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What are the major fontanels to look for in the examination of the head? until when are they palpable? what about sutures?
- Anterior fontanel: towards the front of the head, palpable until 9-18 months.
- Posterior fontanel: towards the back of the head, palpable until 2 months.
- Ossification of sutures take years.
- Saggital suture: in the middle connecting the posterior and anterior fontanels.
- Coronal suttures: towards the front of the head.
- lambdoidal sutture: towards the back of the head.
What should be noted in the infants health history?
- Birth history: vaginal or cesarean, presentation, difficulty of delivery, use of forceps.
- Unusual head shape: bulging or flattening, head heal at angle.
- Quality of head control.
- Acute illness: diarrhea, vomiting, fever, stiff neck, irritability.
- Congenital abnormalities.
- OFC: Occipitofrontal head circumference.
Inspection of the Head and face:
- Head position: upright and still.
- facial features: eyelids, eyebrows, palpebral fissures, nasolabial folds and mouth (shape, symmetry with rest, movement and expression).
- Facies: expression/appearance of the face and features of the head and neck.
What are the 7 attributes?
- Onset, duration, location, character, severity, pattern.
- severity and chronologic patter are very important.
What are the 6 muscles of the eye?
- Lateral rectus.
- Superior and inferior oblique.
- Assessment: use finger to assess the 6 cardinal fields of gaze. (CN III, IV,VI)
What are the part of the eyes?
- Sclera: white of the eye.
- Cornea: clear, sensory, refractory (optical) power .
- Uvea: Iris (color of the eye), ciliary body(aqueous humor), and choroids (oxygen to the retina).
- Lens: transmits images from varied distances.
- Retina: Sensory network of the eye (optic disc, retinal artery & veins, macula or fovea (central vision)
Characteristics of infants and children's eyes: development? Peripheral vision? Lacrimal ducts? Binocular vision? distinguish color? 20/20 vision?
- eyes develop 8 weeks of gestation.
- peripheral vision is fully developed at birth, central vision matures later.
- 2-3 weeks lacrimal duct produces full tear.
- 3-4 months binocular vision is complete.
- 6 months the infant can distinguish colors.
- globe of the eye grows as the head and brain grow: 20/20 vision 6-8 yrs of age.
Visual milestones of infancy: birth? 1 month? 1 1/2 - 2 months? 3 months? and 12 months?
- birth: blinks, may regard face.
- 1 month: fixes on objects.
- 11/2-2 months: Coordinated eye movement.
- 3 months: eye converge, baby reaches.
- 12 months: acuity around 20/50.
common finding in older adults? Common problems?
- Presbyopia: lower ability to focus on near (reading glasses)
- Common problems: Cataract, glaucoma, and macular degeneration.
- cataract: lens (fiber) compressed to a central region (loos of clarity of the lens). Clouding, double vision, and loss of peripheral vision.
- Glaucoma: Increased pressure in eye. halos, tunnel vision and loss of peripheral vision.
- Macular degeneration: Loss of central vision.
What equipment do you need for the eye exam?
- Snellen chart
- cotton wisp.
- Opaque card to cover eye.
How to start the exam of the eyes? first step ...
- external Inspection: eyebrows, eyelids, eyelashes, orbital and periorbital area etc.
- Lacrimal apparatus.
what is xanthelasma?
- Slightly raised, yellowish, well-circumscribed plaques that appear along the nasal portions of one or both eyelids.
- Specially if they have high lipid levels, high cholesterol.
What is Ptosis?
- It is the dropping of the upper lid.
- Could be a muscle issue. Also with age, the eye leads start to fall. could be a paralysis or cranial nerve.
What is blepharitis?
- could be bacterial infection.
- Psoriases, etc.
What is the sclera?
The white part of the eye.
What is the conjunctiva?
- It is the clear membrane that cover the eye and some part of the inner eyelids.
- Pull the eyelid down as the pt looks upwards.
- Note the translucency and vascular pattern of both the sclera and palpebral conjuctivae and the color of the sclera.
what is purulent conjunctivitis?
- Pink eye, bacterial.
- Puss coming out.
- Frequent in Lasik surgery, it could also be some type of abuse ...
What should be examined abt the cornea?
- The corneal light reflex: with the penlight, light is reflected off the cornea (red reflex)
- wisp of cotton (CN V): blink.
what is Pterygium?
- A triangular thickening of the bulbar conductive grows slowly across the outer surface of the cornea, usually from the nasal side.
- Triangular thicken of the conjunctiva.
what is Arcus senilis?
- tends to get acutter with age.
- Maybe related with a lipid disorder (high chol)
- Focusing in the gray around the eye.
How to perform the acuity testing? distance? what CN?Near vision?
- 20 ft from the Snellen chart, test each eye.
- Tests CN II (optic nerve) - central vision.
- Starts on children 3 yrs of age.
- visual maturity 20/20 it is reached around 9-10 yrs.
- Near vision: tests 14 inches, especially used for over 45.
How the eye's external exams?
- Accommodate: Pupil dilate when looking at a distance and constricts when looking at closer objects.
- Corneal light reflex: the light should reflect equally in both eyes.
- Cover-uncover: it tests muscle control, amount of eye deviation.
- Convergence: Eye move in as object moves closer to maintain binocular vision.
what are the different dx of light reflex?
- Esotropia: the light reflects to the side in one of the eyes.
- Hypertropia: the light reflects down in one of the eyes.
- Pseudoesotropia: The eyes are not straight but they look straight under the light.
what is a normal exam findings in the eye?
- Disc margins are sharp: Color, yellowish to creamy pink, shape, round or oval, cup to disc ratio, Less than half.
- Vessels AV ratio: AV crossing (no identation), No arterial light reflex.
- Fundus: background no exudates or hemorrhages, color red to purplish.
- Macula: located 2.5 disc distance temporal to disc, no vessels are noted around Macula, it may be slightly pigmented.
what is AV nicking?
- Causes the veins to collapse.
- Not a normal finding.
- Usually found in HTN.
what is Diabetic retinopathy?
- Pt looses spots of their vision.
- The color is not nice and smooth. There are come patches here and there.
- Droosing bodies under the macula.
What is Cotton wool spots?
- Usually caused by HTN and DM.
- Yellow spots are the cotton wood spots.
What is papilledema?
- Not a nice round disk. We see this with cranial pressure, head injury maybe ...
What happens when there is Macula degeneration?
- the Central and fine vision get affected.
- Vision loss in center of vision.
- Affects center of retina - Macula.
- Macula is for fine central vision.
- This is age related.
What is glaucoma?
- It is an increased fluid pressure in the eye.
- Can lead to permanent damage of the optic nerve.
- Leading cause of blindness.
- Increase in cut to disc ratio (normal is less than 0.5)
what are Cataract?
- Loss of visual acuity.
- Clouding of the lens.
- The lenses could be replaced.
What are the most important parts of the external ear?
- Auricle (pinna)
- External auditory canal.
- Cartilage covered skin.
What are important parts in the middle ear?
- 3 small bones (malleus, incus, stapes)
- Tympanic membrane (translucent)
- Oblique position to the canal & conical shape account for the triangle light reflex.
Infants and children ears, how is the canal different? Eustachian tube?
Are the sinus present?
When do teeth erupt? permanent teeth?
- Ear canal: External auditory canal is shorter, upward curve. Therefore the odoscope is inserted differently, Puna down (young children) PUB: puna up and back (oder than 3).
- Eustachian tube: it is wider, shorter, horizontal.
- Sinus: Sinus are present but small, totally developed by adolescence.
- Teeth: Teeth eruption 6 and 24 months of age.
- Permanent teeth 6 yrs of age, completed by 14 yrs.
What are the main differences with pregnant women?
- Strogen: the level are elevated causing increase vascularity of upper respiratory tract.
- This causes nasal stuffiness, decreased sense of smell, epistaxis, fullness in the ear, impaired hearing.
HX: important things to ask abt ear, nose, and mouth?
- Vertigo: a false sense of motion- falling in adults.
- ear pain: methods of cleaning (no Qtips)
- Hearing loss: speech, do they ask for things to be repeated?
- Nasal disrcharge: seasonal, tenderness over face?
- Snoring: daytime sleepiness could mean apnea.
- Nosebleeds: epistaxis.
- Sinus pain.
- Dental problems: gums, malocclusion, mouth lesions.
- Sore throat, hoarseness, difficulty swallowing.
How to do an otoscopic examination? Adult? infant? What landmarks to look for?
- Adult: Pull the pinna upward and back.
- Infant: Pull pinna down and out. Examine the meatus and the walls (redness, swelling, tenderness)
- Landmarks: Tympanic membrane, cone of light, pars tens a (bottom) pars flaccid (top), slightly conical and concave.
What are the hearing evaluation tests?
- whisper test: mask 1 ear, be 2-3 feet away and whisper "1,2,3". Whisper in high frequency.
- Weber test: Test of lateralization.
- Rinne test: Compares air conduction to bone conduction. Conductive losses.
What is the weber test?
- It is a test for lateralization.
- warp the running fork strongly and then place it on to of the pt's head the midline and ask patient where they hear the sound.
- In a conductive loss, sound materializes to the DEFECTIVE ear.
what is the Rinne test?
- Place the butt of the mastoid eminence firmly.
- pt needs to tell when they don't hear the vibration.
- Then place the U part of the fork near the ear w/o touching it, pt. should tell you when they stop hearing it.
- It should be hear by air conduction 2x more that bone conduction.
What to look for when examining the nose? what does blue, red, pink finding mean?
- Look inside the nose and need to be able to see nice turbinates.
- Swollen, blue and boggy: allergies
- Read and swollen: infection, URI.
- Pink and moist: Normal
what should be check in the mouth?
- Number of teeth. Wisdom tooth is #1. Should be 32 teeth.
- Mucus membrane.
- count caries and missing teeth.
what should be assess in the Oropharynx?
- Palatine tonsiles (note the size- +1,2,3,4)
- Pharynx (pink color)
- Uvula (position)
- Soft palate (color)
- gag reflex (CN IX and X)
how to examine for lymph nodes? what findings should be concerning?
- Inspect head, neck, axillae, arm, and groin.
- Concerns: > 1cm, hard-fixed- nontender nodule.
what are the lymph nodes in the head?