Physical Diagnosis Exam 2: Abdomen PDF

PHYSICAL DIAGNOSIS EXAM 2 WEEK 4 – ABDOMEN - Quadrants - Peritoneum RETROPERITONEAL ORGANS...

PHYSICAL DIAGNOSIS EXAM 2 WEEK 4 – ABDOMEN - Quadrants - Peritoneum RETROPERITONEAL ORGANS S – Suprarenal (Adrenal) Glands A – Aorta/IVC D – Duodenum (2nd/3rd parts) P – Pancreas (excluding tail) U – Ureters C – Colon (ascending/descending) K – Kidneys E – Esophagus - Abdomen Symptoms R - Rectum Upper GI Lower GI Genitourinary Tract Gastrointestinal Disorders Urinary and Renal Disorders Mouth à Duodenum Jejunum à Anus - Abdominal - Diarrhea - Difficulty urinating - Abdominal pain - Suprapubic pain pain - Constipation - Urgency + (acute and chronic) - Difficulty urinating - Heartburn - Change in frequency - Indigestion, (dysuria), urgency, - Nausea Bowel Habits - Hesitancy + nausea, vomiting, frequency - Vomiting - Blood in Stool decreases stream in hematemesis, - Hesitancy, decreased - Dysphagia (Hematochezia/ men anorexia, early stream in males - Hematemesis Frank, Melena) - High urine volume satiety - Excessive urination - Anorexia - Urinating at night - Dysphagia, (polyuria) or excessive - Jaundice - Incontinence odynophagia urination at night (nocturia) - Hematuria - Change in bowel - Urinary incontinence - Flank pain function - Hematuria - Jaundice - Flank pain + ureteral colic - Abdominal Pain Visceral Pain - Felt when noxious stimuli affect an abdominal viscus o Crosses midline o Dull, poorly localized/diffuse o Gnawing or burning o Secondary autonomic symptoms § Sweating and nausea  Parietal Pain - Felt when noxious stimuli affect the parietal peritoneum o Parietal peritoneum is innervated unilaterally via the spinal somatic nerves that also supply the abdominal wall - Precisely localized, intense, sharp - Inflammation of the parietal peritoneum o Peritonitis – steady ache that is more severe and easier to pinpoint than visceral pain § Loss of bowel sounds – rebound tenderness § Typically located over the organ of origin § Hard/rigidity - Movement, coughing, percussion = provocative Referred Pain - Felt in remote areas supplied by the same neurosegment as the diseased organ o Often seems to radiate out from the initial source of pain § Pancreas to thoracic spine § AAA to lumbar spine § Heart attack to extremities (fibers approximate in DRG) - Well localized - Appears with intense visceral stimulus - Definitions o Dysphagia à difficulty swallowing § Solids only à structural cause (esophageal stricture, webbing, neoplasm) – must palpate for masses § Solids and liquids à motility disorder - achalasia = failure of lower esophageal body and esophageal sphincter smooth muscle to relax o Melena à black tarry stool (black b/c blood was digested) § Upper GI bleed – occult blood o Hematochezia à stools that are red or maroon colored § Lower GI bleed – hemorrhoids, cancer, ulcerative colitis o Hematemesis à vomiting blood § Digested blood/stomach = coffee ground emesis o Hemoptysis à coughing up blood, lungs o Jaundice/Icterus à yellowish discoloration of the skin (sclera becomes yellow) § Caused be increased levels of bilirubin (from the breakdown of hemoglobin) § Hemolytic anemia, hepatitis, cirrhosis, obstruction of the common bile duct o Steatorrhea à fatty diarrheal stools – malabsorption § Celiac sprue, pancreatic insufficiency o Obstipation à no passage of either feces or gas – intestinal obstruction o Acute Diarrhea à usually caused by infection o Chronic diarrhea à often non-infectious – Crohn’s. ulcerative colitis, IBS o Nocturnal diarrhea à often pathologic – awakens the patient more than one time a night - Alarm Symptoms  - Dysphagia – difficulty swallowing - Odynophagia – pain with swallowing - Recurrent vomiting - Evidence of GI bleed - Early satiety – sign of malignancy - Weight loss – sign of malignancy - Anemia - Palpable mass o Malignant – hard, fixed, irregular o Benign – smooth, moveable, soft - Painless jaundice – pancreatic cancer - Peritoneal signs – peritonitis o Sharp localizable pain o Pain with percussion o Positive rebound tenderness o Absence of bowel sounds o Rigidity - Epigastric Region o GERD (Acid reflux or heartburn) Etiology Palliative Factors Provocative Factors Associated Symptoms Diff Dx - Hiatal hernia (>50%) – allows - Antacids - Lying down - Cough Is the “indigestion” acid in the stomach to enter - Proton pump - Bending over - Hoarseness precipitated by exertion the esophagus (can lead to inhibitors (flexion at the - Sore throat and relieved by rest? irritation of the esophagus) - Avoiding waist) - GERD vs - Repeated vomiting (bulimia) triggers – - Ingestion of angina - Decreased lower esophageal alcohol, an irritation sphincter pressure smoking, spicy agent (worse o Pregnancy foods/drinks after meals – o Oral BC - Sleeping with spicy head elevated food/drink) o Peptic Ulcers General Information Location/Quality Palliative Factors Provocative Factors Associated Symptoms - Loss of tissues - Intermittent/ recurrent - Antacids and food - Variable - Nausea lining the lower (weeks to month) o Decreased - Vomiting esophagus, epigastric pain acid in - Belching stomach, or o Gnawing or stomach - bloating duodenum burning o Gastric Cancer Location and Quality Palliative Factors Provocative Factors Associated Symptoms - Insidious onset of - NOT relieved by foods or - Food - Nausea persistent, slowly antacids - Anorexia progressive pain - Early satiety - Weight loss o Acute Pancreatitis Etiology Location and Quality Palliative Factors Provocative Associated Symptoms  Inflammation and - Acute, - Trunk - Lying - Nausea autodigestion of the pancreas persistent flexion supine - Vomiting - 40% secondary epigastric - Fetal - Fever to gallstones pain position - Distention - 35% to chronic (sharp) - Signs of peritonitis alcohol abuse that - Cullen sign – ecchymosis and edema in the radiates to subcutaneous tissue around the umbilicus the mid- - Grey Turner sign – ecchymosis of the flank back - ~20% overall mortality o Low mortality for mild cases o ~50% mortality for severe cases - RUQ o Cholecystitis Definition Location and Quality Palliative Factors Predisposing Factors - Inflammation of the - Classic presentation: right upper - N/A - Female gallbladder quadrant abdominal pain with - Multiparous o Obstruction referral to the right shoulder - Around age 40 by a - Gradual onset of steady, aching - Obesity gallstone in pain that lasts 4- hours - Diabetes 90% of - Sedentary lifestyle cases - Genetic Provocative Factors Associated Symptoms DDX predisposition - Fatty meals - Distension - Pancreatitis – epigastric - Oral - Sudden jarring - Nausea pain with referral to the contraceptives - Deep breathing - Vomiting mid-thoracic spine (progesterone) - Clay colored stools and jaundice - Can progress to peritonitis – with complete bile duct acute pain, rigidity, absence obstruction of bowel sounds o Jaundice (Icterus) - Yellowish discoloration of the skin - Caused by increased levels of bilirubin (from the breakdown of hemoglobin) o Hemolytic anemia o Hepatitis o Cirrhosis o Obstruction of the common bile duct - Dark urine indicates impaired excretion of conjugated bilirubin into the GI tract o Bilirubin is reabsorbed and excreted in the urine o Itching occurs with obstruction of ducts à bile salt deposition in the skin - Light colored stool – complete obstruction of bile into the intestine - Painless jaundice points to malignancy - Painful jaundice is commonly infectious o Hepatitis A and cholangitis o Viral Hepatitis Hepatitis A, B, and C Ascites - Hepatitis A = infectious (fecal contamination) - Abnormal accumulation of fluid/edema in the abdominal cavity - Hepatitis B = blood borne o Results in protuberant abdomen with bulging flanks - Hepatitis C = chronic o M/C complication of cirrhosis  o Cirrhosis = liver scarring/fibrosis - Diffuse o Celiac Disease Overview AKAs Gluten-Free Diet Signs/Symptoms - Autoimmune inflammatory disease of the small - Celiac sprue - No wheat, rye, barley, - Diarrhea intestine that is precipitated by the ingestion of gluten” - Non-tropical triticale (form of - Flatulence and affects 1% of the US population sprue wheat), semolina - Characterized by chronic inflammation of the small (form of wheat) intestinal mucosa, which leads to atrophy of the small - Can consume corn, intestinal villi and subsequent malabsorption rice, buckwheat, - Can result in steatorrhea millet, quinoa o Bowel Obstruction Overview Location/Quality Palliative Provocative Associated Symptoms - Obstruction/ blockage - Intermittent N/A - Ingestion - Obstipation – unable to have a bowel of the bowel lumen pain that of food movement or pass gas o Small bowel = progresses and - Vomiting adhesions and to a steady liquids - Previous symptoms of underlying cause hernias cramp/ache - Volvulus – twisting o Large bowel = - Intusseusception – telescoping; “currant cancer and jelly” stools (blood + mucus) diverticulitis o Mesenteric Ischemia Overview Location/Quality Palliative Provocative Associated Symptoms - Occlusion of blood flow to the - Acute onset of diffuse N/A - Food – - Vomiting small bowel pain that is leads to - Bloody stool o Cardiac embolus = 50% “disproportionate to food fear - Signs of o Thrombus = 25% examination findings” peritonitis o Irritable Bowel Syndrome Overview AKA Etiology - Pain relief with defecation - Spastic colon - Unknown and a change in frequency or o Abdominal discomfort o Attacks appear related to stress and emotional form of bowel movements; o Change in bowel habit upset linked to irritants (frequency) and form o Exacerbated by lack of sleep, tobacco, caffeine, o Food/strength alcohol, antibiotics, insufficient fluid intake o IBS vs IBD - RLQ o Acute Appendicitis Location and Quality Palliative Factors Provocative Factors Associated Symptoms - Poorly localized umbilical pain that migrates to the right - If the pain - Movement - Nausea lower quadrant (McBurney’s Point) subsides, and cough - Vomiting o Acute inflammation of the appendix suspect - Low grade fever - Fecolith can occlude appendix – ischemia, inflammation perforation o Crohn’s Disease Overall AKA Signs and Symptoms - An autoimmune disease with debilitating - Regional enteritis - Lower right quadrant pain gastrointestinal and extra-gastrointestinal o Considered to be chronic and o DDx: appendicitis manifestations progressive - Severe abdominal cramping o Causes ulceration of the intestinal § Look for periods of - Diarrhea lining remission – NO cure - Fatigue o When severe, it can destroy o Can lead to secondary lesions in - Anorexia bowel tissue resulting in fistula lymph nodes, liver, skin, eyes, - Malabsorption syndrome (tunnel) formation and joints o Weight loss - Considered an inflammatory bowel disease § Autoimmune - Secondary lesions - LLQ o Ulcerative Colitis Overview Diagnosis - Inflammation and erosion of - Attacks of bloody diarrhea the mucus layer of the colon o Up to 40 bowel o Causes superficial movements/day erosion of the o May pass blood and puss intestinal lining – w/o feces (dehydration, typically starts in electrolyte imbalance) the rectum and - May sometimes be constipated progresses up the - Pain and spasm descending colon - Anorexia and weight loss - Considered an IBD (along - Sigmoidoscopy, colonoscopy, with Crohn’s) biopsy, upper GI studies are often - Primarily seen in adolescents performed and young adults o Diverticulosis Overview Diagnosis - Diverticulum – an abnormal pouch or sac opening from a - May be asymptomatic hollow organ (intestine or bladder) - Abdominal distention - Diverticulosis – presence of small diverticula in the GI tract - Cramping pain and flatulence o Increased bowel pressure and decreased complex - Diarrhea and/or constipation carbs - Advanced imaging – CT w/ contrast, US, barium enema = gold standard § Constipation, minimal fiber - Proctoscopy and/or colonoscopy exam to R/O other conditions o Diverticulitis Overview Diagnosis - M/C in sigmoid or descending colon - Cramping pain and tenderness usually in the LLQ - Accumulation of fecal matter leads to infection, - A palpable mass (LLQ), fever, and constipation are typical inflammation, ulceration and possible perforation - There may be obstruction and subsequent peritonitis o Peritonitis: rebound tenderness, acute pain, rigidity, absent bowel sounds  o Colorectal Cancer Overview Signs/Symptoms - Change in bowel habits with a mass - Onset is insidious o Early satiety o Constitutional signs and symptoms o Thin stools – “pencil thin” - Screening = ~45 yoa o Mass – hard, irregular, fixed - Kidneys (Lower Quadrants) o Pyelonephritis Pyelonephritis Hematuria - Bacterial kidney infection (usually secondary infection) - Blood in the urine - Characterized by: o Always concerning o Flank pain § Myoglobin can also tinge the urine pink o Fever – chills are not uncommon Rhabdomyolysis: muscle break down and o Dysuria statins - Commonly follows a UTI § Infection o UTI ascends into the kidneys § Cancer o Kidney Stones Types of Stones (Renal Calculi, Nephroliths) Description - M/C = Calcium Stones - Kidney stone – cramping colicky pain o Calcium oxalate and calcium phosphate (oxalate > phosphate) that can cause the patient to double over § High levels of oxalates in the diet (beans, spinach, rhubarb, chocolate, o Patient moves around wheat, nuts, raw cruciferous vegetables, berries” frequently trying to get - 2nd M/C = Uric Acid Stones comfortable o Men > Women § DDx: peritonitis – o Acidic urine movement is - Struvite provocative o Women > Men o Acute onset that suddenly o From UTI and kidney infections subsides once the stone is § Stones are prevented by treating the infections passed - Cysteine § Flank to inguinal pain o Rare – occur in men and women path o Genetic disorder o Nephrotic Syndrome  o Nephritic Syndrome - Increased damage to glomeruli - Severe glomeruli damage leads to inflammatory lesions o Azotemia – nitrogenous wastes (urea, creatine) o Decreased GFR – renin/aldosterone pathway = HTN o Kidney Failure - Uremia o Fatigue o Vomiting o Anorexia o Decreased mental acuity o Neuropathy o Muscle cramps o Seizures o Arrythmias - LUQ o Spleen Location Damage - Under the left rib cage - M/C damaged abdominal organ with blunt trauma o Mass: hard, irregular, fixed - Mononucleosis o Severe fatigue, sore throat, enlarged posterior cervical lymph nodes, spleen enlargement - Abdominal Masses o Abdominal Hernias Special Techniques - Assessing ventral hernias o If you do not observe a ventral hernia, ask the patient to raise his/her head and shoulders off the table o Hernias in the abdominal wall excluding inguinal hernias § Umbilical or incisional Do not confuse a ventral hernia with diastasis recti o Diastasis Recti Description - Benign 2-3cm bulge in the linea alba o Obesity and pregnancy § Result of stretching - Exam o Inspection § Surface – bulges, color, scars, striae, dilated veins, rashes, umbilicus § Contours – scaphoid (caved in), protuberant (fat, feces, flatulence, fluid, fetus, fibroid, fatal growth), flat § Symmetry – organomegaly, bulging flanks (ascites), hernias § Movements – peristalsis, pulsations Aneurysms – increased pulsations of an AAA or increased pulse pressure o Normal = 2.5cm o Aneurysm = >3cm § 4cm = 15x more likely to rupture § > 4.5cm = vascular consult o Auscultation § Bowel sounds Normal = 5-34 clicks and gurgles per minutes Must listen to a spot for 5 minutes before noting absent bowel sounds § Rubs – indicates inflammation of the peritoneal surface of an organ Pathologies – liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, splenic infarct (blood clot, rupture) § Bruits – aorta, renal arteries, iliac arteries, femoral arteries o Percussion § Quadrants for tympany Normal = tympany Dullness = fluid/solids (feces or ascites) § Liver borders § Spleen § Costovertebral – Murphy’s kidney punch test o Palpation § Light palpation § Deep palpation § Gallbladder – Murphy’s sign (cholecystitis) § Appendix McBurney point – 2” from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus Rebound tenderness – (+) = peritonitis Rovsing sign – rebound tenderness in the LLQ elicits RLQ pain (appendicitis) Psoas sign – pressing the leg into the hand – (+) = appendicitis Heel Jar Obturator sign § Liver § Kidneys § Spleen § Abdominal aorta o Special Techniques § Masses in the abdominal wall § Carnett test – chronic abdominal pain - performed by palpating the abdomen of the supine patient in the usual way to elicit the area of tenderness § Ascites – fluid wave, shifting dullness § Assessing ventral hernias § Abdominal reflex – abdominal muscles should contract causing the umbilicus to move “toward the stimulus” Above the umbilicus – T8/T9/T10 Below the umbilicus – T10/T11/T12 WEEK 5 – EYE - General anatomy - Conjunctiva – transparent layer of cells that lie over the sclera and mucous membranes o Sclera = bulbar conjunctive o Mucous membrane = palpebral conjunctiva - Only see conjunctive once it becomes inflamed o Conjunctivitis = red/pink (pink eye) - Pupil – window o Light passes through pupil and focuses on the retina - Iris – “shutters” o Changes shape of pupil to control light - Limbus – where sclera and iris meet - Cornea – most anterior surface of the eye - Lens – behind pupil o Focuses light to land on fovea centralis (central field of vision) - Meibomian Glands – sebaceous glands - Star = lacrimal glands o Superior and lateral - Tears are composed of water, oil, mucus o Water – lacrimal gland o Oil – sebaceous gland in eyelid o Mucus – mucus producing cells in conjunctiva - Retina o Peachy portion = optic disc o Bright portion in disc = optic cup o Darker spot = fovea o Surrounding fovea = macula o Thicker vessels = veins o Thinner vessels = arteries - Muscles o SO4, LR6, All Else 3 o Superior Oblique = Trochlear (IV) o Lateral Rectus = Abducens (VI) o All Others = Oculomotor (III) - Vision - Terms o Acuity = clarity/crispness § Increased acuity = good vision § Decreased acuity = bas vision o Accommodation = lens thickness changes § Thins = see distance § Thickens = see near - Emmetropia o Normal vision - Light focuses on fovea centralis - Myopia o Nearsightedness – can see near objects o As we age, elasticity decreases § With decrease, we lose the ability for lens thickening - Hyperopia o Farsightedness o Can see distant objects o Presbyopia: farsightedness caused by loss of elasticity of the lens of the eye - Astigmatism o Irregularly shaped cornea or lens scatters light - Vision Tests - Acuity o Snellen Chart – distance vision § Patient stands 20ft away and covers one eye § Reads the smallest line of print possible § A patient must correctly identify more than half of the letters on a line correctly to receive credit for that line o Rosenbaum Chart – near vision § Test near vision with a hand-held Rosenbaum card § State that the Rosenbaum card must be held 14” from the face o Rosenbaum chart mimics the Snellen chart - Color Blindness o Ishihara Plates § Patient stands 75cm from the plates § Attempts to read plates #1-17 one at a time Must read the plate within 3 seconds § ≤ 9 correctly read plates = deficient color vision - Visual Field o The entire area seen by an eye when it looks at a central point § Blind spot – there are not retinal receptors at the optic disc 15° temporal to the line of gaze o Monocular vs binocular vision  - Anopsia o Visual field defect § Hemianopia § Quadratic defect § Monocular defect – blindness in one eye o Anything identified by medial retina will cross to contralateral side o Quadrant loss = opposite of lesion location § Lower left loss = upper right lesion - Superior retina = inferior field of vision - Inferior retina = superior field of vision - Static Fields by Confrontation - Static Finger Wiggle Test o Stand in front of the patient o Instruct the patient to cover his/her right eye. o Tell the patient to look at a spot on you (preferably your eye) which will keep his/her eyes parallel with the floor. o Ask the patient if any part of your face is missing or difficult to see (Is there a scotoma?). o Starting in position 1 with hands behind the patient’s visual field/ears), rapidly wiggle digits 2 & 3 as you move the hand anteriorly in a straight line parallel to the floor. o Ask the patient to let you know as soon as he/she sees the wiggling fingers. § Make note of the spot where the fingers were seen in relation to the patient’s head (when the patient could first see the rubbing fingers). o Continue with positions 2-6 as shown to the right. o Instruct patient to switch eyes (cover the left eye) § Repeat for the opposite eye  - Kinetic Red Target Test o Face the patient and move a 5 millimeter, red-topped pin inward from beyond the boundary of each quadrant along a line bisecting the horizontal and vertical meridians o Ask the patient when the pin first appears to be red - Eye Exam o Observation § General Observation Position and alignment of eyes o Exophthalmos – autoimmune – protrusion of the eyes o Phoria – deviation under stress/lack of sleep o Tropia = deviation – always present § Esotropia = medial deviation § Exotropia = lateral deviation § Hypertropia = superior deviation § Hypotropia = inferior deviation o Strabismus = eyes will not look straight ahead together Eyebrows o Lateral sparseness = hypothyroidism o Scaliness = seborrheic dermatitis (dandruff) § Unknown etiology - may be related to yeast or an immune response, may come and go Eyelids o Ptosis – drooping of the upper eyelid § Myasthenia gravis, CN III damage, Horner syndrome, congenital § Upper eyelid should cover the upper portion of the iris – should not see sclera between the upper eyelid and sclera § Upper lid should not cover the pupil – “lazy eye” § Mild = 2mm of droop § Moderate = 3mm of droop § Severe = 4mm of droop o Entropion – inward turning of the lid margin (typically lower lid) § Irritate conjunctiva and sclera § M/C in elderly o Ectropion § Outward turning of the lid margin – if the punctum turns outward, the eye no longer drains well § M/C in the elderly o Lid retraction – proptosis and exophthalmos § Lid lag and Von Grafe’s sign (for protrusion of eyes) Lid lag is the static situation in which the eyelid is higher than normal with the globe in downgaze von Grafe's sign is a dynamic sign describing the retarded descent of the eyelid during movement of the globe from primary position to downgaze Eyelashes – edema, color, lesions o Edema = myxedema – hypothyroidism o Color – blepharitis – inflammation of the eyelid § Chronic inflammation of the eyelids at the base of the hair follicles S. aureus, seborrheic dermatitis, clogged sebaceous gland, rosacea  Adequacy of eyelid closure o Nerves § CN 7 closes the eye § CN 3 opens the eye o Hyperthyroidism – exophthalmos – patient cannot close the eye o Bell’s Palsy (CN VII) § Unilateral – cannot close one eye § Drooping of the mouth § Cannot wrinkle forehead o Loss of consciousness – failure to close exposes the corneas to damage Cornea and lens – oblique light o Corneal Arcus (Arcus Senilis) – grayish white arc or circle not quite at the edge of the cornea § Usually benign, normal aging, hyperlipoproteinemia in the young o Kayser-Fleischer Ring – red brown ring, sometimes shading to green or blue, from copper deposition in the periphery of the cornea § Wilson Disease – genetic: autosomal recessive mutation – abnormal accumulation of copper in the liver and other tissues in the body o Keratoconus – asymmetric, progressive thinning that results in a cone-shaped cornea § Due to weakening/thinning of the central cornea § Genetics, diabetes, trauma, connective tissue disorders § Results in myopia and astigmatism – progressive astigmatism, slit lamp, corneal tomography § Eyeglasses, contacts, collagen cross linking, corneal transplant Conjunctiva and sclera o Subconjunctival hemorrhage – leakage of blood from a vessel § Sharply demarcated red area (over the sclera) that resolves over 2 weeks § No pain, no vision changes, no discharge, no corneal involvement, no pupil involvement § Causes – trauma, bleeding disorders, cough, increase in venous pressure o Conjunctival injection – conjunctivitis – redness is greatest in periphery or evenly distributed § Diffuse dilation of conjunctival vessels with redness that tends to be maximally peripherally – conjunctivitis (pink eye) § Mild discomfort and discharge present § No vision changes, no corneal involvement, no pupil involvement – bacterial, viral, allergies, irritation – very contagious o Ciliary injection – redness is greatest right around limbus – moderate to severe pain, decreased vision § Corneal injury or infection – abrasion, viral, bacterial § Acute iritis – herpes, TB, autoimmune § Acute angle glaucoma – increased intraocular pressure § Autoimmune o Hyphema – pooling of blood inside the anterior chamber of the eye (pupil + sclera) § Trauma, hemophilia § Serious – results in loss of eye sight Lesions o Stye (Hordeolum) – infection of the eyelid margin, red and painful § External – eyelash follicle § Internal – obstructed meibomian gland o Chalazion – painless nodule § Obstructed meibomian gland – gland fills with sebum o Xanthelasma – slightly raised yellowish, cholesterol plaque located on the nasal portion of the eyelid § Hyperlipidemia, primary biliary cirrhosis o Pinguecula – harmless yellow nodule in the bulbar conjunctiva § Appears with aging Deposition of protein, fat, or calcium Nasal then temporal  Lacrimal Gland – swelling, excessive tearing or dryness of eyes o Nasolacrimal duct obstruction o Regurgitation test – done by applying pressure over the lacrimal sac area with either thumb or index finger and observing the puncta § Penlight Cornea and lens – oblique light o Cataracts – opacity of the lens; only visible through the pupil § Clouded or blurred vision, halos or stars around lights at night (aging) o Corneal scars – superficial grayish white opacity of the cornea § Injury or inflammation o Pterygium – triangular thickening of bulbar conjunctiva that grows across the cornea § Interferes with vision if it crosses the pupil § Unknown etiology – may be linked to UV light and irritants Iris – tangential light o Increased intraocular pressure results in a bulging of the iris § Bulging will lead to a shadow being cast across the medial iris upon inspection with tangential lighting – narrow-angle glaucoma Corneal reflection – direct light o Cover-Uncover tets for tropias Pupils – PERRLA o P: Pupils - E: Equal - R: Round - R: React to - L: Light - A: Accommodate o Anisocoria – unequal pupils – defect in the constriction or dilation of one pupil § Pupillary constriction = parasympathetic (CN III) - when anisocoria is greater in bright light, the larger pupil cannot constrict CN III paralysis – no light or near reflex o Ptosis – levator palpebrae superioris – inferolateral deviation, mydriasis Tonic (Adie) Pupil – light reaction is severely slowed or absent, near reaction is present but very slow – denervation § Pupillary dilation = sympathetic – when anisocoria is greater in dim light, the smaller pupil cannot dilate properly Horner Syndrome – lesion of sympathetic trunk as it travels to face/eye o Ptosis, miosis (excessive constriction of the pupl), anhidrosis = classic triad o Pancost tumors, carotid artery dissection o Heterochromia in congenital form Argyll-Roberson – small irregular pupils o Near reaction (accommodation) is normal o Do NOT reaction o Prostitute’s pupil – neurosyphilis o Coloboma – pupils round – a congenital malformation of the eye causing defects in the lens, iris, retina § “Keyhole pupil” o Light reaction – should be direct and consensual light reactions (constriction) § Shine light into right eye Both eyes constrict = right direct reflex, left indirect/consensual reflex One eye constricts = oculomotor lesion in eye that does not constrict o Near reaction – eye convergence, constriction, accommodation § Convergence – both eyes shift midline, pupils constrict § Accommodation (CN III) – convergence + constriction Switching between distance and tip of pen – eyes should bulge with lens thickening at tip pf the pen o Mydriasis – dilation of the pupil Extraocular Muscles – cardinal fields of gaze o SO4, LR6, OM3 § If eyes can go through movements smoothly + evenly, muscles and nerves are intact § Can isolate specific muscles to to specific movements to identify deficiencies  Glaucoma o Set of irreversible, progressive optic neuropathies that can lead to severe visual field loss and blindness o Legal blindness – 20/200 or worse corrected visual acuity in the best eye on a Snellen eye chart § Visual field of less than 20° in the best eye o Two M/C forms: § Primary open-angle glaucoma – older age, black or Hispanic descent, family hx of glaucoma, diabetes mellitus § Primary angle-closure glaucoma – older age, Asian descent, female o Exam findings § Optic disc cupping § Pain with palpation over the eyelid § Medial shadow with tangential lighting § Halos around lights § Loss of peripheral vision (static finger wiggle test) § Examination findings during an acute episode of angle closure include a mid-dilated pupil, conjunctival (ciliary) injection, and a cloudy cornea o Ophthalmoscopic/Fundoscopic Examination § Red Reflex Normal – light reflects into retina and then back out Absence – detached retina, corneal abrasion, cataract, tumor/retinoblastoma § Retina/Fundus Abnormal o A/V nicking – apparent nicking at arteriovenous crossings, the vein appears to taper down on either side of the artery § Hypertension o Cotton Wool Patches – white ovoid lesions with soft edges – extruded axoplasm § Hypertension and diabetes o Flame Hemorrhages – superficial bundles of nerve fibers § Hypertension, papilledema, occlusion of the retinal vein  o Drusen – yellow spots that occur between the optic disc and the macula – dead retinal pigment epithelial cells § Age related macular degeneration § 6-point exam 1: Disc o Cup § Papilledema – engorgement and swelling of the optic disc, intracranial pressure causes intra-axonal edema along the optic nerve Blurred disc margins, cup is not visible – intracranial mass or hemorrhage, meningitis § Glaucomatous cupping – increased cupping due to nerve fiber loss, increased intraocular pressure from glaucoma § Optic atrophy – often the optic cup occupies the entire optic disc – degeneration Entire disc appears pale/white o Optic neuritis, multiple sclerosis, temporal arteritis o Color o Contour 2-5: Four Quadrants 6: Fovea WEEK 6 – HEAD, FACE, NECK - Headaches Overview Primary Headaches Secondary Headaches - Headaches affect 50% of people during their - Without a known underlying pathology - With an identified lifetime o Tension – M/C underlying disease - Primary headaches – without a known underlying o Migraine – 2nd M/C o Analgesic pathology (90%) o Cluster ( aching - Unilateral auras Women - Nausea Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Debilitating - Onset: 1-2 hours - Prodrome (60- - Alcohol and certain - Quiet - Duration: 4-72 70%) foods - Dark room - If 4/5 are hours - Visual Aura - Stress - Sleep present, - Course: recurrent (30%) - Menses 92% = - Noise (phonophobia) migraine - Light (photophobia) o Cluster Process Prevalence Location Quality and Severity - Unclear - Women o Around the eye or - Continuous, intense temple - “Ice pick in the eye” Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Onset: abrupt (minutes) - Unilateral autonomic - Sensitivity to alcohol during - None - Duration: 15 min – 3hr symptoms attack - Course: several each o Lacrimation day for 4-8 weeks o Rhinorrhea o Miosis o Ptosis o Conjunctival infection - Secondary Headaches o Cervicogenic Headaches Checklist Referred Pain - Unilateral head or face pain without sideshift; the pain may - Brain may get ‘confused’ w/ cranial nerves + CN V occasionally be bilateral - Tensioning onto dura mater - Pain localized to the occipital, frontal, temporal or orbital regions - Moderate to severe pain intensity - Intermittent attacks of pain lasting hours to days, constant pain or constant pain with superimposed attacks of pain - Pain is generally deep and non-throbbing; throbbing may occur when migraine attacks are superimposed - Head pain is triggered by neck movement, sustained or awkward neck postures; digital pressure to the suboccipital, C2-C4 regions or over the greater occipital nerve; Valsalva, cough or sneeze might also trigger pain - Restricted active and passive neck ROM – neck stiffness - Associated signs and symptoms can be similar to typical migraine accompaniments including: o Nausea and Vomiting o Photophobia, phonophobia, dizziness o Include ipsilateral blurred vision, lacrimation and conjunctival injection or ipsilateral neck, shoulder or arm pain o Errors of Refraction – Vision Headaches Process Prevalence Location Quality and Severity - Sustained use of - Common - Bilateral - Steady extraocular muscles o Around eyes - Dull - Achy Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Onset: gradual - Eye fatigue - Prolonged use of eyes - Rest of eyes - Duration: variable - Red eyes - Near work - Course: Variable - Irritated “sandy eyes” o Sinusitis – pain = maxillary sinus or frontal sinus § Triad = sinus headache, purulent discharge, fever Process Prevalence Location Quality and Severity - Mucosal inflammation of the - Common - Frontal sinus - Variable paranasal sinuses - Maxillary sinus o Throbbing o Aching Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Onset: variable - Nasal congestion - Coughing - Nasal decongestants - Duration: until treated - Discharge - Sneezing - Antibiotics - Course: repetitive until treated - Fever - Leaning forward o Meningitis § Triad = fever, neck stiffness, altered mental status 2/3 + headache = 95% patients have meningitis Process Prevalence Location Quality and Severity - Viral or bacterial infection - Uncommon - Generalized - Very severed - Steady throbbing Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Onset: one o Ice pick in the face Onset, Duration, Course Associated Symptoms Provocative Factors Palliative Factors - Onset: abrupt. paroxymal - Exhaustion from - Touching the face - Medication - Duration: each jab lasts seconds and recurrent pain - Chewing - Neurovascular recurs at intervals of sec to min - Talking decompression - Course: daily for weeks to months, - Brushing teeth can reoccur o Miscellaneous Hypertensive Headache Hypoglycemic Headache - Hypertensive patients = systolic BP >10mmHg - When the blood sugar falls too low or too rapidly, a patient - “Typical” – as non-migranous, present upon awakening and experiences symptoms such as lightheadedness, weakness, resolving during the morning headache, sweating, and change in level of consciousness if the condition is severe enough - Hypoglycemia may occur in patients with Diabetes Mellitus or when a patient fasts for a prolonged period of time o Commonly occurs a few hours after eating - Torticollis and Pseudo-torticollis Torticollis Psuedo-Torticollis - Spasm (of SCM, splenius capitis, trapezius) that put you into rotation or - Causes: no known cause lateral flexion - CN XI - All movements are painful and there is no deviation of the head - AKA: wry neck - Markedly increased passive ROM when examined carefully in the - Causes: CNS infection, tumor, basal ganglion disease, psychiatric disease supine position - Important to determine whether there is a moderate to high fever = o The amount of passive ROM is used as the gauge as to meningitis whether or not manipulation is appropriate - Must palpate SCMs and anterior neck for masses o Manipulation should be applied cautiously as soon as - Neuro check for upper motor and lower motor neuron dysfunction will possible in an attempt to decrease the global muscle spasm reveal any medically referrable causes - Bones of the Cranial Vault Bones of the Cranial Vault Sutures - Suture = membranous areas where the cranial bones meet o Commonly taught that the cranial sutures fuse in adulthood, several chiropractic and osteopathic techniques obtain excellent results from adjustment of these supposedly immovable cranial bones - Fontanelle = soft spot in children Head Face - Normocephalic = skull with ‘normal’ size and shape - The air sinuses located within the frontal and facial bones serve to - Microcephaly = unusually small skull lighten the skull and also introduce a resonant tone to spoken voice - Macrocephaly = unusually large head sounds Cranial Nerves o Cleanse air, humidification, temperature control of inspired air - Overlying the facial bones are many muscles, innervated mostly by cranial nerve VII, with the muscles of mastication innervated by cranial nerve V o CN V § Motor: muscles of mastication § Sensory: overlying face o CN VII § Motor: facial expression § Sensory: taste to anterior 2/3 of tongue - Sensation to face/head = CN V, C2, cervical plexus (C1-C4) - Triangles of the Neck - The SCM muscle divides the neck into anterior and posterior triangles - External jugular vein is found in the posterior triangle - Lymphatics - The eyes, ears, nose, and throat provide many avenues for bacteria to enter the body. - Multiple chains of lymph nodes and ducts drain the head and neck to help protect against these foreign invaders. - Ten pairs of nodes may be palpable within the head and neck - Chains o Pre-auricular - in front of the ear o Post-auricular - behind the ear o Occipital - at the base of the skull o Tonsillar (aka retropharyngeal or jugulodigastric) - at the angle of the jaw o Submandibular - under the jaw on the side o Submental - under the jaw in the midline o Superficial (anterior) cervical - in anterior triangle and over the SCM muscle o Posterior cervical – behind the SCM muscle in the posterior triangle o Deep cervical - deep under the SCM muscle (often not palpable) o Supraclavicular - just above and behind the clavicle - Lymphatic drainage from ¾ of the body is to the left supraclavicular region - Tracheal tugging – rhythmic downward pull in time with the heartbeat, suggests an aortic aneurysm Oliver’s Sign Campbell’s Sign - Downward displacement of the cricoid cartilage that coincides with - Downward displacement of the thyroid cartilage that coincides with ventricular contraction (S1, systole) inspiration o Aortic arch aneurysm o COPD - Thyroid - Thyroid Cartilage = shield shaped o Creates Adam’s apple - Thyroid Gland = butterfly-shaped o Highly vascular - Enlargement – 5% = malignant o Diffuse enlargement (goiter - visually and palpably enlarged thyroid gland = Grave’s disease o Multinodular goiter = metabolic (toxic, genetics, iodine deficient) o Single nodule – cyst, benign, or malignant - Stroke - Brain ischemia due to disruption of blood flow o Ischemic or hemorrhagic Stroke vs Bell’s Palsy - Stroke = lesion in the brain o Brain ischemia due to disruption of blood flow § Ischemic or hemorrhagic o Forehead preserved § R nerve lesion = L side of the face § L nerve lesion = R side of the face - Bell’s Palsy = lesion of a cranial nerve after it has left its nuclei o Temporary disruption of CN VII (facial nerve) § Five branches innervate the muscles of facial expression Treated with steroids - Pathologies Selected Faces - Cushing Syndrome - Myxedema – - Jaundice - Nephrotic syndrome – glomeruli – hypercortisolism hypothyroidism damage o Proteinuria o Hypoproteinemia o Anasarca – diffuse swelling o Dyslipidemia - Nephritic Syndrome o Hematuria (RBCs) - Parotid gland Uremia - Parkinson Disease o Oliguria w/ azotemia enlargement - Fatigue o Neurodegenerative o hypertension - Vomiting disorder that affect - Renal failure - uremia - Anorexia dopamine- - Decreased mental producing neurons acuity in a specific area - Neuropathy of the brain - Muscle cramps - Acromegaly - Seizures o Excess GH - Arrythmias from pituitary  Lumps on or Near the Ear Keloid Auricular Hematoma Tophi Basal Cell Carcinoma - Excessive - Shearing separates - Deposit of crystallin uric - Shiny flesh colored nodule with deposition of scar perichondrium from acid on the skin surface overlying telangiectasia tissue cartilage (Cauliflower ear) Alopecia – Hair Loss Facial Features - Diffuse hair loss - Focal hair loss o Male and o Alopecia female areata pattern hair (autoimmune) loss o Tinea capitis (ringworm) Tracheal Deviation - Ipsilateral = atelectasis, pneumothorax - Contralateral = space-occupying lesion - Muscles Muscles of Mastication = CN V Muscles of Facial Expression = CN VII - Temporalis - Masseter - Medial pterygoid - Lateral pterygoid WEEK 8 – DIZZINESS - Dizziness – a non-specific term used by patients encompassing several disorders that clinicians must sort out - A detailed history usually identifies the primary etiology (80%) Vertigo - ~50% - Spinning sensation o Peripheral vestibular dysfunction ~40% o Central brainstem lesion ~10% Presyncope - ~5% - A near faint from feeling faint or lightheaded - Must consider cardiovascular system - Causes o Orthostatic hypotension (drop 10mmhg in systole or 10mmHg in diastole) o Medication – usually ones that decrease BP o Arrythmias o Vasovagal attacks Disequilibrium - ~15% - Unsteadiness or imbalance when walking, especially in older patients - Causes: visual loss, weakness from musculoskeletal problems, peripheral neuropathy - Cervicogenic dizziness - Can be treated by chiropractors Psychiatric - ~10% - Causes include anxiety, panic disorder, hyperventilation, depression, alcohol and substance abuse Multifactorial/Unknown - ~20% - Multiple pathologies at one time - Vertigo Overview Types - A spinning sensation - Peripheral Vestibular Dysfunction accompanied by nystagmus o ~40 of dizziness, ~80% of vertigo (slow beat + fast beat – named o Elicited by specific head movements that often cause nystagmus for fast beat direction) and § Benign paroxysmal positional vertigo (BPPV) can be successfully treated by chiropractors ataxia - Central Brainstem Lesion - Usually from peripheral o ~10 of dizziness, 20% of vertigo vestibular dysfunction o Atherosclerosis, multiple sclerosis, TIA, stroke Types of Peripheral Vertigo - Benign Positional Vertigo – patient presents with a sudden onset of dizziness due to a particular head position o ertigo lasts for at most a minute or two o Patient has a hx of trauma or is older o Horizontal nystagmus that fatigues and adapts o No tinnitus o Treated with Epley maneuver – will lead to complete resolution of symptoms for 1 in every 2-3 patients treated § Post-Epley movement restriction does not improve symptoms resolution but might promote a negative Dix-Hallpike test result for 1 in every 10 patients treated - Meniere’s Disease – patient presents with a history of recurrent attacks of vertigo o Sudden attacks come without warning and are associated with severe vertigo o They last hours to days o Often a report of fullness in the ear and tinnitus o May be a hx of diabetes or problems with fluid retention - Labyrinthitis – patient presents with a sudden onset of dizziness that is constant o It slowly improves over days or weeks, often with an associated hearing loss o Affects cochlea - Vestibular Neuronitis – same presentation as labyrinthitis WITHOUT hearing loss  - Vertebrogenic Vertigo – patient presents with a hx of whiplash injury and no obvious examination findings except that dizziness is reproduced by body rotation with the head held constant - Bony Structures - Perilymph = between bony and membranous labyrinths - Endolymph = inside membranous labyrinth -  - Semicircular canals – rotational acceleration o Ampulla – cone-shaped gel – shape change is how you assess rotational movement - Macula – horizontal acceleration - Cervicogenic Dizziness – diagnosis of exclusion Characteristics Overview - Disequilibrium - Can be treated effectively with adjustment - Neck pain o Spinal manipulation/mobilization is - Reduced cervical ROM effective in adults for: acute, subacute, - Cervical movement is and chronic low back pain; migraine and provocative cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain - Vertebrobasilar Ischemia HINTS 5 D’s and 3 N’s Risk Factors When Do Signs Appear HI = Head Impulse Test - Dizziness - Smoking - Appear in practitioner’s office N = Nystagmus - Drop Attacks - Hypertension 69% of the time TS = Test of Vertical Skew - Diplopia - Alcohol consumption - 9% w/in one hour - Dysarthria - RA - Another 14% within 24 hours - Dysphagia - Giant cell arteritis o 92% w/in first 24 hours - Nausea - Ligamentous - Numbness hypermobility - Nystagmus Symptoms Prognosis Adjustment Techniques Associated with More Occurrence - Severe neck or head pain - Reported rate of death from - 60% = rotation - Dizziness dissections of the carotid and - 10% = rotation with extension vertebral arteries is less than - 4% = rotation with flexion and hyperextension 5% WEEK 9 – EARS, NOSE, THROAT - Ears - Movement o Semicircular canals – rotary acceleration o Vestibule – linear acceleration o Utricle – horizontal acceleration o Saccule – vertical acceleration - Eustachian Tube – tube that connects the middle ear to nasopharynx - Antrum (passageway) – eardrum to mastoid air sacs - Middle-Ear Bones = malleus – incus – stapes o Pathology - Microtia - Keloid - Cauliflower Ear o Small ear (auricle) o Overgrowth of scar tissue o Perichondrium and cartilage o Congenital undergo shearing force and are separated o Undrained auricular hematoma - Tophi - Otitis Externa o Uric acid crystals – o Outer ear infection uncontrolled gout o Otorrhea = discharge - Perichondritis - Mastoiditis - Basal Cell Carcinoma o Common w/ piercings o Travels from outer ear to o M/C form of skin cancer o Infection of the perichondrium mastoid via antrum o Flesh colored papule w/ o Infection can erode the thin dimpling and telangiectasia sacs and get into the brain o Treatment – strong antibiotics or mastoid resection o Instrumentation Exam External Auditory Canal Tympanic Membrane - Normal - Normal o Direction indicated by cone of life and malleus Otitis Externa External Ear Obstruction Collection of Fluid and Air Inflamed Tympanic Membrane - Redness, swelling, - M/C cause of - Chronic ear infections otorrhea, exudates conductive - Serous fluid hearing loss Perforated Tympanic Membrane Acute Otitis Media - Bulging ear drum - Dull or absent light reflex Obstruction – Foreign Body Fungus Attic Cholesteatoma Attic Perforation - Skin cyst (rapid grwoth and death of cells) visible behind ear drum Scarring Tympanostomy - Tympanosclerosis - Drains fluid not draining - Healed perforation from eustachian tube o Hearing Pathways - Conduction Phase o External Ear and Middle Ear § Air conduction § Bone conduction – through mastoid  External Ear - Cerumen impaction, infection (otitis externa), trauma, foreign objects, squamous cell carcinoma, benign bony growths (exostoses and osteomas) Middle Ear - otitis media, congenital conditions, cholesteatomas, otosclerosis, tumors, perforation of tympanic membrane - Sensorineural Phase o Inner ear § Congenital and hereditary conditions, presbycusis (hearing loss that occurs w/ old age due to damage to hair cells), viral infections (rubella [German Measles] and cytomegalovirus), Meniere disease (excess endolymph), noise exposure, ototoxic drug exposure, and acoustic neuromas § o Hearing Tests Whispered Voice Test Weber’s Rinne’s - Detects mild hearing loss (20-40 - On the crown of the head - On the mastoid process and close to decibels) - Lateralization of sound ear canal - Always first test we do o Normal = if sound is equal in both o Normal o Bilateral loss – refer to ears § Air > Bone audiologist o Louder in ‘Bad’ Ear = conductive o Conduction o Unilateral loss – Weber + hearing loss § Air < Bone Rinne exams o Louder in ‘Good’ Ear = § Air = Bone - Interpretation sensorineural loss o Sensorineural o Normal – patient repeats - Occlusion Effect = sound conducted through § Air > Bone but the sequence correctly bone causes the cochlea, the ossicular chain, decreased o Normal – patient responds and the air in the external auditory canal to compared to incorrectly, so a second vibrate normal test with a different o Some lower frequency sound combination of three escapes from the canal numbers and letters is o When the ear is occluded, these completed – patient frequencies cannot escape, and the repeats at least 3 of the sound seems to be louder numbers and letters correctly o Abnormal – 4 of the 6 possible numbers and letters are incorrect - Progression o Whisper Voice Test – Loss in right ear o Weber’s Test – Louder in R ear = conduction Louder in L ear = sensorineu