PHYSICAL DIAGNOSIS EXAM TWO MATERIAL



Physical Diagnosis Exam Three Material

The Ear Examination

1. List reasons for performing an ear exam.

• She never asks anything about this as we have learned from her great exams, so common sense will say, do it when a pt. complains about something in this area.

2. What are two types of hearing loss?

| |Conductive |Sensorineural |

|Pathological Process |External Ear |Cochlea/Cochlear N. |

|  |Middle Ear |Brain Stem |

|Loudness of Speech |Softer than normal |Louder than normal |

|External Canal |May be abnormal |Normal |

|Tympanic Membrane |Usually abnormal |Normal |

|Impaired |Air conduction |Air & bone conduction |

|Rinne Test |negaqtive |positive |

|Weber Test |Heard on "deaf side" |Heard on better side |

3. Provide causes for hearing loss in children and adults?

| |Conductive |Sensorineural |

|Child |Congenital |Congenital |

| |**Otitis Media** |Mumps Labyrinthitis |

| |Cerumen |Rubella/Syphilis |

| |Trauma/Foreign bodies |Birth Trauma |

|Adult |Serous/Chronic OM |Delayed Onset Congenital |

| |Otitis Externa |Meniere's Ds |

| |Cerumen/blockage |Viral Labyrinthitis |

| |Eustachian Tube Blockage |Acoustic neuroma |

| |Viral Myringitis |Presbycusis (age-related) |

| |Cholesteatoma |Ototoxic drugs |

| |**Otosclerosis** |  |

***Congenital deafness accounts for 50% of all deafness in children***

***Otosclerosis is formation of new bone in the labyrinth; causes fixation of stapes to oval window**

With the exception of otosclerosis, conductive hearing loss alters appearance of tympanic membrane

4. What are causes of vertigo?

• Frequently associated w/ a loss of vestibular fxn (i.e. unsteady gait) and results from:

▪ Otologic ▪ Neurologic

▪ Psychological ▪ Iatrogenic

▪ Meniere’s disease: causes severe paroxysmal vertigo from labyrinthine lesions

5. What is the clinical triad for Meniere’s Syndrome?

• Vertigo with vomiting

• Tinnitus

• Hearing Loss

6. List causes for otalgia. (aka “ear pain”)

• Localized:

▪ Otitis Externa (aka “swimmers ear”) and Otitis media

• Referred

▪ Teeth, TMJ, cervicals (C2-3), pharynx (mucosal swelling)

▪ Inflammation, trauma, or neoplasm anywhere along C.N. V, VII, IX, X

▪ Will present in ipsilateral ear and is referred

7. What is tinnitus and what might cause it?

• Vertigo is the sensation of hearing sound, such as buzzing or ringing, in the absence of environmental input. It is associated with a conductive or sensorineural hearing loss.

|Location |Pulsatile/Clicking |Nonpulsatile |

|External Ear |Otitis Externa |Cerumen |

| |Bullous myringitis |Tympanic Membrane perforation |

| |Foreign Body |Foreign Body |

|Middle Ear |Otitis Media |Otosclerosis |

| |Vascular anomalies |Serous Otitis media |

| |Neoplasm |  |

| |Eustachian tube dysfxn |  |

|Inner Ear |Vascular anomalies |Cochlear Otosclerosis |

| |  |Meniere's disease |

| |  |Labyrinthitis |

| |  |Trauma/toxicity |

| |  |Presbycusis |

|CNS |Vascular anomalies |Syphilis |

| |Hypertension |Degenerative Ds |

| |  |Cerebral Atheroscleosis |

8. What are causes for nodules in and around the ear?

• Tophi (from gout) on helix or antihelix

• Carcinoma & hematomas

• Scar tissue from trauma (i.e. piercing)

9. How would the examination procedure differ when evaluation the inner ear of a child vs an adult?

• Access the external auditory canal, tympanic membrane, malleus, etc.

▪ Adults: pull posterior superior to straighten auditory canal

▪ Infants/Toddlers: pull posterior inferior to straighten auditory canal

• When holding the otoscope:

▪ Adult: you may hold straight up and down or downward (like we do in lab)

▪ Child: you must hold it downward like we do in lab

10. What are the features of the normal tympanic membrane?

• Should appear as an intact, ovoid, semitransparent, pearly gray membrane

▪ Diseased will be yellow or red

• The “light reflex” should be anterioinferior of the pars tensa

• The long process of the incus is usually posterior to the malleus

11. How is patency of the Eustachian tube determined?

• Pneumatic otoscopy uses pressure to observe movement of the tympanic membrane:

▪ Obstructed eustachian tube will move sluggishly inward = RETRACT

▪ Fluid in the middle ear will have decreased or absence of movement = BULGING

12. List the signs/symptoms for otitis externa, bacterial, and secretory otitis media.

• Acute Otitis Externa

▪ Painful when pulling on tragus and auricle

▪ Inflammation of external canal but normal tympanic membrane

▪ Yellowish-green discharge

• Acute Otitis Media (aka Bacterial)

▪ Primarily in children

▪ No pain when pulling on auricle and tragus

▪ Tympanic membrane is fiery red and bulging outward

• Secretory Otitis Media

▪ Primarily in adults

▪ Air becomes trapped w/in middle ear (air bubble); tympanic membrane will retract

▪ Amber color

13. Discuss the Weber and Rinne hearing test. What can be deteremine by lateralization and air vs bone conduction?

• Weber: compares bone conduction in both ears (512 MHz)

▪ Place the tuning fork on the patients forehead/top of head and ask if they feel/hear the sound/vibration in the left ear, right ear, or in the middle.

▪ Normal = middle

▪ Lateralization to the affected side in conductive hearing loss

• Rinne: compares air and bone conduction separately (512 MHz)

▪ Place tuning fork handle on the mastoid. Ask the patient if they hear the sound and to indicate when it is no longer heard. When they can longer hear it, move the tongs in front of the EAM and ask if they can still hear it. Normally air conduction (AC) is better than bone conduction (BC).

▪ Positive test = AC>BC (normal or sensorineural loss)

▪ Negative test = BC>AC (conduction hearing loss)

▪ False negative = total deafness; pt. will hear fork on mastoid of deaf ear because it transmits vibrations across the skull to the healthy ear.

14. How would a perforation look with an otoscopic exam?

• Perforations may be central or marginal. They present as a hole and the name will obviously describe where the perforation is. A central does not involve the margin of the tympanic membrane. Marginal is more severe.

Nose and Paranasal Sinuses

15. What are the reasons for performing this exam and differentials for these?

• Trauma • Hx of polyps

• Tobacco Use • Inhaled Particles/Substance exposure

• HA • Repeated Sinus Infection

• Allergies

16. Discuss causes for obstruction and differentials for various types of discharge.

• This is the major complaint of nasal conditions, usually occur in middle meatus

• Symptoms: blockage, sneezing, discharge

▪ Thin watery discharge: viral or allergic reaction

▪ Thick purulent: bacterial infection

▪ Bloody: neoplasm, trauma, fungal infxn

▪ Foul smell: foreign object, chronic sinusitis, malignant disease

▪ Clear watery discharge increase w/ coughing or bending head forward = CSF

17. What is noted during the examination of the vestibule? The nasal septum?

• Vestibule

▪ Insert speculum ~ 1 cm into vestibule

▪ Note:

▪ Mucosa: deep pink or dull red, moist

▪ Septum: beefy red or deep pink

▪ Size & color of turbinates

▪ Perforation of septum

• Nasal Exam • Sinus Exam

▪ Inspection ▪ Inspection

▪ Palpation ▪ Palpation

▪ Olfactory ▪ Percussion

▪ Internal Exam ▪ Transillumination

18. How are the turbinates clinically differentiated from a polyp?

• Polyp

▪ Most common cause of anosmia

▪ pale, translucent, and moveable

▪ ?Round, darker pink, smooth, and on the medial meatus?

• Turbinate

▪ Round, light pink, and ridged

19. How does acute rhinitis differ from allergic rhinitis?

Both have same symptoms: nasal obstruction, sneezing, clear-watery discharge

• Acute Rhinitis is non-seasonal and due to stress, nasal spray abuse, pregnancy, hypothyroidism

• Allergic Rhinitis is seasonal and non-seasonal congestion due to allergens

▪ Seasonal

▪ Spring: weeds, pollen, and trees

▪ Fall: weeds and pollen

▪ Summer: grass

▪ Non-seasonal

▪ Animal dander

▪ Dust

▪ Mold

20. What are the 4 cranial/facial sinuses and how are they evaluated? Which of the 4 paranasal sinuses can be examined clinically?

• Frontal and maxillary can be evaluation thru physical exam

▪ Palpation and percussion

▪ Transillumination of maxillary is lateral to nose below medial aspect of eye

• Ethmoid and sphenoid sinuses are evaluated via X-ray

• Sinuses drain into different meatus:

▪ Nasal lacrimal duct drains into the inferior meatus

▪ Anterior ethmoid drains into the middle meatus

▪ Posterior ethmoid drains into the superior meatus

21. List the location of pain and clinical signs/symptoms of sinus disease?

| |Maxillary |Ethmoid |Frontal |Sphenoid |

|Local Pain |Behind eye |Periorbital |Supraorbital |Rarely |

| |Cheeks |Retronasal |  |involved |

| |Nose |Retrobulbar |  |but will |

| |Upper teeth |  |  |present |

| |Upper lip |  |  |as a deep |

|Referrred Pain |Teeth |Occipital |Bitemporal HA |diffuse |

| |Retrobulbar |Upper Cervical |Occipital HA |headache |

Oral Cavity and Throat

22. What are some of the reasons for performing an exam of the oral cavity and throat? What are some differentials for these symptoms?

• See Page 321 in the book if you really care. Symptoms include:

▪ Pain ▪ Bleeding ▪ Halitosis (bad breath)

▪ Ulceration ▪ Mass ▪ Xerostomia (dry mouth)

23. Discuss some abnormalities found on or around the oral cavity (also included is normal): [not sure how much detail we needed to know on these but its like 7 pages of information; there is a huge chart on page 357-359 that sums them up if you wanna look. Learn what you will children]

24. List etiologies of acute pharyngitis.

• Viral

• Bacterial

▪ Group A beta hemolytic Streptococci are most dangerous and most common

25. What are some likely findings associated with acute follicular tonsillitis, streptococcal pharyngitis and pharyngitis in mononucleosis?

• Acute Follicular Tonsillitis

▪ Pain in throat extending to the ear, unpleasant smell and taste in mouth, hoarseness, snoring and breathing thru mouth, red swollen tonsils

▪ Tendency for repeated attacks of cough and cold

• Streptococcal Pharyngitis

▪ Sudden onset, present in winter or early spring

▪ Sore throat, fever, DA, nausea, vomiting, and abdominal pain inflammation of pharynx/tonsils, tender enlarged cervical lymph nodes

▪ Age 5-15 w/ history of exposure

▪ White patches on back of throat

• Pharyngitis in Mono

▪ Same symptoms as strep pharyngitis with the addition of:

▪ Conjunctivitis ▪ Cough

▪ Coryza ▪ Diarrhea

26. What are some of the complications of streptococcal pharyngitis?

• If untreated:

▪ Rheumatic fever

▪ Heart valve damage

▪ Streptococcal glomerulonephritis

27. What are Ludwig’s Angina, Quinsy’s abscess, and Vincent’s angina.

• Ludwig’s Angina

▪ Type of cellulitis (inflammation of the tissues under the tongue)

▪ Follows mouth injury or infection of the roots of the teeth (i.e. tooth abscess)

▪ Uncommon in children

• Quinsy’s Abscess

▪ A peritonsillar abscess of pus following tonsillitis if it spreads beyond the tonsils

▪ From bacterial organism: group A streptococci

• Vincent’s Angina

▪ Acute or chronic gingivitis with redness or swelling

▪ Necrosis extending from the interdental papillae along the gingival margins

▪ Pain, hemorrhage, necrotic odor, and pseudomembrane

Eye Examination

28. List reasons for performing an eye exam and differentials for these reasons?

• When a patient complains of the symptoms in question 29 (

29. What are some of the common visual eye symptoms and the causes?

|Symptom |Cause |

|Loss of Vision |Optic neuritis |

| |Detached retina |

| |Retinal hemorrhage |

| |Central retinal vascular occlusion |

|  |CNS disease |

|Spots |No pathological significance |

|Flashes |Migraine |

| |Retinal detachment |

|  |Posterior vitreous detachment |

|Loss of Visual field |Retinal detachment |

|  |Retinal hemorrhage |

|Glare/Photophobia |Iritis or meningitis |

|Distortion of vision |Retinal detachment |

|  |Macular edema |

|Difficiulty seeing in dark |Myopia |

| |Vit A Deficiency |

|  |Retinal detachment |

|Halos aound light |Acute narrow angle glaucoma |

|  |Opacities in lens/cornea |

|Colored vision changes |Cataracts |

|  |Drugs |

|Double Vision |Extraocular mm paresis/paralysis |

30. Discuss some of the common non-visual painful and painless symptoms with associated disease states.

|Painful | | |Painless | |

|Foreign Bodies |Corneal Abrasion | |Itching |Dry Eyes |

|Burning |Conjunctivitis | | |Eye fatigue |

| |Sjogren's | |  |Allergies |

|  |Uncorrected refractive error | |Tearing |Blocked drainage |

|Throbbing |Acute iritis | |Dryness |Sjogren's |

|  |Sinusitis | |  |Aging |

|Tender |Conjunctivitis | |Sand/Grit |Conjunctivitis |

| |Eyelid inflam. | |Fullness |Proptosis |

|  |Iritis | |  |Aging |

|Headache |Migraine | |Twitching |Orbicularis Oculi |

| |Sinusitis | |Heavy eye |Fatigue |

|  |Refractive Error | |  |Edema |

| | | |Dizziness |Refractive error |

| | | | |Cerebellar Ds |

| | | |  |Vestibular Ds |

| | | |Excessive blinking |Local irritation |

| | | |  |Facial tic |

| | | |Eyelids Stick |Inflammatory ds. of eyelids |

| | | | Together | or conjunctivae |

31. Provide a differential dx and distinguishing features for red eye.

| |Acute Conjunctivitis |Acute Iritis |Narrow Angle Glauc |Corneal Abrasion |

|History |Sudden onset |Sudden onset |Rapid onset |Trauma/Pain |

|Vision |Normal |Impaired if no tx |Rapid loss if not Tx |Affected if CENTRAL |

|Pain |Gritty feel |Photophobia |Severe |Exquisite |

|Laterality |Bilateral |Bilateral |Bilateral |Unilateral |

|Vomiting |No |No |YES |No |

|Cornea |Clear |Varies |Steamy |Irregular light reflex |

|Pupil |Normal |Sometime irregular |Partial dilation |Normal |

|  |reactive |sluggish reactive |non-reactive |reactive |

|Iris |Normal |Normal |Difficult to see |Shadow or corneal defect |

|Ocular discharge |Watery |Watery |Watery |Watery |

|  |Mucopurulent |  |  |Mucopurulent |

|Systemic effect |None |Few |Many |None |

32. Discuss some of the abnormal inspection findings around and in the eye?

• Abnormalities of the: orbits, eyelids, lacrimal apparatus, conjunctiva, sclera:

▪ Enucleation – missing eye ▪ Ptosis

▪ Erythema ▪ Infection/swelling/mass/crusting

▪ Kearns-Sayre syndrome ▪ Sturge Weber Syndrome

▪ Herniated orbital fissure ▪ Herpes Zoster

▪ Lagophthalmos (incomplete closing of eye

▪ Entropion (inward eyelid) ▪ Ectropion (outward eyelid)

▪ Theres about 30 more … if you really want to memorize them all, check the book

• Abnormalities of the: cornea and lens

▪ Arcus senilis – white ring

▪ Kayser-Fleischer ring – greenish-yellow ring (indicative of Wilson’s disease)

▪ Corneal ulcer

▪ Keratoconus

▪ Cataracts

• Abnormalities of the: pupils

▪ Anisocoria – uneven pupils

▪ Adie’s tonic pupil

▪ Argyll Robertson pupil – “Hooker Pupil”

▪ Horner’s Syndrome

• Abnormalities of the: iris

▪ Iris coloboma – notch in iris

▪ Iritis

33. How and why do we evaluate the anterior chamber of the eye?

• Check to see if it is clear or filled with pus or blood

• Assess depth using Schiotz tonometer

▪ Shallow anterior chamber is predisposing condition to narrow angle glaucoma

34. What should happen with the light reflex (direct and consensual response), and discuss the abnormalities of the afferent vs efferent fibers.

• Light shined on the eye will cause both pupils to constrict

▪ The “direct” is the eye the light is shined in

▪ The consensual response is the other eye constricting as well

• Afferent fibers

▪ Carry impulses away from the retina

▪ CN III transmits afferent via Edinger Westphal nucleus

▪ Marcus Gunn pupil ( afferent limb defect in the eyes being illuminated; pupil dilates instead of constricts (will see this in blind eyes)

• Efferent fibers

▪ CN III transmits efferent via ciliary body to constrict

35. What is the accommodation response?

• It is near focusing of the eye which is affected by increasing the power of the lens by contraction of the ciliary muscle. Innervated by CN III

36. Discuss visual acuity testing.

• Expressed as a ratio (20/20) assessed using the Snellen Chart

▪ First number is distance which the PATIENT can read the chart

▪ Second number is the distance NORMAL people can read the chart at the same line

37. How are the visual fields tested? List some visual field defects and findings.

• This is the confrontation testing we learned in lab.

38. How are the extraocular muscles tested and what cranial nerves are involved?

|Muscles |Position |

|Medial Rectus |Nasal |

|Inferior Oblique |Up & Nasal |

|Superior Oblique |Down & Nasal |

|Lateral Rectus |Temporal |

|Superior Rectus |Up & Temporal |

|Inferior Rectus |Down & Temporal |

• Tests:

▪ 6 Cardinal positions of gaze

▪ Squint (Strabismus)

▪ Diplopia

▪ Nystagmus

• CN III, IV, VI (LR6 SO4 R3)

39. What is strabismus (paralytic vs nonparalytic)? Discuss testing and findings.

• Strabismus is a deviated or crossed eye. The object being observed is not projected simultaneously on the fovea of each eye. Could not find paralytic vs non in the book; but I am assuming that paralytic is when a muscle(s) of the eye are paralyzed so you would only have the problem of strabismus in the direction of that muscle.

• Cover Test:

▪ Pt. looks at distant object. Cover one eye. If the uncovered eye moves to focus on the object; that eye was not straight.

• Findings:

▪ Exotropia: deviates temporally

▪ Esotropia: deviates nasally

▪ Hypertropia: deviates upward

▪ Alternating Tropia: either eye deviates

40. What is nystagmus?

• Involuntary, rapid back-and-forth motion of the eyes; different types are:

▪ Horizontal: from abnormal of the labyrinth

▪ Vertical: brain-stem disorders

▪ Ocular: retinal lesions (slow and irregular searching quality of eyes)

▪ Rotatory

▪ Mixed

• The direction of nystagmus is determined by the direction of the quick component

41. What structures are seen in ophthalmoscopic exam. How should they appear normally?

• Pupil - Red reflex should be visualized as Dr comes in at 20 degrees IF lens not opaque

• Cornea and Lens - Both should be transparent, not opaque

• Optic Disc - should be round or slightly oval with the long axis vertical and sharp borders, nasal border normally slightly blurred, pinkish in light-skinned individuals and yellow-orange in dark skinned patients, optic cup is in the middle and is lighter in color, cup to disc ratio should be 0.1 - 0.5 and should be even bilaterally

• Retinal Vessels - veins are larger than arteries, arteries have a light reflex, central retinal artery enters the eye through the physiologic cup giving rise to four main branches.

• Macula - about 1.5 - 2.0 disc diameters temporally from optic disc, avascular area with a pinpoint reflective center (fovea)

• Retina - should be free of any lesions or tears

42. How does the doctor accommodate for myopia and hyperopia regarding diopters.

• Myopia ( nearsightedness

▪ Light is focused anterior to the retina and requires the use of the minus lenses

▪ red numbers

• Hyperopia ( farsightedness

▪ Light is focused posterior to the retina and requires the use of the plus lenses

▪ black numbers

43. How does the normal optic disc and physiologic cup appear? Discuss abnormal findings or causes of blurring of margins?

• See Question 43 for normal

• Myelinated or medullated nerve fibers is a benign condition where nerve fiber layer continues to medullate into the retina, fiber appears as white patches with feathery borders that radiate from the optic disc and obscure the retinal vessels

• Optic pit - small depression (on the temporal side in 75% of cases) in the optic nerve that is usually gray or yellow.

44. Discuss abnormal findings: changes in size, color or light reflexes.

• Hypertension may causes narrowing or spasm of vessels causing light reflex to narrow, over time this vessel will become thickened or sclerotic and the light reflex will be wider and have an orange metallic color (copper wiring).

45. Note the features of the Keith, Wagner, Barker (KWB) classifications for HTN.

• It is used to describe hypertensive effects on the retina

• KWB" classification--4 stages, each indicating longer period of ongoing HTN (hypertension)

▪ 1: arteriolar narrowing

▪ 2: AV nicking (when artery crosses over a vein, there appears to be a discontinuity of the venous column as a result of the widened, but invisible arterial wall)

▪ 3: exudates/hemorrhages

▪ 4: papilledema (indicates rapid rate of rise, see question 51 for more)

46. What are the changes with macular degeneration?

• Retinal drusens (yellowish-white lesions around the posterior pole) between the retinal pigmented epithelium and Bruch’s membrane

• Dry macular degeneration: cells of the macula slowly begin to break down

▪ Diagnosed in 90 percent of the cases

▪ Yellow deposits called "drusen" form under the retina between the retinal pigmented epithelium (RPE) and Bruch’s membrane

▪ Drusen deposits are "debris" associated with compromised cell metabolism in the RPE and are often the first sign of macular degeneration

▪ Drusen deposits are associated with spotty loss of "straight ahead" vision.

• Wet macular degeneration: abnormal blood vessels grow behind the macula, then bleed

▪ Breakdown in Bruch’s membrane, which usually occurs near drusen deposits where the new blood vessel growth occurs (neovascularization)

▪ These vessels are very fragile and leak fluid and blood (hence ‘wet’), resulting in scarring of the macula and the potential for rapid, severe damage

▪ "Straight ahead" vision can become distorted or lost entirely in a short period

▪ Wet macular degeneration accounts for approximately 10% of the cases, however it results in 90% of the legal blindness.

**Macular Degeneration is the leading cause of blindness over the age 60 in the US

47. Discuss some abnormal findings of the fundus (hemorrhages and light colored spots) and the significance of these.

• Flame shaped hemorrhages, cotton-wool spots, exudates, preretinal hemorrhage, vitreoretinal fibrous bands, hollenhorst plaques (cholesterol emboli)

48. Describe retinal characteristics of diabetes, hypertension and Papilledema.

| |Primary Findings |Distribution |Secondary Findings |

|Diabetes |Microaneurysms |Posterior Pole |Hard exudates |

| |Neurovascularization | |Deep hemorrhages |

| |Retinitis proliferans | |Retinal venous occlusions |

| |  |  |Vitreous Hemorrhages |

|Hypertension |Arteriolar narrowing |Throughout |Hard & soft exudates |

| |"Copper wiring" |retina |Retinal venous occlusions |

| |Flame hemorrhages | |Macular stars |

| |Arteriovenous nicking |  |  |

|Papilledema |Hyperemia of disc |On or near |Hard exudates |

| |Venous engorgement |disc |Optic atrophy, late |

| |Retinal hemorrhages | |  |

| |Disc elevation | |  |

| |Loss of spontaneous |

| |venous pulsations |

| |Cotton-wall spots |  |  |

**Diabetic retinopathy is the leading cause of blindness in Americans aged 20-75

49. Discuss characteristic of narrow angle vs simple glaucoma.

| |Simple (Primary Open Angle) |Narrow Angle |

|Occurrence |85% |15% |

|Cause |Open angle |Closed angle |

|Age of Onset |Variable |50-85 |

|Anterior Chamber |Usually normal |Shallow |

|Chamber Angle |Normal |Narrow |

|Symptoms |NO PAIN |Pain, halos, poor vision |

**Primary Angle/Chronic Simple Glaucoma is the leading cause of slow progressive blindness

Just a random tidbit: The macula is lateral and inferior to the optic disc. It contains the fovea. Images on the retina are upside down and reversed. Right world is on the left half of the retina. .

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