of


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*ppears to $e the -clera, $ut actually is the $on@"ncti4a

(Mucous Membrane

1n these patients, yellow discoloration is all the way to the

=14#*= =1

O Peri7limbal s*aring@

'ed !clera

ty*es30% Episcleritis

/here is involvement of the vasculature and the -clera (not involving

the -clera Proper)

?nilateral, localiAed spot of inflammation of the pisclera

/hought to $e a hypersensitivity reaction to some ;ind of disease

pisodic

. !cleritis

1nvolves the &= -clera (the -clera proper)

#ilateral (starts off unilateral)

Muc& dar;er color(more iolet)

/ro#n discoloration

6. Scleral Nevus(mole on the -clera)

e4"s mole

Chromatophores are cells which contain pigment

4elanosis &culi H lots of $rown spots all over the Cornea (Pre!

cancerous condition)

D O- O2T!ID O- Y/ALL

(NS(E T+E EYE3)LL

1. Irisa. 9eneral 1nformation

&rdinarily, is '*' to have pathology

*ll we do is note the color

$. Possi$le complications0: *erip&eral (ridotom#

ia 9laucoma therapy

* ole in the 1ris that helps drain *"ueous fluid from Posterior cham$er

. P"*ila. P"*illarydiameter

-hould $e e"ual #ilaterally (J3! 7 mm)

b. 'o"ndand reg"lar

4argins are round and all the same curvature (regular)

c. Directand $onsent"al Light 'efle0

Direct Light 'efle00% Place hand on Centrum of nose, to prevent light to each side of eye

1% -wing light from P&-/'&!=*/'*=

+& &/ create a


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/'%&', to do it properly, only go from Posterolateral (hold it there), then flood it from the

front (and hold it) only once@@

2% -ee if pupils constrict *upillar# Meiosis

Indirect E $onsent"al Light 'efle06. hen pupil of opposite eye constricts in reaction to the directly stimulated eye2. 1f there is a pro$lem, the effect will $e differentB

4ore sluggish response (delayed response)

1t will not constrict to the same degree

P"*illary $onditionsB6. -i0ed Mydriasis(&ver L mm in +ilation %1+ means that it will OT respond to light)

a. Increase in Intracranial Press"re

+ /& # C&C'+ *#&?/ /1-@@

b. Ac"te Gla"coma

1f there was pain in the eye

c. Dr"gs

*nything that has)tropine(used clinically in &pthamology in patients with !trabism"s 7

to stop mechanism of *ccomodation)

*tropine also used in 91 Pathology ! to decrease 91 motility, decrease secretions (*nti!

4uscarinic)

2. -i0ed Meiosis(less than 2mm in diameter that does OTreact to +ar;ness)a. Patient is under treatment for 9laucoma ($3c ;eeping pupil constricted is good for the condition)$. *nterior -egment 1rritationc. orner>s -yndromed. +rugse. Morp&ine

'%I)B ! Pupil should $eB6. "ual2. 'oundD. 'eaction

=ight

*ccomodation

/o list thisBP..'.L.A (Pupils e"ual, round, regular that react to =ight and *ccommodation)

Accommodation1. Mechanism ofAccommodation

a. yes converge$. Pupils constrict

/his is the &=8 thing Pupils do with *ccommodation@@@

c. Ciliary muscle contracts

Ciliary muscle contracts causing A 7 Pdiameter of lens to increase 1C'*--

'%'*C/&'8 Power of lens

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$'Y!TALLI L!

O'MAL A/O'MAL

Clear and transparent 1f opa"ue

eed to use a J62 =ens

$ATA'A$T!1. Ty*esof $ataracts

a. "clear $ataract

/he nucleus of the =ens is $ecoming opa"ue

b. Posterior !"bca*s"lar$ataract

ard to see $ecause it develops in the posterior lens

c. $"neiform$ataract

-tarting in periphery to center of =ens

. !igns and !ym*toms of patient developing CataractsBa. Glare

ater filled structure refracts more light when light hits it

b. %is"alDiscolorations

#lue or yellow casts to o$ects in room

c. Halosseen around lightsd.


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1t fits into this space

&. Hyaloid$anal

yaloid *rtery runs through this to supply the developing =ens

hen =ens is fully developed, it no longer needs this artery !!artery will atrophy

Canal will fill in with =ens su$stance (sol!gel su$stance)

-ometimes, remnants of the atrophied yaloid *rtery remain and can $e seen with an

&pthalmoscope ! Mittendor"".s ot

'TIA

Cup!li;e structure

1. 'etinal-"nd"s

#ase of the cup (Posterior concavity of cup)

. O*ticDisca. =ocation

&n nasal side of the 'etina

b. -hape

-hape is &val ! 'ound

1s more oval than round (vertical length is greater than horiAontal length)

c. 4argins

-uperior, /emporal and 1nferior margins are clearly demarcated@@ (well ! defined@)

asal margin is fuAAy

d. Color of the +isc

O'MAL A/O'MAL

-almon colored (orange!pin;) 'ed +isc

hite +isc

e. Physiological$"*

* depression in the +isc

/his is where vascular emergence and convergence occurs (vessels come out and in to it)

/here must $e *PP'C1*#= disc material $etween $orders of disc and physiolgical cup

1f $orders are not seen, this is $ad@@

O'MAL A/O'MAL

$"* Disc 'atio

-hould $e 6B2

1f $orders $etween Physiological cup and

&ptic +isc are not seen

8ellowish cast color

/lood %essels of 'etina1. !"*erior Pa*illaryArtery

#ifurcates superior to the dge of the +isc

. Inferior Pa*illayArtery

#ifurcates & the confines of the disc

&. Tem*oral/ranches !ystem

(. asal/ranch !ystem

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Ho# to differentiate bet#een Arteries and %eins1. $olor

*rtery H red

eins H dar;er

. Diameter

eins are larger

&. Lightrefle0

hen light hits it, you will 2 tracts of red (you will see a strip of light on the artery)

/his does not occur with eins

(. P"lsations

eins often pulsate near or on the disc

+. A%$ross

*rtery lies on top of vein on periphery of 'etina

O'MAL A% $'O!! PATHOLOGI$AL A% $'O!!

6. =ong *is *ngle is always less than 0F(*cute angle)

2. *rtery is always on top of the vein(superficial)

D. #lood of vein always comes up to the marginof the artery

6. *therosclerosis of the =umen

Causes vessel to get heavy and sin; intothe underlying vein

=oo;s as if there is & $lood circulating

around the artery

=oo;s li;e $lood is falling ust short of the

artery)V Nic;ing or Concealment

2. * =ong *is angle widens past 0F

The 2ndifferentiated 'etina Differentiated 'etina(4acula)

/he outer wall of the 'etina

+iffusely red

4iture of 'ods and Cones

*ill loo# dar#er!!

Fovea Centralis+ may be seen as a tiny white

dot this is the end of the visual a,is &nly contains cones

Pathologies of the ye1. Diabetic 'etino*athy

on7*roliferati4e !tage(#ac;ground 'etinopathy)

Proliferati4e !tage(=ater stage of +ia$etic retinopathy)

'nly - rogress to this stage!!

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!eries of things that de4elo*36. Micro


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=ots of pressure against *O' walled vessels

arly

0% 1ncrease in)rterial Tortuosit#

idth of light refle 1C'*-- due to *therosclerotic

changes

*s it widens, the color of the arteries changes to a Copper

Color!

1% A%'atio

ormal * 'atioB 2 B D

ypertension * 'atioB6 B D (widens due to light refle)

2% A% ic;ing3 $oncealment

G"nn8s !ign3 enous $lood flow does not come up to

*rterial wall

!al"s8 !ign3 /here is a 0$etween the artery and vein

Intermediate

1. %lame type hemorrhages

. !il4er #ireartery

*rterial wall changes color

Lig&ter and more Silver!

&. $otton )oole0"dates

1ndicates areas of infarction

!e4ere Pa*illedema

7. Pa*illedema(a;a T/l"rred DiscS or T$ho;ed DiscS)

!igns and !ym*toms ofthe O*tic Disc

6. ery 'edoptic disc

+isc is red and swollen $ecause it is TCho;edS

#lood cannot get out@

2. !#ollenE physiological cup o$literated 4argins are very raised and $lurred@

&. o distinct margination

7. Dilated 4einsreturning peripheral $lood

#ecause $lood cannot get $ac; in

$a"sed by

1. 8ed Intra!cranial *ress"re

4C at Posterior Cranial %ossa

. !%' Hy*ertensi4e 'etino*athy

&. $entralretinal 4ein occl"sion

(. $ranial Arteritis

&ptic nerve arteritis from 4?=/1P= -C='&-1-

+. Gla"comaa% Physiological cup $ecomes $$T'I$to the Temporal side

Nasal isplacement o" Vessels @ essels appear to $e on the Nasal sideof the cup

1n reality, it is the cup that has moved /4P&'*==8@

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$% 4argin with +isc margin $ecomes O margin

c% Increased *ress"reon Physiological cup causesB

Cup +iameter to increase

Cup +epth to increase

Cu gets *250%05 and 50060/!!

%ormal ressure + 17 8 99 mmHg 4 Glaucoma + :7 8 ;7 mmHg

d% Can SEEortions of theLamina Cri$osa!!!

+ %&' 41+/'4 6

OTO'IOLA'YGOLOGY

0ternal ar1. Pinna

Anatomyof the 0ternal arB6. eli (6)

/he outer rim of the ear

2. -capha (2)D. +arwinGs /u$ercle (D)7. /ragus (7)5. *nti!tragus (5)L. Cavum3concha (L) E depressionM. %ossa (M)

K. Fran;As Crease(K) *n indentation in the lo$ule

-uggested that L0R of these patients may develop Coronary *rtery +isease

. Lob"lea. Properties

4ade of %i$ro!fatty tissue

& Cartilage

* stiff lo$ule may suggest *ddisonGs

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$ee !%$ diagrams page &'


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$. 4ust loo; for presence of O=&1+

1n Beloid Formers, when their =o$ule is damaged (usually from ear piercing), the

scar formation will remain hypertrophied@@ ($ig ugly $ump)

. AM

Middle ar or Tym*anic $left

1s &/ a Cavity@@

Inner ar1. $ochlea

1ncludes the &rgan of Corti

%or hearing

. %estib"larA**arat"s

%or $alance

Pathologies of the 0ternal ar36. arwinAs Tu$ercleE normal finding

a. $hondro7dermatitis Helic"s $hronic"s

#enign lesion of +arwinGs /u$ercle

2f 5arwin


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yelids

4alar aspect of face

4idline of chest

Post!auricular sulcus

Cavum to *4

Pinnae

$% Ec'ema

Vuicy papules

'ed

-caly

1ll!defined

?. Psoriasis %"lgarisa) )ound in many laces (-ame locations similar to -e$orrheic +ermatitis)

1n I around ear

Pre!auricular area

Post!auricular area

. Her*etic Infection

/rac;s /rigeminal nerve

Can infect 9eniculate ganglion of C 11

Heres ?oster 'ticus /amsey$Hunt (yndrom

. !ebaceo"s $yst

Can form over cavum (posterior side of ear)

A' $AAL(27 mm in length)

6. $artilagino"s *ortion(outer 63D of canal H K mm)a. 9eneral 1nformation

K mm

4ade up of little $its of cartilage, ust li;e the Pinna

his ortion of the Canal has FLE,(3(L(TY!!!

/hus, ideally when you insert -peculum into ear, you must ;eep it in this section ($ecause

you need to move it around for the eamination)

$. Cle"ts o" SantariniH spaces $etween the cartilage6) */'1&' to this portion of the canal areB

Parotid gland

TM

hese Clefts were a athway of disease and could get to the M@ or 6arotid Gland

2) P&-/'1&' to this part of the canalB

Mastoid Air $ells! +isease that got through would lead to Mastoiditis

27 of 77

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his does not occur anymore due to 3ntibiotics@@

c. !;inH thic;er in canal (vs. osseus portion)0% +air "ollicles < eed to rule these out@

%olliculitis

%urunculosis

1% Se$aceous glandsE produces Cerumena. !cant amo"ntof Cerumen in the lumen

Possi$le s;in disease in the Canal

4ay produce a dry canal Pruritic (1tchy)

=eads to itchy canal we will scratch it a lot@

$. 0cessi4eCerumen in =umen

1f we see it, you don>t do anything

+o not advance -peculum or try to clean it out

1n absence of symptoms H do nothing

1f there are symptoms H must clean out wa and inspect ear canal

2. /ony *ortion(inner 23D of canal H 6L mm)): Otoscopice6amination

Oeep tip of speculum in outer 63D of canal, &?/ of this #ony portion@@@

-;in is tightly adhered to the Canal

/here are & hair follicles and & -e$aceous glands

/hus easily damaged if &toscope -peculum is advanced into this area

3: Pathologies3*roblems19 Itchy l"mendue to dryness. -cratching can causeB

1ntroduction of $acteria

#rea;ing of the s;in ($ecause the s;in is /19/=8 adhered to this portion of the canal)

4ay $e due to underlying ermatitis

9 $er"men Im*actionH 4ost common finding@

&9 -ollic"litis

(9 -"r"nc"losis

+9 Otitis 0terna

/he *4 has normal s;in flora (-taph. epidermis mainly)

Cerumen ;eeps the ndogenous %lora from multiplying via a LO) *H ($acteriostatic)

1% no wa, $acteria multiply and invade the s;in

/his inflames the s;in allowing the invasion of &9&?- #*C/'1*

%1+19-B0% Pre or Post *uricular *denopathy

1% Pain

=oo; for this $y pulling on Pinna

2% =oo; at &steum (*4) for signs of Otorr&eadrainage of debris

1f this is present, you must refer out@@

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4% all will $e redand edemato"s(swollen)

5% 8ed diameterof the =umen =caliber9

% udation in the lumen

Pus

-erous fluid

Beratin debris(from efoliation)

,9 A"ral Poly* =&9 7 Pedunculated red mass ($ul$ li;e)Wcan also $e sessile (flat li;e)

4&/1= if you push on it with a stic;

+&- &/ P?=-*/@

CausesB as*irinC asthamaC allergiesCmycoplasma pneumonia, cystic fri$rosis

?9 Glom"s "g"lare =(9

#enign /umor that arises from the /unica *dventitia of the Jugular $ul$

rodes through floor of canal, invading the middle!ear cleft

Pulsates

Can arise on either side of tympanic mem$rane

/& +3+ %'&4 * *?'*= P&=8PB

1f you touch a stic; to it 1/ 1== OT4&@@

Pulsates

9 $holesteatoma =+9

Can $e found on either side of tympanic mem$rane

4ass of # s;in cells

9 0ostoses =,9

#one proliferation due to lots of Cold ater swimming

/hus is 4C in TCold waterS swimmers@ Can proect to either side of tympanic mem$rane

1J9 $hondroma

#enign tumor of epithelium

4ass of s;in cells

%ound in outer Cartilaginous portion

119 -oreign body in the ar $anal(liceW)

19 !agging !c"t"m

#asal part of cochlea E gives 1sthmus of Canal

2F to 4astoiditis

!c"t"mH -uperior U Posterior part of wall E thin #egins to sag due to Mastoiditis

1&9 Otalgia K ear *ain

Can refer to C 111, D, 11 , (occulomotor, mandi$ular of trigeminal, facial, vagus)

TYMPAI$ MM/'AGeneral Information

2L of 77

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/he lateral wall of the 4iddle ear cleft

&/ part of the ternal ear

-its in a position where it is reflected -?P'1&'=8 (tilted)

& ! Layered Membrane6. &uter pithelium layer (s;in)

2. Core 4ade of collagen fi$ers (thic;er fi$ers at middle)

D. 1nner 4ucus 4em$rane (cu$oidal epithelium)

Parts19 Ann"l"s =19H outer ring

9 Malleolar -oldsE thic; (loo; thic;er than other folds $ecause they have more collagen)a) Posterior %old ()$) *nterior %old (&)

&9 Pars -laccida or S&arpnellAs Mem$rane =(9

/hin triangular mem$rane

(9 Pars Tensa =+9/ony Landmar;s of Dr"m

6. Malle"s 7 'esponsi$le for position of /ympanic 4em$ranea. Man"bri"mK Long *rocess (a)

b. !hort Process =?9

c. 2mbo =,9H tip of 4anu$rium

1n approimate center of Pars /ensa

Point where processes touch the /ympanic mem$rane

. Inc"sa. Lentic"lar Process(b)

*rticulates w3stapes

$. Long $r"s =9(J3E)

4ay $e hidden parallel $ehind =ong Process (or may not $e)

D. $hordae Tym*ani =9(J3E)

+3+ $etween fluid line (from effusion) E $ring patient from supine to seated

-l"id lineH fluctuates with movement

$hordae Tym*aniH vertical while supine

/rea; the Dr"m into ( "adrants

$riteria of ormal Tym*anic Membrane

$olor -hould $e *earl gray o*"lescent str"ct"re

/ony Landmar;s -hould $e a$le to identify the Man"bri"m

Dr"m *vascular

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$one of Light =1J9

Ma@or criterion of healthy membrane(can $e seen in normal ear)

hen light of the &toscope stri;es the drum, there is a reflection of

light $ac; to us

Called a


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: #u$$les; $one of lightwill $e distorted (a$normal)

- Mobility

o response to insufflation

$) *urulent! #*C/'1* induced

#ulging of /ympanic 4em$rane into the Canal (may rupture)

#uildup of eudate causes vasculariAation 'ed and s#ollen dr"m

D) Tym*anosclerosisvia l#mp&adenopat(originating from nasopharyngeal area)

a Organso" 7osenmuller

1nvolved (oral cavity tonsilsB adenoid a;a pharyngeal, lingual, and palantines) E part of

>ald#erAs 7ing

b Eustacean Tu$eH occluded from infection

*ir trapped in tu$e

*ir from middle ear cleft pulled into tu$e

c 7etraction o" t#mpanic mem$rane(concavity) occurs $one of LightH a$normally replaced

Tym*anic MembraneH mo$ility upon insufflation

!hort *rocessH very prominent via drum retraction

!IG! and !YMPTOM!B1. Hearingdeficit

Middle$0ar CleftH devoid of ear

%ullness of ear felt

. /"ild7"* of e0"date

Causes vasculariAation 'ed and s#ollen dr"m

T'ATMT1. ?sually */1#1&/1C-

#?/ lymph does &/ respond to *nti$iotic therapy (purulence H treated)

1% M#ringotom#

Po;e hole in drum (releasing eudate)

*=19B

Collagen does notregenerate

pithelium does regenerate, $ut the healed area is /1'@

)indings of a hole in the drum healingB

/hin areas loo; greyedE w3otoscopic light eamination

Tym*ano7sclerosisH deposition of Ca2J(white spots on drum)

6ainH from stretching of drum

2% T#mpanostom# Tu$e

*llowing constant drainage

(. a spontaneous rupture can also result, which is most common at the ann"l"s

2 of 77

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I' A'

$ochlear Di4isionE earing valuation

Test otes

>&ispered Voice Test(+epends on intensity of whisper)

-illy to do $ecause these tests are &/ -tandardiAed@

Spo;enVoice Test>atc&Tic; Test

*ure


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eneral +earing Evaluation'"les6) Patient must ;now signal prior to testing (stri;e for; I heel of hand)2) 1nform patient what to do (instructed to say when can hear signal)D) Patient must close eyes

7) on7test earmust $e mas;ed from distracting noises

ot a$sence of sound Push /ragus $ac; U forth

5) +&C/&' -/*C ! in front of patient

L) -tri;e tuning for; at heel of hand

olding at armGs length until can no longer hear signal

+C is the TstandardS

old for; so sound waves H parallel to patientGs ear

stimate distance from ear (e.g. in line w3shoulder)

ote +=and +'

DL

D' ormal

If DLD' A/O'MAL3 re"uires 7 tests to +3+ deafnessB1. $ond"ction deafness

a. $analdamage fromB6. Atresiaof canal via Tcongenitally missingS Pinnae

2. Im*action (4C H cerumen)

D. Pathologies

*ural polyp(s)

Chondroma

b. Dr"mdamage fromB Perforation

#arotrauma E not common

c. Ossic"lar $haindamage fromB

Otosclerosis

+islocation

%racture E rare

. !ensory Lossa. 1n a normal individual, J d/3

Can produce permanent hearing deficit

+estroys inner U outer hair cells (in cochlea)

b. $ochleadamage fromB1. Soundat high d#

1% *res$#cusis

T&ld hearingS E degeneration

&rgan of Corti (cochlea)

-piral ganglion degeneration (pericaria)

D6 of 77


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:. )coustic NeuromaE rare

'are

eurofi$romatosis 11 ($ilateral)

Cerebello$ontine 3ngle umorH more common

%eurofibromatosis 2H on 'ec;linghausenGs +:

CafX au =ait spots +evelopment of neuromas on s;in

;. MeniereAs isease 0ndolymhatic Hydros

-. +#potroidism 9Cretin:H irreversi$le

. +#potroidism(ac"uired) H reversi$le

D, Tests "or +earing e"icits

ormalB *ir Conduction H 2 #one Conduction

HA'IG T!TIG

T!T $ond"ction !ensory>e$erAs Place vi$rating for; on verte

&'4*= H e"ual loudness in #&/ ears

=ouder in /ADear =ouder in 9&&+ ear

7inneAs yes closed

4as; non!test ear

+C in front of patient

-tri;e U hold for; I armGs length until silent

Place for; on mastoid

'ecord time

hen pt. cannot hear E $ring for; in front of ear

(%or; on mastoid H D0 sec, for; front of ear H L0 sec)

PO!ITI% 'inneH normal findings

#C (time) *C (time)

GATI% 'inne8s

*C H 2 #C

P&-1/1 /est(ormal pattern)

Sc&wa$ac&As Compare patientGs hearing to +CGs

4as; other ear

-tri;e U hold for; at armGs length until silent

Put for; on mastoid (record time)

Patient8s timeH longer D$8s timeH longer

3ingAs old vi$rating for; on mastoid

&cclude Canal $y pushing against patientGs /ragus

ormal

-ound is =&?+' with occlusion

-ound softens with & occlusion@

PO!ITI% /ingH normal findings

o change

&'

GATI% Test

=ouder with /ragus C=&-+

-ofter with /ragus &P

P&-1/1 #19(ormal pattern)

, Tests "or +earing e"icits 9VEST(3-L)7 )**)7)T-S:LA/Y'ITHITI!!endolymphatichydroB endolymph has water in it!old /B aluminum hydroide (draws fluid out of places it doesnGt $elong)

0% 'homberg Testa. Patient Position

/ight adduction of lower etremities

D2 of 77


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C. 2005

*rms at side

Close eyes

Caution E patient may sway

1% Bobra; Test(cold3warm water stimulation) N#stagmus

ystagmus is the finding that is epected. 1t should occur within 60!62 seconds, with the effects

lasting 2!D minutes. /he direction of the nystagmus is named for the "uic; component. 1f it isless than 60 seconds H hyperactive. 1f it is greater than 62 seconds H hypoactive. 1f no reactionH dead

Cold!water E opposite side

arm water E same side

NOSE *)7)N)S)L S(N-SES

%AL2ATIO(patientGs head in hyperetension so +r. can see the T#ase of the oseS)

6. Chec; for 7&inorr&ea(eudate from eternal nares)

1f present sto* e0amination and '-' O2T IMMDIATLY

TTriangle o" angerS

1f infection present in nose E possi$ility of pushing it $ac; into Cavernous -inus

2. Loo; for symmetryof $oth /'*= *'- pic

!ymmetrical Asymmetrical

ormal

6. /he !MALL' one is the &'4*= one2. DILATD one is due toB

&$struction of Nasal *assagesto getting

air through!

-o it is compensating $y enlarging

&. Pal*ation

Palpate nasal ala to center

*ssess patency of %ossa

Push '19/ ala to septum *s; patient to $reathe w3mouth closed

valuate other side

AATOMY0% Nasal Vesti$ule

as hair follicles

1% Mucocutaneous Junction

=ocation where crusts form ($oogers)

2% Superior Tur$inate

-uperior E cannot view

4% Middle Tur$inate

Can see the Anterior ti*of this

5% (n"erior Tur$inate@

Can see the Anterior ti*of this

% Nasal Septum

'arely is the -eptum P'P+1C?=*' to the floor (ecept in new$orns)

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% MiddleNasal Meatus

Can see this

G% +iatus Semi


35/44

C. 2005

De4iated !e*t"m -eptum encroaches onto the T"rbinates

Bisselbache8s Ple0"s

!ite for nose bleed

1t is where vessels **-/*4&- (at TLittleAs )rea>)

=ittleGs *rea H $lood supply to the septum

-uperior $ranchB greater palatine artery.

Posterior $ranchB sphenopalantine artery

1nferior $ranchB anterior ethmoidal artery

*nterior $ranchB septal $ranch of superior la$ial artery

Ty*es of *ista0is6. 0R of nose $leedsB *nterior $leed E *t Oissel$acheGs Pleus2. Posterior $leedD. causesB dryness, pic;ing, aspirin a$use, /#, cocaine, syphyillis, gun

shot wound, Cl, fire, mastur$ation

Hematoma

c% T"rbinates

-hould $e pin; U moist (glistening) 6 E 2 mm space $etween the -P/?4 U /?'#1*/-

4iddle nasal meatus should have no evidence of eudation@@

+. 'emo4especulum for steriliAation

,. $OLO' of M2$O!A

7ed Mucus mem$rane 1nfection

3lanc&ed>&ite *llergies

3lue D C#anotic asomotor +istur$ance (rhinitis)

?. Paranasal !in"sesa% -rontal !in"s

Palpate and Percuss

NO7M)L o pain

Congested Sinus o pain

Frontal Sinus (n"ection /enderness and Pain at !"*ra7orbital otch

/rans!illuminate

Palpate !"*ra7orbital otch(or %oramen) for P*1@

6) Supra


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6. ?se &/&-C&P with the largest caliberspeculum

1% Frontal Sinus

Push under $ony ridge of supra!or$ital margin

=ight should illuminate sinus

NO7M)L -hould see orange glow (do $ilateral)

Abnormal =infection9 o glow

2% Ma6illar# Sinus Palpate and percuss ($etween the -?P'1&' 9191* and 1%'1&' &'#1/) Push against the // with a /ongue $lade yperetend head and open the mouth

%lash light onto 4*1==*'8 -1?- (from the outside of the sinus)

&range illumination should come down from maillary sinus

=oo; at hard palate for this glow

NO7M)L -hould see orange glow (do $ilateral)

Abnormal =infection9 o glow

Complications of sinus infectionsB

&steomyelitis

%acial cellulitis

4eningitis E a$scess

4ucosal E causing ocular displacement

CacosmiaB odor that really is not there. 1maginary.

Oro*haryngeal 0am =7*art9Oral e6amination

0% -pper Lower Lip

May ha4e scar(Connecting upper lip to nose)

Hare7li*or $left7li*deformity

4C associated w3cleft!palate

Corrected at $irth

Angio7ne"rotic edema *llergic $ase

pisodic recurrences of swollen lips (mar;ed deformity)

DL of 77


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%esicles

Su$gingiva Stomatitis8 at Corners of Mouth

ia +SV


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Pyorrhea 9ingivitis via pyogenic $acteria

udate seen

Gingi4al hy*er*lasia

+entures

+ilantin therapy (older patients)

Leu;emia

Lead into0ication

0% Solid $lue wav# line

. Pbso"rces

+esigner mugs

P$ pipes

/ism"th into0ication

0% Stippled $lue wav# line

. /ism"thso"rces

Pepto!$ismol

Peptic medications

4% 3-CC)L M-COS) D Oral Cavit#

eed /ongue +epressor (good idea to ;eep wet)

eed pen light

+isposa$le glove

P'OTO$OL31. /a;e tongue depressor U push chee; out

. =oo; at $uccal mucosa

-hould $e moist U pin;

&. 1dentify opening of !tenson8s D"ct

+rains parotid gland

&pens opposite 2ndmolar

(. '?= &?/Bi demaii 1nflammationiii 1nfection and +rainageiv hite lesions (Leu;opla;iaI T&rus&I 7eticulated lesionsLichens lanus

-IDIG! I /2$$AL M2$O!A

-ordyce !*ots(9eriatric patients)

%ound in &lder patients

+ue to Mucus mem$rane atrop

Creamy!yellow se$aceous glands (holocrine)

ormal finding

Bo*li;8s !*ots 7u$eolaE in young children

hite spots

Le";o*la;ia

!igns and !ym*toms36. hite patch on lips2. -lightly raisedD. *lways P'!C*C'&?-

+evelops into SHuamous Cell carcinoma

$a"sed by3 TPipe smo;ingS for a long time

DK of 77


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'etic"lated )hite !*ot =ace!li;e (non!homogenous)

-een in Lic&en


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-asic"lationsAbnormal finding

Portion of muscle spasms

TicAbnormal finding

hole muscle spasm

!mooth Tong"e('egular areas)

3LL of tongue is 7EI SL(CB and EVO( o" *apillae!!

#62deficiency

%e deficiency

Hairy Tong"e ia dirty deposits (tongue is &/ ;ept clean)

(-mo;ing, $ad oral hygiene)

Hairy Le";o*la;ia

hite horn!li;e proections (&n sides of tongue)

*1+- related (mar;er), precursor for C*

Particularly see at the glossalpalantine arch a;a CoffinGs area (far

$ac; and lateral sides of tongue) where most cancers develop

Tong"e De4iation C 11

/ongue points to side of lesion

)harton8s D"ct(at entrum of /ongue)

T&ere is an Aed c&ance o" S)L(V)7Y ST)S(S &ere $ecause

6. oriAontal plane of ducts2. /ortuosity of the ducts

Prone to calcifications=Salivar# Calculus?

=ingual nerve crosses 2

$a4iar Lesions(at entrum of /ongue)

Pleus of veins E caviar lesions

!tra#berry tong"e Oawasa;i -yndrome, -carlet fever

/lac; tong"e from anti$iotic use for fungal infection (*spergillos niger)

!trength N 'OM of Tong"ea. !trength

Push tongue to sides of chee;

/est3 ?se /ongue $lade for resisted '&4

M"scle testH dart tongue in U out rapidly

b. 'OM

?se tongue $lade for resisted '&4

c. 'OM E m"scletest

*s; pt. to touch nose w3tongue

% HA'D PALAT

0ostoses Torus Mandi$ularis Torus *alantinus

70 of 77


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('edundant $one)4idline atB

=19?*= side of mandi$le4idline of hard palate

*&ar#ngeal e6amination1. !oftPalate

a% *&onation

ormal

T*ahhS*alantine arc&esrise symmetrically

%ot too loud or too soft or else it will yield )3L(0 6'(22D0(!

24"la De4iation(*symmetric rising)

Vagus nerve1nnervation

-ide of uvula deviation is C&/'*=*/'*= to lesion

QuinceGs +isease H infected uvula. Presents swollen

$. TonsilsE determine presence or a$sence of the /onsils

Absence /onsillectomy

Tonsilar tiss"e

/ends to regenerate

6artialH /onsilar /ags )ull /egeneration

QuincyGs H tonsillitis. * peritonsilar a$scess

Abnormalities in Tonsilar Location

ormal Tonsil

+raw a line down from the Posterior /onsilar Pillar and *nterior

/onsilar Pillar

/onsils should not etend passed that 14*91*'8 =1@@

Palatine Tonsil 1 Partially etends outside pillar $oundaries

Palatine Tonsil Y way $etween $oundary U uvula

Palatine Tonsil & *$uts =*/'*= aspect of uvula

Palatine Tonsil ( #ilateral approimation in midline

TonsilsH considered &/ enlarged unless found w3*athology

*at&ologies6) Tonsilitis

1nected (red)

nlarged E $3c swollen

nlarged Crypts

hite eudates

QuincyGs

2) !y*hilitic $hancre ="lceration9

Can $e anywhere in &ral Pharyngeal area, $ut /onsils are a favora$le spot for Spiroc&etes!

D) $ancer an o*en lesion on the tonsil may be tonsil cancer

PO!T'IO' PHA'YGAL )ALL

Tong"e /lade

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/o minimiAe ag 7e"le6H use wet tongue $lade

/o ;eep tongue out of way H push down U pull forward

1. ty*es of Pharyngitis

Gran"lar Pharyngitis(viral)

6. Posterior wall pain H mildly inected2. o evidence of edemaD. -tudded w3$umps (L#mp&atic perplasia)

1n response to iral infection@

-ollic"lar Pharyngitis($acterial)

9reatly inected ('8 red@@)

-tudded w3yellow creamy eudate

4ar;ed rythema '8 P*1%?=@@

. Post7asal Dri*a. -oft palantine arches rise symmetrically$. Palantine arches are presentc. Posterior pharyngeal wall E without evidence of pharyngitis or post!nasal drip presentd. !igns and !ym*toms

ill see a T'+S trac; where Nasal E6udateis dripping@

e. $a"ses3

Chronic -inus 1nfection

Chronic asal 1nfection

nd PA'T O- O'AL 6AMIATIO3 ?se a '?##' 9=&@6. Palpate floor of mouth via a TPincer moveS2. Palpate sides of /ongue in same manner

=oo;ing for =umps and3or #umps

1ndicative of $ancer

AT'IO' $B 6AMIATIO

19 Thyroid $artilage E Laryn0 -hould $e symmetrical

-hould &/ $e prominent (displaced in a forward position)

9 Thyroid Glanda) ormalH non!palpa$le

b9 Pal*able

1n thin nec;s

1f palpa$le, should feel li;e the -trap muscles

c) 3i


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TechniF"e of Thyroid 0am6. Patient holds mouthful of 2& (donGt swallow yet)2. +C stands $ehind patient E palpate in area of gland

D. *s; patient to fle forward U lateral fle toward side of eamination

%ingers down on medial -C4 E pushing against trachea

*s; patient to swallow 2& 1nferior poles should move superior

+o $ilaterally

ormal H non!palpa$le

=oo;ing for $umps (isolated troid nodule)

7. Isolated Thyroid od"le

4ost are #19@

4alignant H possi$le

#erryGs sign H palpa$le tumor over the carotid. 1f the pulse is felt, it is $enign. 1f not, then

it is malignant.

5. nlarged Thyroid Gland K /osillated(multiple $umps) 1ndicates meta$olic change

3ruitH can $e heard on auscultation E (can hear at angle of aw)

Tromegal#E not all necessarily anterior (can have su$sternal goiter)

PempertonGs sign is possi$le. 'esults from a retrosternal goiter. 'aise hands, and the

face flushes and patient may get giddy $ecause of the lac; of oygen to the head.Possi$ly faint.

f9 Trachea /hyroid cartilage is symmetrical U not unduly prominent /hyroid gland is non!palpa$le /rachea is palpa$le in the midline

Chec; for midline position E ma;e sure it is C/'+@ %ingers should fit $etween e"ual spaces $etween -C4 and trachea ($ilaterally)

Palpate through the -upra!manu$rial notch

Z K0R /racheal tugs are due to &'4*= *'1*/-

Z 20R are due to Pathology

LAT'AL $B K %asc"lar 4al"ation

0% Carotid Evaluation Palpate =& in nec; ($ut listen 19), medial to -C4

-tay away from $ifurcation E Carotid receptors (at angle of aw)6) 'ate

2) 'hythmD) -ymmetry

'ate U rhythm are symmetrical

Carotid arteries are compressi$le

2. C&ec; "or $ruits(finding of atherosclerosis) E D possi$ilities

*uscultate posterior to angle of aw, using $ell and ta;ing a deep $reath and hold it

#ruit E proimal to $ifurcation

a. $arotid Occl"si4e Arterial Disease

7D of 77


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C. 2005

b. Thyromegaly

Can cause $ruit at angle of aw

1f no $ruit at thyroid then $ruit at aw is from)t&erosclerosis so chec; the friggin thyroid

c. Aortic !tenosis

'19/ Peri!sternal $order, 2nd1ntercostal space will hear $ruits@ murmurs

d. istended Nec; Veinsfrom Congestive eart %ailure

2% L#mp&adenopat: Su$

7Q - Physical Diagnosis Midterm

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