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Advanced Physical Assessment

Most common cause of blindness is age related macular degeneration- cannot do anything about it- ARMD
Older adults and vision impairment refractive errors, cataracts, ARMD, & glaucoma (Leading cause of blindness in AA)
How are things perceived on the retina? is up side down & reversed-nerve impulses are conducted through the retina, optic nerve & optic tract on each side to end in the visual cortex, a part of the occipital lobe
The Near Reaction- 3 things- 1. The pupil constricts shifting gaze from far object to a near one 2. Convergence by the medial rectus & 3. Accommodation of the lenses by ciliary muscles to bring near objects into focus
Anything that effects pupil size is a big deal- effects intracranial nerves- window to the brain- can be a tumor
The light reaction light on one eye- create nerve impulse called transduction- goes ↓ optic nerve-efferent impulses goes to both eyes to constrict both pupils- Direct reaction (eye w/the lt)-Consensual reaction (contralateral eye)
The light reaction is lost when in any condition that damages the optic nerve- optic neuritis-
The most accurate way to dx optic neuritis loss of the light reaction- called afferent pupillary light defect
The sensory pathways retina, optic nerve (CN II), and optic tract, which diverges in the midbrain
The motor pathways impulses back to the constrictor muscles of the iris of each eye are transmitted through the oculomotor nerve CN III
For each eye, there is a temporal and nasal field- describe Photoreceptors in the retina change light to nerve impulses that travel to the visual cortex of the occipital lobe via the optic nerve-
Impulses from the nasal side of the retina cross to the contralateral side to the visual cortex on the opposite side-lesions can =visual defects
Impulses from the temporal side of the retina go to the same-side visual cortex-Lesions= visual field defects- from right temporal retina to right occipital lobe, from left temporal retina….
Only fibers that come from the nasal retina cross to the opposite side
Test question- If a pt does not see the temporal fields, only the middle fields bitemporal hemianopsia- pressing on the optic chiasm- pituitary adenoma
Any pituitary tumor, when it grows big enough will press the optic chiasm- pressing on the nasal fibers
3 nerves that control the 6 muscles of the eye cranial nerve 3 controls all except 2 LR6 & SO4- lactated ringer 6 and sulfate 4- lateral rectus and superior oblique
What do the oblique muscles of the eye do? the opposite of what they sound- superior oblique moves it down and inward whereas lateral rectus- to the side, inferior rectus is ↓
For conjunctiva, the most important question is… can you see me, can you drive? Alarming
Visual acuity is expressed how inn two numbers (e.g. 20/30)- the first indicates the distance of the pt. from the chart, and the second, the distance at which a normal eye can read this line of letters
What if your office is not big enough to hang a Snellen chart 20 ft from the pt? hang it on a mirror
Confrontation testing of the visual fields is valuable for detection of lesions in the anterior and posterior visual pathways- static finger wiggle test- combining tests- red target test- part of the visual field may be missing
Position & Alignment of the Eyes- deviations of the eyes are called inward is esotropia, outward is exotropia and bulging is exothalmus
scaliness of eyebrows occurs in seborrheic dermatitis
Dryness: from impaired tear secretion is seen in Sjögren syndrome
Nasolacrimal duct obstruction testing press on the duct if it’s not painful- look for puss-
Cornea, lens, Iris, and Pupils/ depth of anterior chamber corneal opacities, cataract, & light reflection, assess the depth of the anterior chamber with light shining directly from the temporal side, look for a crescentic shadow on the medial side of iris- assesses glaucoma d/t ↑pressure
conjunctiva and sclera look at the color
what 8 areas do you check during the eye exam? visual acuity, visual fields, {alignment, eyebrow, eyelids}, lacrimal apparatus, conjunctiva/sclera, cornea/lens/pupils, extraocular movements, and fundus examination
what does PERL No RAPD mean? no relative afferent pupillary defect- ask the pt to stare ahead & w/the lts off check pupils response to lt, do swinging lt test to make sure there’s no RAPD- pt can converge and fix on an object from a distance- optic neuritis detected with swing test
afferent vs efferent brain →pupil is efferent and pupil to brain is afferent
Direct reaction constriction of the same-side (illuminated) pupil
What if you shine the light in one eye and it does not constrict and the other eye doesn’t either? optic neuritits
Swinging light test upon swinging light into one pupil, then into the other, the illuminated pupil constricts & also does the opposite one
The relative afferent pupillary defect direct and consensual reaction are lost when light is shone on the affected side- it’s okay on the normal side but not on the affected side (optic nerve- swing light test)
The Near Reaction test with gaze shift to near objects 3 things happen 1) Pupillary constriction 2) convergence 3) Accommodation
6 cardinal directions for gaze in order extreme right, right upward, down right, no pausing, extreme left, left ↑ and then left↓
Do cranial nerves cross in the eyes? NO
What are some reasons you would not use mydriatic drops? (1) head injury& coma, (2) suspicion of narrow-angle glaucoma (shallow anterior chamber)
Ratio of cup-to-optic disc is 1/3 or less, if it’s greater it can be chronic open angle glaucoma
Red reflex absence Absence in elderly = cataract. In children, a retinoblastoma may obscure the reflex
Swelling of the optic disc and bulging of the physiologic cup, loss of SVPs is papilledema
Arteries and veins crossing AV nicking, copper wiring in hypertensive changes
Retina adjacent to disc Hemorrhages, exudates, cotton-wool patches, microaneurysms, pigmentation
Check macular area of fundus for Macular degeneration- temporal to the optic disc and ↓ward
Anterior structures of the fundus Vitreous floaters, cataracts
Inspect eyelids for swelling, epicanthal folds of neonates (may be suggestive of Down syndrome)
Sunsetting sign in kids look for sclera above the iris in hydrocephalus- sunken down
Hypertelorism in kids wide spacing between the eyes, associated with craniofacial defects including some intellectual disability
Congenital glaucoma: might manifest as enlarged corneas
Coloboma (Keyhole pupil) failure of fetal tissue to form normally. Usually asymptomatic. Visual acuity may be decreased (needs correction of refraction). Amblyopia may occur.
Red reflex Assess bilaterally in every newborn for opacities, cataract, retinoblastoma
Red eye too much blood in the conjunctiva- (may be infection, Acute angle closure glaucoma, uveitis or iritis)
anterior uveitis (infx of ciliary body/iris), iritis if pupillary constriction causes severe pain- severe cause it’s in the iris
danger signals of red eye burred vision (glaucoma), ↓visual acuity, pain, photophobia, halo, ciliary flush, corneal opacity, abnormality in pupils size, shallow ant chamber (glaucoma), ↑pressure, sudden proptosis (hemorrhage in back)
Iritis can be differentiated from conjunctivitis by determining whether pupillary constriction causes pain in the red eye. Painful pupillary constriction in response to light or accommodation is consistent with iritis
What are the fibers in the optic chiasm nasal fibers- and a pituitary tumor can compress here- so if there’s a disruption here, there are no temporal fields- bitemporal hemianopsia
The nasal fiber of the right eye sees what? the right temporal field and nasal fiber of the left eye sees, the left temporal field- so a disruption at the chiasm disrupts the temporal fields
What if there’s a lesion that damages outside the optic chiasm? ie; calcification in the internal carotid- nasal field is interrupted- binasal-hemianopsia
Total blindness left eye Due to a lesion of the left optic nerve
Any lesion behind the optic chiasm, lets say on the right side will not see on the left side- it’s the opposite Left homonymous hemianopia- left side of both eyes cannot see-Due to lesion of the optic tract
Homonymous Left Superior Quadrantic Defect “pie in the sky” Due to partial lesion of the optic radiation in the temporal lobe- a lesion that’s up effects down and a lower lesion effects what’s up
Ptosis droopy eyelid- myasthenia gravis, horner syndrome, CNIII
Lower eyelid inverted entropion-
Lower eyelid turned outward ectropion
Episcleritis triangular, localized ocular inflammation of the episcleral vessels-movable over the scleral surface- May be nodular- Seen in rheumatoid arthritis, Sjögren syndrome, herpes zoster
Blephritis inflammation of the eyelids- s.aureus- or scaling seborrheic
Stye/ hordeolum infection/staph infection- topical antbx- warm compresses- sebaceous glands- no steroids
Chalazion cyst or gland inside the eyelid- meibomian- not an infx- use warm compress
Arcus Senilis (Corneal Arcus) A thin greyish white arc or circle not quite at the edge of the cornea, accompanies aging- In young adults, suggests possible hyperlipoproteinemia.
Kayser-Fleischer Ring too much copper- slit lamp exam- Wilson syndrome- A golden to red brown ring, sometimes shading to green or blue-present with liver disease, neurologic and psychiatric symptoms
Lisch nodules These are nevi of the iris that are associated with neurofibromatosis-asymptomatic. May be associated with glaucoma
Pterygium A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side-Reddening may occur-may interfere with vision as it encroaches on the pupil
Corneal abrasion Do fluorescein stain/wood lamp exam- Refer Herpes keratitis to ED or ophthalmologist STAT.
A cataract absent red reflex- is an opacification/clouding of the lens- steroids can accelerate
Sympathetic fibers __________ the pupils and the parasympathetic fibers _________ the pupils dilate, constrict
If the difference in your pupils is greater in bright light than in dim light and when you dim the difference does not show (eyes dilate) the larger pupil cannot constrict- in bright light- it should constrict- it’s parasympathetic trauma or open angle glaucoma
When the difference in size is more in dim light it’s sympathetic the smaller pupil cannot dilate horner syndrome
Anisocoria is what? unequal pupils- CN III- It occurs when there is asymmetric disease of the iris
Adie vision pupil constrict to near vision but not to light- unilateral- when it is bilateral it is called Argyll-Robertson pupils
Test question- Marcus-Gunn Pupil optic neuritis- It is a RAPD from optic neuritis- Abnormal dilatation of the pupil of the affected eye when light is shown in it- When light is shown in the normal eye, the pupil of the affected eye will dilate
What is disconjucate gaze cross eye- caused by imbalance of ocular muscle tone, strabismus- examine extraocular movements- intracranial nerve issues (lesions) LR6 SO4 (nasal upshooting) or CR3 esotropia/in, exopropia/out, hypertropia/up- which vranial nerve?
SO4 does what? cranial nerve 4- damage w/trauma- superior oblique -downward- inferior oblique is upward
LR6 does what?  eye crossing- cranial nerve 6- gets damaged w/ ↑intracranial tension
3rd cranial nerve supplies what pupils and eyelid- oculomotor damage- out down droopy dilated
Most common causes CN damage diabetes and HTN
The fibers that cause pupillary constriction run where outer surface of the nerve- diabetes and HTN start inside so the pupils will NOT be effected- looks out and down- pupils okay- anything causing pupil constriction is DANGEROUS- ie; tumor
In optic neuritis, the disc margin is blurred- so when you see it blurry and fuzzy, is it papilledema or optic neuritis--? Swinging lt test
Papilledema is ↑ intracranial pressure
Optic neuritis causes pain with eye movement, acute loss of central vision, and afferent defect in the involved eye (swinging eye- will not constrict with light) – more serious
Glaucoma has an increase cup/disc ratio, ↑ pressure, The diagnostic test is Schiotz tonometry to measure the intraocular pressure- measure the lateral fields
Hypertensive retinopathy- 4 grades from narrowing→AV nicking- interruption of blood flow→ cotton-wool spots, arteriosclerosis, flame-shaped hemorrhages& exudates→ Neuroretinal edema, including papilledema
Diabetic retinopathy- non-proliferative- effect on fundus and retina the earliest retinal changes- background retinopathy→ 1. Microaneurysms 2. hard exudates, 3. blot hemorrhages 4. cotton wool spots, and 5. venous beading- not much can be done
Diabetic retinopathy- proliferative-effect on fundus and retina- see the retina full of new vessels- no light- laser or VEGF inhibitors used- final and most severe stage of diabetic retinal disease. PDR is characterized by 1. neovascularization and 2. fibrous proliferation
Macula is what the center where you see things the clearest
Age-Related Macular Degeneration gradual loss of central vision- wet type-new bv can laser and do VEGF and dry type (most common)- yellow exudate called DRUSEN- cannot do anything for it
Retinal detachment hx trauma-sudden vision loss or floaters, flashing lights- ophthalmologist should be consulted to evaluate any difference in “red reflex” (lighter red reflex) between the two eyes
Pterygium A yellow triangular thickening of the conjunctiva that extends to the cornea on the nasal cornea- redness of eye- foreign body sensation-
Allergic conjunctivitis will be accompanied by allergic rhinitis
Acute uveitis ciliary congestion- red flag- Photophobia, ↓vision in affected eye, Watery discharge, No f/c, no recent illness. No ill contacts, STAT ophthalmology referral for slit-lamp examination and a dilated fundus exam
amaurosis fugax with TIA- loss of vision comes and goes
age related eye impairment- 3 things macular degeneration, glaucoma, cataracts
Horner’s syndrome eyelid ptosis, myosis and anhidrosis- pseudoenophthalmos- sinking of the eyeball into the face- ↓sweating on affected side of the face-sympathetic paralysis
The ear lesions are reported how same as a clock
What is vertigo? a false sense of rotational motion; it points to an inner ear lesion, CN VIII lesion, or a brain lesion
Ménière disease is suspected when tinnitus is associated with hearing loss and vertigo
Weber and Rinne test air conduction is better than bone conduction and twice as long as bone- Rinee. If air is worse, there is conduction issue. Weber’s- on top of head- should hear equally in middle
Viral vs allergic rhinitis both swollen but in allergies it’s pale vs red
Otoscope for kids down and out- adults up and back
Test question- Epiglottitis-bacterial Child w/acute, onset ↑fever, sore throat, drooling, difficulty breathing- not eat- difficult swallowing, Hot pto voice. Hyperextended neck, open- mouthed breathing, tripod position Stridor, cyanosis, tachycardia, tachypnea- NO COUGH ddx croup
Acute tonsillitis Red swollen tonsils, Crypts filled with purulent exudate, Enlarged anterior cervical LNs, Palatal petechiae- strep- Sore throat, fever, malaise-Fetid breath-May have associated abdominal pain & headache- amoxicillin or chronic do tonsillectomy
Strep can cause what pharyngitis or tonsillitis and mono
Peritonsillar abscess tonsil pushed from the inside,Dysphagia and drooling, Severe sore throat w/ pain radiating to ear;pain worse on one side, & on swallowing, Malaise , fever, Unilateral red, swollen tonsil and adjacent soft palate, augmentin/zosyn, tonsillectomy- drain pus
Benign paroxysmal positional vertigo seconds
Vertebro-basilar insufficiency, migraine- vertigo minutes
Ménière disease/vertigo hours
Viral labyrinthitis/vertigo days
Signs of acute otitis media red, bulging, IMMOBILITY- use air in otoscope- purulent effusion, Painful hemorrhagic vesicles, blood-tinged ear discharge, conductive hearing loss- Seen in mycoplasma and viral infections and bacterial otitis media
Bullous Myringitis viral otitis media or mycoplasma pneumonia- painful vesicle on ear canal or TM- test for cold agglutinins
External or middle ear hearing issue conduction problem voice does not get louder- more in the young and can see it in the ear canal
Sensorineural hearing loss cochlear issue- not processed correctly have louder voice
Weber and Rinne can be done separately? no, have to do together
Normal for weber and rinne weber is heard midline or equally in both ears- and rinne is AC is better than BC
Conductive hearing loss example- foreign body in right ear sound will not make it through the air but will make it through the bone BC > AC in affected ear for rinne (sensory neural you will not hear whatsoever)
Weber test for the right ear- has foreign body you will hear it better in the right ear (affected ear) :? Whatever for Weber- sensorineural, you will not hear anything.
Angular cheilitis softening of skin angles of the mouth→fissuring d/t folate and iron deficiency
What’s important about pharyngitis? make sure it’s not beta hemolytic strep that causes rheumatic fever and glomerulonephritis do rapid strep test
Candidiasis thrush CHEESY- if it scrapes off
Oral hairy leukoplakia doesn’t scrape off precancerous This condition is caused by Epstein-Barr virus infection when seen in HIV/AIDS.
Gingival hyperplasia caused by phenytoin, CCB cyclosporin- stop the offending drug
Fissure tongue is seen in elderly
Strawberry tongue Enlargement of tongue papillae- caused by Group A Beta Hemolytic- Streptococci (GABHS), Kawasaki disease, and vit B12 deficiency. Rapid strep test is diagnostic for GABHS
Smooth tongue/ atrophic glossitis deficiency of riboflavin,niacin, folic acid, vit. B12, pyridoxine, or iron. Seen also in treatment with chemotherapy
Otitis externa (malignant) Intense right ear pain (started with itching of the ear canal after swimming) d/c coming from the right ear, started as watery, now purulent/smelly- tender pinna and tragus- if life threatening it’s malignant- pseudomonas
Acute otitis media no mobility- red swollen, clear rhinorrhea, sore throat, fever, non-productive cough, tonsils enlarged- Tympanostomy tube- immobility of TM (air insufflation)-Most accurate test: tympanocentesis- culture/sensitivity (ONLY for recurrent cases)
Cleft palate Difficult sucking, Failure to gain weight
Pharyngitis exudate on the tonsils, is it bad strep?--> Rapid strep test: for the nephritogenic strains of strep- If positive give penicillin (amoxicillin)- enlarged ant. Cervical lymph nodes
Infectious mononucleosis Enlarged Posterior cervical LN mono test- give analgesics/steroids- caused by Epstein-Barr virus
Child with asthma oral candidiasis- d/t steroids advise to rinse mouth
Fracture of the base of the skull hematoma over the mastoid process- Associated with blood in the TM- do head CT
Aphthous ulcers (canker sores) Shallow, tender ulcers on labial, buccal, gingival mucosa
Angular cheilitis Painful red fissures at the angle of the mouth- d/t HIV, can be fungal- oral fluconazole- folate and iron deficiency
Warning s/s for headache progressive, Sudden onset “thunderclap,” after 50, change of position, valsalva maneuver,fever, night sweats or weight loss, presence of cancer, HIV infection, or pregnancy, trauma, pattern change, papilledema, neck stiffness, or focal neurologic deficits
Neck examination Inspect for swellings/masses, Palpate for lymph nodes, Examine for tracheal shift, Examine the thyroid
Test question Tracheal shift exam By inspection& palpation, Deviation could be due to: a mediastinal mass, atelectasis/lung collapse, or a large pneumothorax
Enlarged supraclavicular node (esp. the Lt.) suggests possible metastasis from a thoracic or an abdominal malignancy bad sign
A tender lymph node means infection
A hard non-moveable lymph node means cancer/malignancy
Retrosternal goiters when goiter is huge and extends down into he thorax- can block the inlet- might not always be palpable, can cause hoarseness, shortness of breath, stridor or dysphagia- ask pt to Neck hyperextend and elevate arms= flushing- Pemberton sign
Goiter is a big gland- have to do a blood test to differentiate whether it’s hypo or hyper
Thyroiditis tender thyroid
Caput succedaneum Significant scalp edema as a result of compression during transit through birth canal. Edema does cross suture lines
Hydrocephalus enlarged head, thinning of the scalp with dilated scalp veins, “sunsetting sign.”
Pierre-Robin sequence in baby- a triad of micrognathia, glossoptosis, and palatal clefting-retruded mandible
Test Fetal alcohol syndrome acquired intellectual disability- poorly formed philtrum; widespread eyes, with inner epicanthal folds and mild ptosis; hirsute forehead; short nose; and relatively thin upper lip
Pregnancy and thyroid hypertrophy of thyroid- increase the levo by 30%
Cluster headache unilateral, more in males, sharp intense and severe, autonomic symptoms in the eye and nose- lacrimation, ptosis, myosis
Tension headache band around your head
Migraine starts around age 12-15, 1-2x week, n/v, throbbing, mostly unilateral
Analgesic rebound headache Results from withdrawal of certain medications. The previous headache pattern will occur
Errors of refraction glasses Due to sustained contraction of EOM. Around & over the eyes. Steady, aching, dull. Associated with eye fatigue and “sandy” sensations in eyes and redness of conjunctiva
Acute glaucoma pain in the eye rather than headache- Sudden increase in IOP. Pain in and around one eye. Severe, steady, aching. Associated with blurred vision, halos around lights
Sinusitis headache frontal sinuses above the eyes or over maxillary sinuses. Aching or throbbing. Often repetitive daily. Local tenderness, with nasal congestion, discharge and fever. Aggravated by coughing, sneezing, or jarring the head.
Meningitis Generalized, steady, throbbing, severe headache that develops within a day. Associated with fever, stiff neck, photophobia, may be altered mental status
Subarachnoid hemorrhage worst headache of my life- Generalized, very severe. Sudden in less than a minute. Associated N&V, loss of consciousness, neck pain. Possible prior neck symptoms from “sentinel leaks”.
Brain tumor Variable locations. Aching, steady, dull pain worse on awakening. Associated seizures, hemiparesis, field cuts, personality changes, N&V, vision change, gait change. Aggravated by coughing, sneezing, sudden head movements, vasalva
Temporal giant cell arteritis More in women. Localized near the temporal artery. Throbbing, severe. Tenderness over the temporal artery. Associated fever (50%), jaw claudication (50%), loss of vision (20%). Aggravated by movements of neck& shoulders
Post concussion headache Often localized to the injured area. Dull, aching, constant. Within 7-90 days of injury and may last up to a year. Associated with drowsiness, poor concentration, confusion, memory loss, blurred vision, fatigue, irritability.
Trigeminal neuralgia Over cheek, jaws. Shock-like, stabbing, burning, severe. Abrupt onset and recurrent course. Aggravated by touching certain areas of the lower face, chewing, talking, brushing teeth.
Bell palsy Left facial palsy (cranial nerve VII). Facies include asymmetry of one side of the face, eyelid not closing completely, drooping lower eyelid and corner of mouth, and loss of nasolabial fold
Hot thyroid nodules are almost always benign takes a lot of radioactive iodine
Multinodular goiter describe the condition where at least two detectable nodules are palpable within the thyroid tissue- firm and sometimes calcify
Diffuse goiter both lobes can enlarge but stay smooth and non-nodular- may feel constraining- may cause tracheal deviation and difficulty swallowing
a large goiter extends from the neck into the superior mediastinum through the thoracic inlet is called substernal thyroid
When a patient with a large substernal thyroid elevates his or her arms above the head, the thoracic inlet may obstruct. As a result, venous congestion and cyanosis/flushig of the face occurs and is called Pemberton’s sign
Thyroglossal Duct Cyst a tense, nontender, mobile, round mass in the midline of the neck at the level of the hyoid bone
Freely movable cystic mass in neck midline, Moves upward with tongue protrusion and swallowing, May have small opening in skin, with drainage of mucus, difficulty swallowing, tenderness, redness midline of neck of young pt thyroglossal duct cyst
If you see ciliary flush refer pt to an ophthalmologist
Best initial test for acromegaly and then most accurate test initial→ Insulin-like growth factor level (IGF-1) (Growth hormone has a very short half-life and has its peak secretion in the middle of night during sleep)-Most accurate test: failure of a glucose infusion to suppress growth hormone levels
consensual reaction constriction of the opposite illuminated
confrontation testing is done for what visual fields- need to refer to ophthalmologist if there's a problem- any part missing? do wiggling test- need to do the Humphrey Visual Field- they do automated berimetric testing
superior rectus eye goes up
superior oblique down and inward-- cranial nerve 4
inferior rectus down
lateral rectus cranial nerve 6
Relative afferent pupillary defect (RAPD) or Marcus Gunn pupil is a medical sign observed during the swinging-flashlight test whereupon the patient's pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye.
papilledema hazy- optic disc- not clearly demarcated and blurry- hemorrhages In optic neuritis, it’s blurred too, but there’s pain with movement, loss of central vision and with swinging light test, there’s deficiency
Created by: arsho453
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