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Adv. Health Assessment- Head and Neck (Ch 7)
Terms in this set (129)
Primary headaches include...
Caused by problems of overactivity of pain-sensitive structures in your head. Examples include: migraine, tension, cluster, chronic daily headaches
Arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life threatening.
Thunderclap headaches that reach maximum intensity over several minutes occur in 70% of patients with subarachnoid hemorrhage. Often preceded by sentinel leak headache (vascular leak into subarachnoid space).
Two most important attributes of a headache
Severity and chronologic pattern
EX: if severe and sudden subarachnoid hemorrhage or meningitis.
Attributes of tumor, abscess, or mass lesion
new and persisting and progressively severe headaches.
Attributes of subarachnoid hemorrhage (SAH)
sudden, thunderclap onset, with worst pain of their life. preceded by sentinel leaks (sudden or focal pain that may be severe). Can also be associated with nausea and vomiting.
Attributes of brain tumors
can be associated with nausea and vomiting. Here the pain is new, persisting, and progressively getting worse.
Warning signs of headache
-progressively freq. or severe over 3 month period
-new onset after age 50
-aggravated or relieved by position change
-precipitated by Valsalva maneuver or exertion
-associated with fever, night sweats, weight loss
-presence of HIV, cancer, or pregnancy
-recent head trauma
-change in pattern from past headaches
-lack of similiar headache in past
-associated with papilledema, neck stiffness, or focal neurologic deficits
early symptom that may indicate the start of a disease or condition before it happens. 60-70% of migraine patients experience this, and they can appear as a visual aura:
-spark photopsias=flashes of light
-fortifications=zig zag arcs of light
-scotomata=area of visual loss with surrounding normal vision
Women with migraines over 35 and women with migraines and aura are at a greater risk of _____ and _____ if they use estrogen-progestin contraceptives
ischemic stroke and cardiovascular disease
Valsalva maneuvers increase pain in what two conditions because of the increased ICP?
acute sinusitis and mass lesion (some sort of large growth, can be an abscess, something benign, malignant, etc.)
5 Possible causes of unilateral vision loss (painless)
vitreous hemorrhage, MD, retinal detachment, retinal vein occlusion, retinal artery occlusion
5 Possible causes of unilateral vision loss (painful)
corneal ulcer, uveitis, hyphema, acute glaucoma, optic neuritis
Sudden bilateral vision loss (painless)
medications may be the cause (cholinergics, anticholinergics, steroids)
Sudden bilateral vision loss (painful)
chemical or radiation exposures
Gradual vision loss causes (2)
macular degeneration or cataracts
Macular degeneration attributes
slow central loss of vision, painless, unilateral.
A gradual loss of vision as a result of the loss of retinal ganglion in cell axons. There is initial loss of peripheral visual fields, and pallow and increasing size of teh optic cup.
It is the leading cause of blindness in African Americans, and the second leading cause of blindness overall
results in visual loss on one side of the eye (1/4 field)
cause moving specks or strands to appear in the visual field. If these are fixed in place, it suggests lesions in the retina or visual pathway.
Detachment of vitreous from retina
flashing lights or new vitreous floaters present.
double vision. seen in lesions in the brainstem or cerebellum, or if there is weakness in one or more extraocular muscles. Diplopia in one eye with the other closed suggests a problem in the cornea or lens.
Conductive hearing loss
results from problems in the external or middle ear. noisy environments may actually be helpful.
Sensorineural hearing loss
stems from problems in the inner ear, cochlear nerve, or central connections in the brain. These people have particular trouble understanding speech, often complainign that others mumble. Noisy environments make hearing harder
pain occurs in the external ear canal; pain can also be referred from other structures in the mouth, throat, or neck
pain in the inner and external ear accompanied by respiratory infections. Pain may also be referred from the mouth, throat, or neck. Unusually soft wax, debris from inflammation, or discharge through a perforated eardrum is present.
a disease that causes hearing loss, tinnitus, and vertigo. comes from an issue with hte labyrinths of the inner ear or cranial nerve 8 (vertigo). first tinnitus, then vertigo then hearing loss, it is progressive and nonreversible. tinnitus bothers people mostly at night.
Common causes of rhinorrhea and accompanying nasal congestion
viral infections, allergic rhinits (hay fever), vasomotor (nonallergic) rhinitis
* allergic often accompanied by itching
Causes of drug-induced rhinitis
excessive use of decongestants or use of cocaine
Bacterial vs Viral sinusitis
acute bacterial sinusitis is unlikely unless respiratory infection symptoms have persisted for more than a week. Bacterial is accompanied by purulent (milky, colored) drainage from the nose and facial pain.
One sided nasal congestion is caused by (5)
1. deviated nasal septum
2. nasal polyp
3. foreign body
4. granuloma (wegener's)
Acute hoarseness caused by
voice overuse and acute viral laryngitis
Hoarseness that lasts more than 2 weeks
refer for laryngoscopy and consider hypothyroidism, reflux, vocal cord nodules, head and neck cancers, neurological disorders (Parkinson's, amyotrophic lateral sclerosis, MG).
Glaucoma Risk Factors
older than 65 y/o, family history, African American descent, diabetes, myopia, ocular hypertension.
Hearing loss risk factors
hx of congenital or familial hearing loss, syphilis, rubella, meningitis, or exposure to hazardous noise levels at work/on the battle field.
Hair differences in hypo vs hyperthyroidism
Hyperthyroidism: fine hair
Hypothyroidism: coarse hair
Possible dx of an enlarged skull
hydrocephalus or Paget's disease (excessive formation of bone)
excessive facial hair, seen in women with polycystic ovary syndrome
muscle that raises the upper eyelid, innervated by cranial nerve 3
when a beam of light shown in one eye causes that pupil to contract, the other pupil will contract as well even if there is no light source, mediated by CN III
The near reaction
when a person shifts there gaze from a far object to a near one their pupils constrict, mediated by CN III. convergence of the eyes and accommodation (lens decreases in size and becomes thicker)
Sympathetic pathway for pupil dilation
hypothalamus--> brain stem--> cervical cord--> neck--> follows carotid artery--> branches into orbit
Extraocular muscles associated with CN IV
Superior oblique (medial, bottom)
Extraocular muscles associated with CN VI
lateral rectus (lateral middle)
a person is considered legally blind when vision in the better eye corrected by glasses is 20/200 or less. this can also result from a constricted field of vision.
Causes of visual field defects
glaucoma, optic neuropathy, optic neuritis, and glioma.
local redness in the sclera, caused by arthritis, lupus, zoster, sjogrens
Dark, crescent shadow on iris increases the risk of
Glaucoma (iris bows abnormally foward forming a narrow angle with the cornea)
Unilateral Protrusion of the eyeballs
orbital tumor or retrobulbar hemorrhage (from trauma)
Important areas of eye exam
-conjunctiva and sclera
-cornea, lens, and pupils
-fundi including: optic disc and cup, retina, and retinal vessels
Visual acuity (20/20)
the first indicates the distance of the patient from the chart, and the second is the distance at which a normal eye can read the line of letters
swelling of the optic disc and anterior bulging of the physiologic cup. Indicative of: intracranial mass, lesion, hemorrhage, meningitis
unequal size of the pupils. unilateral blindness does not cause this as long as sympathetic and parasympathetic innervation to the irises is normal. A light directed in the good eye causes a consensual reaction in the blind eye, but light in the blind eye will not cause constriction in either eye. If pupillary reactions are normla, aniscoria is considered benign.
unilateral; nausea/vomiting and photophobia/phonophobia; 4-72 hours
bilateral, can be generalized to the back of the head and upper neck or to the frontotemporal area; no nausea but sometimes photo/phono; 30 min to 7 days. pain can decrease but is omnipresent when having an episode.
unilateral behind the eye or temple; lacrimation, rhinorhea, miosis, ptosis, edema, up to 3 hours. excruciatingly painful cannot function.
Secondary Headache-Analgesic rebound
occurs from withdrawal of meds, can be very variable. location and severity varies.
Secondary Headache- Errors of Refraction
sustained contraction of EOMs, occurs around and over eyes, could also be in occipital area. steady, aching pain, sandy sensation of eyes, red conjunctiva, occurs after long use of eyes resting helps
Secondary Headache- acute glaucoma
in and around one eye, steady aching pain after rapid onset. could have decreased vision, nausea and vomiting.
Headache from Sinusitis
above the eye or above maxillary sinus, aching pain with congestion, discharge, fever.
generalized headache, rapid, associated with fever, stiff neck, changes in mental status. need immediate antibiotics to determine if bacterial or viral.
Brain Tumor Headache
location varies with location of the tumor. aching, steady, variable with intensity tumor. may be aggravated by coughing, sneezing, or sudden movements of teh head. pain intermittent
sharp pain in the face because of the trigeminal nerve. even mild stimulation to the face can cause severe pain.
Parotid Gland Enlargement Facies
may be associated with obesity, diabetes, cirrhosis, and other conditions. swelling occurs anterior to ear lobes and above angles of the jaw. gradual unilateral enlargement indicates neoplasm. acute enlargement is seen in mumps.
enlargement of both bone and soft tissues. head is elongated with bony prominence over forehead, nose, and lower jaw. nose, lips, and ears also enlarge.
decreased facial mobility blunts expression. decreased blinking and a characteristic stare present. patient seems to peer upward towards observer. facial skin becomes oily and drooling may occur.
affected pupil, although small, reacts briskly to light and near effort. ptosis of the eyelid is present, and the affected iris could be lighter in color. also could be inability to sweat on one side of the face (damage to sympathetic nerves on side of neck).
Horizontal Defect in the Eye
occlusion of a branch of the central retinal artery may cause this. ischemia of optic nerve can produce this as well.
Homonymous left Superior Quadrantic Defect
partial lesion of optic radiation in the temporal lobe, may involve only a portion of nerve fibers.
What constitutes simple aniscoria?
Difference in pupil size of .04 mm or greater
Physical Findings of Glaucoma
no ocular discharge, pupil fixed and dilated, cornea steamy/cloudy
Benign Positional Vertigo
sudden onset after rolling onto affected side, lasts less than a minute. no loss of hearing or tinnitus. sometimes there is nausea, vomiting, nystagmus
Vestibular Neuronitis (acute labyrinthitis)
infection of the vestibular nerve in the middle ear. presents with vertigo, without tinnitus or hearing loss. can also have nausea, vomiting, balance difficulties, and can last a couple of weeks.
Drug Toxicity Vertigo
may or may not be reversible, hearing may be impaired and tinnitus may be present. presents with nausea and vomiting and is associated with diuretics, amingoglycosides, salicylates, alcohol
occurs from CN VIII. one side hearing is affected and tinnitus may be present.
vertigo that occurs because of a CNS issue. often sudden, no LOH or tinnitus. usually occurs with other brainstem deficits like ataxia, crossed motor and sensory deficits; includes acoustic neuroma as a subset
Nephrotic Syndrome Facies
face is edematous and pale. swelling appears around the eyes and in the morning. eyes may become slitlike when edema is severe. periorbital edema, puffy pale face, and lips may be swollen.
hypothyroidism, dull puffy facies. edema is pronounced around the eyes, and does not put with pressure. hair and eyebrows are coarse, dry, and thinned.
wavy lines in field of vision; could be a casue of damage to the brain, MD, part of aura in migraine
Can be an issue with the lens due to trauma. Light would be deflected if the lens is messed up, OR it could be an issue with the anterior chamber.
External Ear Hearing Loss Causes
infection, trauma, SCC, benign bony growths such as exostoses or osteomas.
Middle Ear Hearing Loss Causes
congenital conductions, benign cholesteatomas, otosclerosis, tumors, perforated TM
Inner Ear Hearing Loss Causes
presbycusis, viral infections, Menieres disease, noise exposure, acoustic neuroma
nontender nodular swellings covered by normal skin deep in the ear canal. these are nonmalignant overgrowths which may obscure the drum.
Acute Otitis Externa
canal is swollen, narrowed, moist, pale, and tender. It may also be reddened. Be sure to put them on drops and culture some of fluid, STAPH AUREUS IS BIG
Chronic Otitis Externa
skin of the ear canal is often thickened, red, and itchy
tests for lateralization; in conductive sound is lateralized to bad ear, in sensorineural sound is lateralized to the good ear. Sensitivity is 55%, specificity is 79 for SN and 92 for Conduction.
In ______________ hearing loss, sound is lateralized to (heard in) the impaired ear.
Unilateral Conductive Hearing Loss Reasoning
otosclerosis otitis media, perforation of eardrum, cerumen.
in conductive, sound is heard through bone as long or longer than trough air. Sensitivity 60-90, specificity 95-98
Whispered Voice Test
high specificity and even higher sensitivity to detect significant hearing loss/
32 teeth in adults
1-16 right to left on upper jaw
17-32 left to right on lower jaw
mucosa in viral rhinitis vs allergic rhinitis
viral: red and swollen
allergic: pale, bluish, or red.
Conditions that cause nasal polyps
allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, cystic fibrosis.
If the patient sticks out their tongue and it is not symmetrical, what does that indicate?
A lesion of CN XII (hypoglossal)
Soft palate issues are associated with what cranial nerve?
X (vagal); soft palate fails to rise and the uvula deviates to the good side
Generalized Lymphadenopathy is seen in what conditions?
measures motion of the tympanic membrane, and if there is an effusion it won't move normally.
Why might one eye blink at a different rate than the other?
Lid Lag is seen in...
thyroid problems (both eyes)
white blood cells inside of the eye from an infection
Cell and Flare
like a snow globe, there are WBC floating around in the anterior chamber.
A 35 yof presents with intermittent episodes of vertigo, tinnitus, nausea and hearing loss within the past week. DiDx?
C) Vestibular neuronitis, labyrinthitis, benign positional vertigo, Meniere's disease, Acoustic neuroma
A 55 yof offers a c/o of dizziness for the past 24 hours. she feels faint and has been having diarrhea for the past two days. she takes a diuretic for HTN. didx?
A) Benign positional vertigo, orthostatic hypertention due to dehydration,
Acute viral gastroenteritis, Labyrinthitis, Influenza
A 44 y/o female c/ dizziness with head movement to the left. She feels that the room is spinning around her head. Dix-Hallpike test produces nausea and nystagmus. What is the most likely diagnosis?
D) Benign positional vertigo, vestibular neuronitis, labyrnthitis, Meniere's disease
A 26 y/o female presents to your office with a c/o sore throat, fever, severe fatigue and anorexia for the past week. She reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend experienced similar symptoms recently. Which of the following is the best differential diagnosis?
B) Infectious mononucleosis, hepatitis, acute pharyngitis, acute HIV infection, secondary syphilis
A 26 y/o female presents with a sore throat, fever, rash and weight loss He has a history of IV drug use and sharing needles. Which of the following are the most likely differential diagnoses?
A) HIV / acute retroviral syndrome, infectious mononucleosis, hepatitis, viral pharyngitis, streptococcal pharyngitis, secondary syphilis
A 30 y/o male comes to your office c/o "night sweats " x 1 month. He smokes a pack of cigarettes a day, when he can get them. After some time he admits to associated symptoms of cough and swollen glands. Which of the following choices most accurately reflects a differential diagnosis for this patient?
C) Tuberculosis, Acute HIV infection, Lymphoma, Leukemia
A 44 y/o female presents to the clinic c/o an 11 kg weight gain over the last two months. She quit smoking three months ago. She is on amitriptyline for depression. She also admits to cold intolerance and constipation. Which of the following processes most likely explain her symptoms?
A) Smoking cessation, Hypothyroidism, Drug side effect, polycystic ovary syndrome.
A 42 y/o female presents to you your office c/o a 7 kg weight loss over the past two months. She has a fine tremor and her pulse is 112 bpm. Which of the following is the most complete differential diagnosis?
C) Hyperthyroidism, Cancer, HIV infection, Dieting/Diet drugs.
yellow raised plaques that appear along nasal portions of one or both eyelids. Seen in lipid disorder.
leakage of blood into areas around vitreous
open sore in cornea outer layer caused by infection
inflammation of optic nerve, associated with MS
flashes of light
zig zac arcs of light
can originate in paranasal sinuses or nasopharynx; bleeding from posterior may actually go down the throat instead. could present with hematemesis
Bacterial Pharyngitis Symptoms
fever, tonsillar exudates, swollen anterior lymph nodes, no cough.
orbital tumor or retrobulbar hemorrhage
Paralysis of CN 6
eye does not pull laterally, it stays midline
Poor convergence associated with...
Symptoms of Diabetic Retinopathy
retinal hemorrhages, microaneurysm, neovascularization, hard exudate
Symptoms of HTN
cotton wool spots, AV nicking, hard exudates
Kaposis Sarcoma (AIDS)
deep purple lesions in the mouth
bony growth on hard palate, harmless
4 Types of Dizziness
vertigo, lightheadedness, presyncope, disequilibrium. Vertigo is most common
Physical Finding consistent with acromegaly?
coarsening of facial features
WHen looking at the tympanic membrane, what normal landmark is seen?
Physical finding upon exam of otitis media
erythematous, bulging tympanic membrane
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