1
Q
What should you look out for when examining a patient’s hair?
A
- Note its quantity, distribution, texture, and any pattern of loss. You may see loose flakes of dandruff.
- Fine hair is seen in hyperthyroidism, coarse hair in hypothyroidism.
- Tiny white ovoid granules that adhere to hairs may be nits (lice eggs).
2
Q
What should you look out for when examining a patient’s scalp?
A
- Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.
- Look for redness and scaling that may indicate seborrheic dermatitis or psoriasis; soft lumps that may be pilar cysts (wens); and pigmented nevi that raise concern of melanoma.
3
Q
What should you look out for when examining the size of a patient’s head?
A
- Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or tenderness. Learn to recognize the irregularities in a normal skull, such as those near the suture lines between the parietal and occipital bones.
- An enlarged skull may signify hydrocephalus or Paget disease of bone. Palpable tenderness or bony step-offs may be present after head trauma.
4
Q
What is the name of CN 1, what does it control, and how do you test its function?
A
- Name: Olfactory
- Controls: Sense of smell
- Test by: Test sense of smell by holding a scent up to nose
5
Q
What is the name of CN 2, what does it control, and how do you test its function?
A
- Name: Optic nerve
- Controls: Visual acuity, visual fields, and ocular fundi
- Test by: Use a snellen chart to test visual acuity, test visual field by confrontation (static finger wiggle test)
6
Q
What is the name of CN 3, what does it control, and how do you test its function?
A
- Name: Ocularmotor
- Controls: Pupil size and reactivity, eyelid elevation, and extraocular movements
- Test by: Check pupillary reaction
7
Q
What is the name of CN 4, what does it control, and how do you test its function?
A
- Name: Trochlear
- Controls: Extraocular movements (Moves eyes downward and laterally)
- Test by: 6 Cardinal directions of gaze and check convergence of the eyes.
8
Q
What is the name of CN 5, what does it control, and how do you test its function?
A
- Name: Trigeminal
- Controls: Corneal reflex, facial sensation, mouth motor function
- Test by: Asking pt. to clench teeth, test for facial sensation in 6 points, and check corneal reflex
9
Q
What is the name of CN 6, what does it control, and how do you test its function?
A
- Name: Abducens
- Controls: Extraocular movements (turns eye laterally)
- Test by: Having patient move eyes from side to side
10
Q
What is the name of CN 7, what does it control, and how do you test its function?
A
- Name: Facial
- Controls: Facial expression, taste, corneal reflex, and lip closure
- Test by: Looking for facial droop/asymmetry. Ask. pt. to smile, frown, and show teeth.
11
Q
What is the name of CN 8, what does it control, and how do you test its function?
A
- Name: Vestibulocochlear
- Controls: Ability to hear
- Test by: whisper into the patient’s ear and ask them to repeat what was heard
12
Q
What is the name of CN 9, what does it control, and how do you test its function?
A
- Name: Glossopharyngeal
- Controls: Gagging and swallowing (sensation)
- Test by: Having pt. swallow, have pt. say “AH”, test gag reflex
13
Q
What is the name of CN 10, what does it control, and how do you test its function?
A
- Name: Vagus
- Controls: Gagging and swallowing (motor), speech
- Test by: Having pt. swallow, have pt. say “AH”, test gag reflex
14
Q
What is the name of CN 11, what does it control, and how do you test its function?
A
- Name: Accessory
- Controls: Shoulder movement and head rotation
- Test by: Ask pt to move their head from side to side against your hand, have patient shrug shoulders
15
Q
What is the name of CN 12, what does it control, and how do you test its function?
A
- Name: Hypoglossal
- Controls: Tounge movement & speech articulation
- Test by: Have pt. stick out tongue and move it internally from cheek to cheek. Look for asymmetry, atrophy, or deviation of the tongue
16
Q
Describe the cardinal directions of gaze and each CN associated with them
A
- CN 3: Moves eyes up, top (left & right), & bottom (left & right)
- CN 4: Moves eyes left and right
- CN 6: Moves eyes down
17
Q
How do you test for visual acuity using a Snellen eye chart?
A
- Have pt. sit 20ft away from the chart
- If they use corrective lenses have them put them on
- Test each eye individually
- Have pt. read the smallest line
- Record visual acuity (top number is the distance from the chart, and bottom number is the the distance at which a normal eye can read the letters)
18
Q
How do you conduct an ophthalmoscopic exam?
A
- Darken room
- Turn ls disc to the 0 diopter
- Hold the ophthalmoscope in your right hand and use your right eye to examine the patient’s right eye; hold it in your left hand and use your left eye to examine the patient’s left eye.
- Hold the ophthalmoscope firmly braced against the medial aspect of your bony orbit, with the handle tilted laterally at about 20° slant from the vertical. Check to make sure you can see clearly through the aperture. Instruct the patient to
look slightly up and over your shoulder at a point directly ahead on the wall. - Place yourself about 15 inches away from the patient and at an angle 15° lateral to the patient’s line of vision. 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
- Now place the thumb of your other hand across the patient’s eyebrow, which steadies your examining hand. Keeping the light beam focused on the red reflex, move in with the ophthalmoscope on the 15° angle toward the pupil
until you are very close to it, almost touching the patient’s eyelashes and the thumb of your other hand
19
Q
What are the steps for examining the optic disc?
A
- Locate the optic disc (a round, yellow-orange to creamy pink structure with a pink neuroretinal rim and central depression)
- Bring the optic disc into sharp focus by adjusting the lens of your ophthalmoscope
- Inspect the optic disc:
- The sharpness or clarity of the disc outline. The nasal portion of the disc margin may be somewhat blurred, a normal finding.
- The color of the disc, normally yellowish orange to creamy pink. White or pigmented crescents may ring the disc, a normal finding.
- The size of the central physiologic cup, if present. It is usually yellowish white. The horizontal diameter is usually less than half the horizontal diameter of the disc.
- The comparative symmetry of the eyes and findings in the fundi.
20
Q
What are the steps for examining the retina?
A
- Inspect the retina, including arteries and veins as they extend to the periphery,
arteriovenous crossings, the fovea, and the macula. Distinguish arteries from
veins (arteries are light red whereas veins are dark red and larger) - Follow the vessels peripherally in each direction, noting their relative sizes and the character of the arteriovenous crossings.
- Identify any lesions of the surrounding retina and note their size, shape, color, and
distribution - Inspect the fovea and surrounding macula. Direct your light beam laterally or
ask the patient to look directly into the light.
21
Q
What does papilledema indicate?
A
- Swelling of the optic disc and anterior bulging of the physiologic cup suggest
papilledema (Fig. 7-31), which is associated with increased intracranial pressure. - This pressure is transmitted to the optic nerve, causing stasis of axoplasmic flow,
intra-axonal edema, and swelling of the optic nerve head. - Papilledema signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions, so searching for this important disorder is a priority during all your funduscopic examinations
22
Q
What are cotton-wool patches and what do they indicate?
A
- Cotton-wool patches are white or grayish, ovoid lesions with irregular “soft” borders.
- They are moderate in size but usually smaller than the disc.
- They result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of the retinal nerve fiber layer.
- Seen in hypertension, diabetes, HIV and other viruses, and numerous other conditions
23
Q
What is and what causes AV nicking?
A
- Occurs when the vein appears to stop abruptly on either side of an artery
- This is a result of ongoing damage that is occurring due to high blood pressure
24
Q
What causes glaucoma?
A
- POAG, there is a gradual loss of vision in the peripheral visual fields, resulting from loss of retinal ganglion cell axons. The eye’s optic nerve is damaged due to increasing ocular pressure.
- Patients who are African America, have diabetes, myopia, or ocular hypertension are at risk.
25
Describe what you would find in an assessment of a patient with Glaucoma?
* Blurred vision & vision loss that is painful
* Gradual loss of peripheral vision
* **Retinal examination reveals pallor and increasing size of the optic cup (enlargement more than half the diameter of the optic disc**
26
What is strabismus?
* Strabismus is the misalignment of the eyes
* This can lead to visual impairment and is common in young children
* **Strabismus persisting beyond 3 months of age or persistent strabismus of any type may indicate ocular motor weakness or another abnormality in the visual system**
27
What is and what causes conjunctivitis?
* Inflammation of the conjunctiva caused by abacterial, viral or other infection; allergies; or irritation
* This leads to diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally
* It is highly contagious
28
What are cataracts and what causes them?
* Cataracts are opacities of the lenses visible through the pupil: this results in clouding of the lens
* risk factors: older age, smoking, diabetes, corticosteroid use
29
What should you examine when inspecting the ear?
* Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or
swelling.
* Cerumen, which varies in color and consistency from yellow and flaky
to brown and sticky or even to dark and hard, may wholly or partly obscure your
view.
* Inspect the eardrum, noting its color and contour
30
What are the characteristics of a normal eardrum?
* tympanic membrane is pinkish gray.
* No discharge or inflammation
* No foreign objects
* Blood vessels are normal
31
What are some characteristics of acute otitis externa on inspection?
* the ear canal is often swollen, narrowed, moist, pale, and tender. It may be reddened.
* The tug test (movement of the auricle and Targus) up and back is painful with otitis externa
32
What are some symptoms of otitis externa?
* Itchy ear canal in the beginning
* Earache that is aggravated when pulling on the ear lobe
* Release of fluids from the ear canal
* Temporary diminished hearing due to puss accumulating in the ear canal
* Fever
* Inflammation of ear canal’s skin
33
What are some characteristics of acute otitis media on inspection?
* red bulging drum on inspection with most landmarks obscured.
* Dilated blood vessels can be seen in all segments of the eardrum
* Unilateral conductive hearing loss
* Spontaneous rupture of the eardrum may follow
34
What are some symptoms associated with otitis media?
* Earache
* Fever
* Hearing loss
* A sense of fullness in the ear
* Leaking of fluid from the ear
35
What are the functions of the nasal cavities?
Cleansing, humidification, and temperature control of the inspired air.
36
How do you correctly inspect the nares with an otoscope?
1. Inspect the inside of the nares with an otoscope and the largest available ear speculum.\*
2. Tilt the patient’s head back a bit and insert the speculum gently into the vestibule of each nostril, avoiding contact with the sensitive nasal septum (Fig. 7-53).
3. Hold the otoscope handle to one side to avoid the patient’s chin and improve your mobility.
4. By directing the speculum posteriorly, then upward in small steps, try to see the inferior and middle turbinates, the nasal septum, and the narrow nasal passage between them. Some asymmetry of the two sides is normal
37
What should you monitor for when inspecting the nasal mucosa?
* The nasal mucosa that covers the septum and turbinates.
* Note its color and any swelling, bleeding, or exudate. If exudate is present, note its character: clear, mucopurulent, or purulent.
* **The nasal mucosa is normally somewhat redder than the oral mucosa.**
38
How would the nasal mucosa appear with viral rhinitis?
the mucosa is reddened and swollen
39
How would the nasal mucosa appear with allergic rhinitis?
it may be pale, bluish, or red.
40
What should you monitor when inspecting the nasal septum?
* Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient’s finger can reach) is a common source of epistaxis (nosebleed).
* Any abnormalities such as ulcers or polyps.
41
What are common causes of septal perforation or septal ulceration?
Causes of septal perforation include trauma, surgery, and intranasal use of cocaine or amphetamines, which also cause septal ulceration.
42
What are nasal polyps and with what conditions are they seen?
* Nasal polyps (Fig. 7-55) are pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses
* They are seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis.
43
How do you palpate the sinus for tenderness?
Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes (Fig. 7-56). Then press up on the maxillary sinuses (Fig. 7-57).
44
What are some symptoms suggesting acute bacterial rhinosinusitis involving the frontal or maxillary sinuses?
* Local tenderness, together with symptoms such as
* facial pain
* pressure or fullness in sinuses
* purulent nasal discharge,
* nasal obstructions,
* and smell disorder
* especially when present for \>7 days
45
Describe the anatomy of the undersurface of the tongue
The undersurface of the tongue has no papillae. Note the midline lingual frenulum that connects
the tongue to the floor of the mouth and the ducts of the submandibular gland (Wharton
ducts) which pass forward and medially (Fig. 7-63). They open on papillae that lie on each side of the lingual frenulum. The paired sublingual salivary glands lie just under the floor of the mouth mucosa.
46
Describe the anatomy of the posterior pharynx
Above and behind the tongue rises an arch formed by the anterior and posterior pillars, the soft palate, and the uvula (Fig. 7-64). A meshwork of small blood vessels may web the soft palate. The posterior pharynx is visible in the recess behind the soft palate and tongue. In Figure 7-64, note the right tonsil protruding from the hollowed tonsillar fossa, or cavity, between the anterior and posterior pillars. In adults, tonsils are often small or absent, as in the empty left tonsillar fossa.
47
What would you observe for when inspecting the lips?
* Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness.
* **Watch for central cyanosis or pallor from anemia.**
48
How would you inspect the oral mucosa?
Look into the patient’s mouth and, with a good light and the help of a tongue blade (Fig. 7-66), inspect the oral mucosa for color, ulcers (Fig. 7-67), white patches, and nodules
49
What would you inspect for when inspecting the gums and teeth?
* Note the color of the gums, which are normally pink. Brown patches may be present, especially but not exclusively in darkskinned individuals. Inspect the gum margins and the interdental papillae for swelling or ulceration.
* Inspect the teeth. Are any of them missing, discolored, misshapen, or abnormally
positioned?
50
What would you inspect for when inspecting the tongue?
Ask the patient to put out his or her tongue (Fig. 7-68). Inspect it for symmetry— a test of the hypoglossal nerve (CN XII) (Fig. 7-69).
51
What are some characteristics of cancer on the tongue and who is most at risk?
* Any persistent nodule or ulcer, red or white, is suspect, especially if indurated. These discolored lesions represent erythroplakia and leukoplakia and should be biopsied
* **Men aged \>50 years, smokers, and heavy users of chewing tobacco and alcohol are at highest risk for cancers of the tongue and oral cavity, they are usually on the side or base of the tongue**
52
What would you inspect for when assessing back of the mouth?
Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx. Note their color and symmetry and look for exudate, swelling, ulceration, or tonsillar enlargement. If possible, palpate any suspicious area for induration or tenderness. Tonsils have crypts, or deep infoldings of squamous epithelium, where whitish spots of normal exfoliating epithelium may sometimes be seen
53
What type of hearing loss is common in older adults?
* Aging is the most important risk factor for hearing loss and presbycusis is the most common age-related cause
* In presbycusis, degenerating hair cells in the ear lead to gradually progressive hearing loss, particularly for high-frequency sounds.
54
What should you inspect the neck for?
Inspect the neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes.
55
In what sequence should you palpate the head and neck lymph nodes?
Using the pads of your index and middle fingers, press gently, moving the skin over the underlying tissues in:
1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of the mandible.
7. Superficial cervical—superficial to the sternocleidomastoid.
8. Posterior cervical—along the anterior edge of the trapezius.
9. Deep cervical chain—deep to the sternocleidomastoid and often inaccessible to examination. Hook your thumb and f ingers around either side of the sternocleidomastoid muscle to find them.
10. Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid.
56
What are the characteristics of normal lymph nodes?
* You should be able to roll a node in **two directions: up and down, and side to side**
* Non-tender
* Should be soft
57
What are the characteristics of inflamed lymph nodes?
* Mobile
* Tender
* Enlarged
58
What are the characteristics of malignant lymph nodes?
hard or fixed nodes (fixed to underlying structures and not movable on palpation) suggest malignancy.
59
When inspecting the trachea what should you look out for?
Inspect the trachea for any deviation from its usual midline position. Then palpate for any deviation. Place your finger along one side of the trachea and note the space between it and the sternocleidomastoid. Compare it with the other side. **The spaces should be symmetric.**
60
What are goiters?
* An enlargement of the thyroid gland to twice its normal size.
* Goiters may be simple, without nodules, or multinodular, and are usually euthyroid.
61
What are causes for thyroid enlargement?
* Includes the isthmus and lateral lobes; there are no discretely palpable nodules.
* Causes include Graves disease, Hashimoto thyroiditis, and endemic goiter.
62
What can cause a single nodules on the thyroid and what are the risk factors for it?
* May be a cyst, a benign tumor, or one nodule within a multinodular gland. **It raises the question of malignancy.**
* Risk factors are prior irradiation, hardness, rapid growth, fixation to surrounding tissues, enlarged cervical nodes, and occurrence in men.
63
What are some characteristics of a multinodular thyroid?
An enlarged thyroid gland with two or more nodules suggests a metabolic rather than a neoplastic process. Positive family history and continuing nodular enlargement are additional risk factors for malignancy.
HA Ex2
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