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• The Eye
• The Ear
• Nose and Throat

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SYMPTOMS:

• SUDDEN LOSS of VISION: Potential Causes
• AMAUROSIS FUGAX: Temporary, monocular, ischemic blindness.
• Painless
• Caused bu ipsilateral Carotid stenosis or embolization of the retinal artery.
• RETINAL DETACHMENT: Flashing lights, floating halos, and blurry vision before the blindness is indicative of retinal detachment.
• UVEITIS: Inflammation of uveal tract -- iris, ciliary body, and choroid.
• Always painful
• Associated with multiple diseases: connective tissue diseases, histoplasmosis, sarcoidosis, tuberculosis.
• GRADUAL LOSS of VISION: Potential Causes
• CATARACTS: Opacities of the lens, occurring with age.
• GLAUCOMA: Increased intraocular pressure.
• It is the most common reason for loss of vision over age 50.
• MACULAR DEGENERATION: Secondary to Diabetes, and expected to cause visual blindness.
• Diabetic Retinopathy.
• OPTIC NERVE COMPRESSION: Caused by an intracranial neoplasm, or pituitary adenoma.
• OPTIC NEUROPATHY (Optic Neuritis): Multiple Sclerosis, and drugs such as Ethambutol, Methanol, can all cause optic neuritis and gradual blindness.
• PRESBYOPIA: Gradual loss of ability of Accommodation for near-vision, occurring with age.
• CORTICAL BLINDNESS: Infarct of the Occipital Lobe can lead to cortical blindness. Patient will have binocular blindness, but will retain the pupillary light reflex which is unaffected.
• DIPLOPIA: Double vision.
• Monocular Diplopia: Should suggest corneal or lens problem.
• Binocular Diplopia: Indicative of cranial nerve palsy or ocular muscle problems, or a brainstem problem.
• Myasthenia Gravis (MG): Diplopia without pain is often the presenting complaint in MG.
• EYE PAIN:
• The cornea is innervated by the Ophthalmic Nerve, CN V¹.
• Possible causes of eye pain
• CNS problems affecting CN V¹: Meningitis, cavernous sinus thrombosis, aneurysms, migraine
• Adjacent structures: sinus problems
• Eye problems / inflammations: Conjunctivitis, stye, chalazion
• Photophobia: Eye pain upon exposure to light, indicative of
• SCOTOMATA: Specific islands or spots of impaired vision; an impaired visual field.

EYELIDS:

• PTOSIS: Droopy eyelids; failure of lids to open fully.
• Caused by failure of levator palpebrae, innervated by CN III, or failure of Tarsal Muscle, innervated by sympathetics.
• Some causes: Horner's Syndrome, Myasthenia Gravis, Encephalitis
• LID LAG: Evidence of white sclera between the iris and upper lid margin. This is normally not found.
• It is a sign of Grave's Disease
• STYE: Small abscess caused by infection of sebaceous glands of Zeis.
• CHALAZION: Acute inflammation of the meibomian gland.

SCLERA:

• SCLERITIS: Inflammation of the sclera, visible as brown / red infiltrates in sclera on gross examination. Found in autoimmune and collagen vascular diseases, such as SLE, RA.
• BLUE SCLERA: Pathognomonic of Osteogenesis Imperfecta.
• Results from very thin sclera in which the choroid shows through.
• BROWN SCLERA: Found in disorder Alkaptonuria (metabolic disorder)
• YELLOW SCLERA: Found in Jaundice. It should raise the question of liver disease or hemolytic anemia.

EXOPHTHALMOS: Eyes jutting out past eyelids. A sign of Grave's disease, acromegaly, and cavernous sinus thrombosis.

CORNEA:

• KERATOCONJUNCTIVITIS (KERATITIS) SICCA: Found in Sjögren's Syndrome, resulting from autoantibodies against salivary glands resulting in no salivary secretion.
• Classic triad of symptoms with Sjögren's Syndrome:
• Keratitis Sicca (dry eyes)
• Xerostomia (dry mouth)
• Rheumatoid Arthritis
• INTERSTITIAL KERATITIS: A sign of congenital syphilis.
• Hutchinson's Triad: Triad of interstitial keratitis, deafness, and notched teeth is classical evidence for congenital syphilis.
• ARCUS SENILIS: Gray band of opacity around the cornea.
• KAYSER-FLEISCHER RINGS: Copper in Descemet's Membrane.
• Circular bands of brownish pigment on lateral and medial margins of cornea.
• Found in Wilson's Disease
• PINGUECULAE: Small, yellowish elevations of the conjunctivae, which appear brown in Gaucher's disease. It is caused by hyaline degeneration of conjunctival tissue.
• ANISOCORIA: Unequal pupils, caused by miosis or mydriasis of one pupil.

PUPILS:

• MARCUS GUNN PUPIL: A pupil that dilates (rather than constricts) as light swings toward it.
• It indicates either severe macular disease or optic nerve disease in the affected eye.
• PUPILLARY REFLEXES:
• Absent Direct Reflex: Indicates a problem with the afferent branch (Trigeminal V¹) of the reflex.
• Absent Consensual Reflex: Indicates a problem with the efferent branch (CN III, Edinger-Westphal Nucleus) of the affected eye.
• CONVERGENCE: Ability of eyes to focus inward and accommodate for near vision.
• Impaired convergence is seen with Grave's Disease.
• ARGYLL ROBERTSON PUPIL: Indicates a form of CNS Syphilis, Tabes Dorsalis.
• Weak or absent direct pupillary reflex.
• Normal response to accommodation.
• Failure of pupillary dilation with painful stimulation or after atropine administration.
• ADIE'S PUPIL: Similar to Argyll Robertson Pupil.
• Weak or absent direct pupillary reflex.
• Impaired or absent accommodation.
• Eye appears larger than the other eye on inspection.
• MYDRIASIS: Abnormal dilation of pupil, can occur in Diabetes.
• MIOSIS: Abnormal constriction of pupil, seen in Horner's syndrome.
• HORNER'S SYNDROME: Lost sympathetics from the Superior Cervical Plexus. Ptosis, Miosis, Anhydrosis.

NYSTAGMUS: Nystagmus is normal when looking in the periphery for extended times. All other nystagmus is abnormal.

• Causes: Labyrinthitis, MS, Wernicke-Korsakoff, Meniere's Disease

EXTRAOCULAR PALSIES:

• Internal Strabismus: Eye points in, due to denervation of the Abducens, CN VI.
• External Strabismus: Eye points out and down, due to denervation of the Oculomotor, CN III.
• Eye points out because of influence of Abducens (CN VI)
• Eye points down because of influence of Trochlear (CN IV) ------> Superior Oblique muscle.

VISUAL FIELD DEFICITS:

• BITEMPORAL HEMIANOPSIA: Loss of peripheral vision; tunnel vision, occurs with Pituitary Tumor.
• HOMONYMOUS HEMIANOPSIA: Loss of same visual field in both eyes. Occurs due to lesion in Optic Tract.
• QUADRANT HEMIANOPSIA: Lesion in the optic radiations.

FUNDUSCOPIC INSPECTION:

• RED REFLEX: Its absence indicates a cataract.
• VESSELS:
• The veins are normally slightly bigger than the arteries.
• ARTERIO-VENOUS (AV) NICKING: Hypertension narrows the arteries and creates indentations in the veins, where arteries cross the veins.
• MACULA: Dimmer, darker area in fundoscope, containing the fovea.
• OPTIC DISC: Out of which vessels travel. The brightest area of fundoscope.
• RETINOPATHOLOGIES:
• DIABETIC RETINOPATHY: Shows hard exudates on the retina, which are lipid laden. They are dense, well-defined creamy white spots.
• Cotton Wool Exudates are poorer defined and can occur with hypertension.
• PAPILLEDEMA: Swelling of retinal vessels, from impaired venous return in the eye ------> venous distension.
• Papilledema is caused by increased intracranial pressure.
• Causes: Brain tumors, malignant hypertension, hydrocephalus.
• As opposed to Pappilitis, there is no loss of vision.
• HYPERTENSION: Changes in retina are graded 1 thru 4. An abnormally high V/A ratio can be found, indicating venous distension.
• Stage I: Arteriolar narrowing but no AV-nicking.
• Stage II: Focal spasm, AV-nicking.
• Stage III: Hemorrhages and exudates
• Stage IV: Papilledema, Optic disc edema (due to ischemia) and hemorrhage, which can lead to retinal detachment.

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TINNITUS: Ringing in ear.

VERTIGO:

• Objective Vertigo: The earth is moving around you.
• Subjective Vertigo: You are moving in space.

RINNE TEST: Test for conductive hearing loss by comparing air conduction to bone conduction.

• First hold tuning fork right near auricle, then place it over the Mastoid Process.
• NORMAL: It should sound louder near the auricle, because air conduction should be better than straight bone conduction.
• ABNORMAL: If it sounds louder over the mastoid process instead, that indicates a conductive hearing loss in the middle ear.

WEBER TEST: Place tuning fork over head. It should be heard equally in both ears.

• ONE EAR IS LOUDER: If one ear is louder, than there is either conductive hearing loss in that ear or sensorineural hearing loss in the other ear.

MENIERE'S DISEASE: Triad of tinnitus, vertigo, and sensorineural hearing loss. May see nausea, vomiting, nystagmus.

BENIGN POSITIONAL VERTIGO: Transient attacks of vertigo, induced by movements of the head and trunk. Symptoms can be induced by having the patient merely think about the movements.

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NOSE:

• EPISTAXIS: Bloody nose.
• Transient Epistaxis: May occur with forceful nose-blowing, sneezing, nose-picking, facial trauma.
• Recurrent Epistaxis: Differential diagnosis = hypertension, coagulopathies, renal failure, cirrhosis, hereditary hemorrhagic telangiectasia.
• RHINOPHYMA: Severe acne rosacea found in association with skin hypertrophy and congestion of subcutaneous tissue, around the nose.

THROAT:

• SOAR THROAT: Infection mononucleosis, strep-throat (streptococcal pharyngitis).
• HOARSENESS: Larynigitis, Laryngeal cancer, hypothyroidism, smoking ------> broncho-genic carcinoma.

ABNORMAL TASTE:

• Hypoguesia: Impaired ability to taste. Seen in URI's, glossitis, stomatitis.
• Dysguesia: Unpleasant taste. Differential diagnosis:
• Medications: metronidazole
• Vitamin and mineral deficiencies: zinc depletion
• Chyronic hypercalcemia, hyperparathyroidism.
• Viral hepatitis

TONGUE:

• MACROGLOSSIA: Large tongue can occur with amyloidosis and acromegaly.
• GLOSSITIS: Inflammation on sides, base, and underside of tongue.
• Vitamin and mineral deficincies
• Medications: metronidazole, phenytoin
• Infections: candidiasis
• Pernicious Anemia
• Cytotoxic drugs, radiotherapy.

MOUTH EXAMINATION:

• ORAL ULCERS: Recurrent oral ulcers differential diagnosis:
• Recurrent aphthous ulcers (canker soars): Common, frequently associated with Inflammatory Bowel Disease.
• Infections: HSV-1, Herpes Zoster, tuberculosis, histoplasmosis, syphillis.
• Trauma
• Cytotoxic drugs
• Rare: Erythema Multiforme, Wegener's Granulomatosis, Stevens-Johnson Syndrome, Reiter's Syndrome
• SYNDROMES:
• PEUTZ-JEGHER'S SYNDROME: Melanin spots on lips are found.
• OLIVER-WEBER-RENDU SYNDROME: Telangiectasia, vascular lesion formed by dilation of small group of blood vessels.
• KOPLIK'S SPOTS: White spots on the buccal mucosa, indicative of the measles.
• STRAWBERRY TONGUE: Erythema of tongue, occurs with scarlet fever.

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