7q - physical diagnosis midterm
TRANSCRIPT
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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
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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
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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
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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)
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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 $elong)
0% 'homberg Testa. Patient Position
/ight adduction of lower etremities
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*rms at side
Close eyes
Caution E patient may sway
1% Bobra; Test(cold3warm water stimulation) N#stagmus
ystagmus is the finding that is epected. 1t should occur within 60!62 seconds, with the effects
lasting 2!D minutes. /he direction of the nystagmus is named for the "uic; component. 1f it isless than 60 seconds H hyperactive. 1f it is greater than 62 seconds H hypoactive. 1f no reactionH dead
Cold!water E opposite side
arm water E same side
NOSE *)7)N)S)L S(N-SES
%AL2ATIO(patientGs head in hyperetension so +r. can see the T#ase of the oseS)
6. Chec; for 7&inorr&ea(eudate from eternal nares)
1f present sto* e0amination and '-' O2T IMMDIATLY
TTriangle o" angerS
1f infection present in nose E possi$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
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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 $ase
pisodic recurrences of swollen lips (mar;ed deformity)
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%esicles
Su$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
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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
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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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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 $ruits@ murmurs
d. istended Nec; Veinsfrom Congestive eart %ailure
2% L#mp&adenopat: Su$