PxDx Exam 1

Visual Acuity Test testing what cranial nerve

CN II- optic nerve

Visual Acuity tests (2)

Distant visual acuity with Snellen chart
Near visual acuity with handheld Snellen chart

Near visual acuity test aids in identifying needs for

reading glasses

Visual field tests by confrontation looking for

lesions in anterior and posterior visual pathways

Visual field tests by confrontation (2)

Static finger wiggle test
Unilateral test

Inspect eyebrows for

Hair fullness, scaliness, distribution of hair, lateral sparseness

Inspect eyelids for (6)

lid lag
width of palpebral fissures
edema
color
lesions
adequacy of eyelid closure

Ptosis

drooping of eyelid

dermatochalasis

presence of loose and redundant skin (on eyelid)

Inspect eyelashes for

condition and direction

Eye Exam history questions

Pain around eyes
changes in vision
excessive tearing or watering
Do they wear glasses or contacts
blurred vision
redness

Inspect lacrimal system for

swelling, excessive tearing, dryness

Lacrimal gland located

within bony orbit

Fluid flows from lacrimal sac into

nasolacrimal duct

Bulbar conjunctiva located

on anterior eyebal

palpebral conjunctiva located

on eyelids

Assess sclera and conjunctiva for

nodules swelling, color, vascular pattern

Inspect cornea for

opacities, defects, foreign bodies

To inspect cornea

Shine split light from side and bring across

Corneal reflex is testing what cranial nerve

CN V- trigeminal nerve

Corneal reflex test looking for

involuntary blinking- testing trigeminal nerve

Inspect iris for

color, nevi, coloboma, tears, surgical scars

Coloboma

Pupil appears to cross entire radius of iris

To assess anterior chamber

Use slit light to estimate depth between iris and cornea

Deep anterior chamber depth

low risk of narrow angle glaucoma or angle closure glaucoma

Shallow anterior chamber depth

high risk of sudden angle-closure attack, narrow angle glaucoma or angle closure glaucoma

Grade 4 of anterior chamber depth test

Fully illuminated

Grade 1 of anterior chamber depth test

Open angle glaucoma would have what grade on anterior chamber depth test

Grade 4- normal

Normal pupil size

3-5mm

Inspect pupil for

size, shape, symmetry

Near reaction test

Have patient look at wall then look at finger close to them

Near reaction test normal reaction

pupils constrict when gaze shifts from far to near object

Near reaction test assesses

constriction and convergence, accommodation as well but that is not visualized

Convergence test

bring finger progressively closer to nose

Hirschberg test

shine light in patient's eye from two feet away- reflection should be in same spot on both eyes, slightly nasal to pupils

Esotropia

One eye pointing inward

Exotropia

One eye pointing outward

Hypertropia

One eye pointing upward

Hypotropia

One eye pointing downward

Direct and consensual light reflex

Shining light beam into eye causes pupillary constriction in both eye that has light and opposite eye

Direct light reflex

Pupil with light shined on it constricts

Consensual light reflex

Opposite pupil constricts when light is shined on one eye

convergence

Move target in toward nose- medial rectus movement

accomodation

bringing near objects into focus through increased convexity of lenses caused by contraction in ciliary muscles

Relative afferent pupilary defect (RAPD)

when both eyes are dilated instead of constricted when a light is flashed in one eye

Cover/uncover test shows

tropias

Tropia

misalignment of the eye that is visible looking at patient- present all the time

Cover/uncover test (how it works)

Affected eye that is deviated at rest corrects when opposite eye is covered

Cross cover test shows

Phorias

Phoria

affected eye appears normal at rest but deviates when other eye is covered or when one is tired- not present all the time

Extraocular movements test what cranial nerves

III, IV, VI

nystagmus

fine rhythmic oscillation of the eyeballs

Superior rectus muscle innervated by

CN III

Inferior rectus muscle innervated by

CN III

Medial rectus muscle innervated by

CNIII

Lateral rectus muscle innervated by

CNVI

inferior oblique muscle innervated by

CNIII

Superior oblique muscle innervated by

CNIV

Leading cause of visual impairment and blindness in the US

primary open angle glaucoma

CNIII

Oculomotor nerve

How to perform test for cardinal fields of gaze

Instruct patient to follow fingers without moving head- move finger in H pattern

Cardinal fields of gaze (6)

1. Extreme right

2. right and upward 3.right and downward

3. extreme left

4. left and upward

5. left and downward

conjugate movement

eyes moving together allowing them to fixate on a singular object

hyperopia

farsightedness, difficulty to see near objects

presbyopia

aging vision- focusing issues with near vision

Myopia

nearsightedness- difficulty seeing distant things

scotomas

fixed defects that suggest lesions in the retina or visual pathways

Diplopia

double vision- can be horizontal or vertical

Inspect skull for (5)

size, contours, symmetry, deformities, tenderness

inspect face and skin for (6)

expression, symmetry, contours, involuntary movements, edema, masses

palpate skull for (3)

tenderness, masses, injuries

Examine hair for (3)

distribution, thickness, infestation

Inspect scalp for (6)

scaling, lumps, masses, lesions, plaques, and nevi

Primary headache

headache without underlying disease

Secondary headache

headache due to other causes - meningitis, subarachnoid hemorrhage

3 things to ask about headaches

severity, chronologic pattern, associated symptoms

Tests to perform for eyes (11)

Inspection
Visual acuity distant and near
Static finger wiggle test - Unilateral also if defect suspected
Convergence
Near reaction
Hirschberg Test
Direct/consensual light reaction
Cardinal fields test
Cover/uncover test
Cross-cover test
Fundoscopic

Inspect ears for

pain, inflammation, erythema

Three areas of external ear to check in exam

auricles- correct position
mastoid region
canal for discharge

Examine tympanic membrane for

cone of light, malleus bone, erythema, swelling, fluid

Test mobility of tympanic membrane with

Valsalva, pneumatic

Gross hearing test

Have patient block one ear, rub fingers together 3 ft from unobstructed ear and then move fingers in until patient can hear rubbing of fingers

Rinne test

Place vibrating tuning fork on mastoid bone
have patient raise hand once they cant hear it
move tuning fork to outside ear
Air conduction should be twice as long as bone conduction

Conductive hearing loss

Bone conduction sound is longer than or equal to air conduction sound

Conductive loss caused by

problems in external or middle ear- blockage of ear canal, perforation of TM, fluid in middle ear

Sensorineural hearing loss caused by

problems in inner ear, cochlear nerve, or brain

Sensorineural hearing loss

air conduction heard longer than bone conduction, but not twice as long

Weber test

Set fork into light vibration and place base on patient's forehead- ask patient if they hear louder on one side or same in both ears

Conductive loss in weber test

sound travels toward impaired ear

sensorineural loss in weber test

sound travels toward good ear

Ear tests (4)

Gross hearing
otoscopy
Rinne Test
Weber test

Nose patency test

Ask patient to inhale through each nostril separately while opposite nostril is held shut

Check nose for

lesions
swelling
deviation
nasal patency
moist, pink turbinates
rhinorrhea
polyps

Sinuses to check

frontal and maxillary

Things to inspect on internal nose (3)

Floor
septum
turbinates

Two actions with sinuses

Transilluminate and percuss
light will fail to shine through if sinus is inflamed or blocked

Test cranial nerve I (Olfactory) for

ability to smell

Oropharynx observations (5)

Voice
Hoarseness
Nasal Quality
Stridor
breath odors

Sign of viral infections in turbinates

red and swollen