Exam 2 Study Guide
Chapter 11 (Head and Neck)
Cervical lymph nodes p.343-345
You can usually examine both sides at once, noting both the presence of lymph nodes as well as
asymmetry. For the submental nodes, however, it is helpful to feel with one hand while bracing the top of
the head with the other.
1. Submental—palpate in the midline a few centimeters behind the tip of the mandible.
2. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually
smaller and smoother than the lobulated submandibular gland against which they lie.
3. Preauricular—palpate in front of the ear.
4. Posterior auricular—palpate behind the ear and superficial to the mastoid process.
5. Tonsillar (jugulodigastric)—palpate at the angle of the mandible.
6. Occipital—palpate at the base of the skull posteriorly.
7. Anterior superficial cervical—palpate for these nodes anterior and superficial to the SCM muscle.
8. Posterior cervical—palpate along the anterior edge of the trapezius by flexing the patient’s neck
slightly forward toward the side being examined.
9. Deep cervical chain—deep in the SCM muscle and often inaccessible to examination. Hook your
thumb and fingers around either side of the SCM muscle to find them.
10. Supraclavicular—palpate deep in the angle formed by the clavicle and the SCM muscle
-A small hard tender “tonsillar node” high and deep between the mandible and the SCM is probably an
elongated temporal styloid process.
- Enlargement of a supraclavicular node, especialy on the left (Virchow’s node), suggests possible
metastasis from a thoracic or an abdominal malignancy.
-Tender nodes suggest inflammation; hard or fixed nodes (fixed to underlying structures and not movable
on palpation) suggest malignancy.
-Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such
as HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.
Thyroid gland p.346-347
-Inspection. Inspect the neck for the thyroid gland. Tip the patient’s head slightly back. Using tangential
lighting directed downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage
to identify the contours of the gland.
-Observe the patient swallowing. Ask the patient to sip some water and to extend the neck again and
swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetry. The thyroid
cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then fall to their resting
positions.
-Palpate the thyroid gland. Find your landmarks—the notched thyroid cartilage and the cricoid cartilage
below it. Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings;
Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate
laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed SCM
muscle.
-Retrosternal goiters can cause hoarseness, shortness of breath, stridor, or dysphagia from tracheal
compression; neck hyperextension and arm elevation may cause flushing from compression of the
thoracic inlet from the gland itself or from clavicular movement (Pemberton sign). More than 85% of
goiters are benign.
- The thyroid is soft in Graves disease and may be nodular; it is firm in Hashimoto thyroiditis (though not
always uniformly) and malignancy.
1
,- The thyroid is tender in thyroiditis
- A localized systolic or continuous bruit may be heard in hyperthyroidism from Graves disease or toxic
multinodular goiter.
- For palpable solitary nodules, ultrasound and possible fine needle aspiration are advised. Ultrasound
usualy reveals multiple additional nonpalpable nodules; only 5% of nodules are malignant.
Chapter 12 (Eyes)
Vision changes p.362-363; Begin with open-ended questions such as “Have you had any trouble with
your eyes?”
- Is vision worse during close work or at distances? Difficulty with close work suggests hyperopia
(farsightedness) or presbyopia (aging vision), and, difficulty with distance vision, suggest myopia
(nearsightedness).
- Is there blurred vision? If yes, is the onset sudden or gradual? If sudden and unilateral, is the visual loss
painless or painful? Is it associated with headache?
- If sudden visual loss is unilateral and painless, consider vitreous hemorrhage from diabetes or trauma,
macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.
- If painful, causes are usualy in the cornea and anterior chamber such as corneal ulcer, uveitis, traumatic
hyphema, and acute angle closure glaucoma. Optic neuritis from multiple sclerosis may also be painful.
Immediate referral is warranted. If associated with headache, a thorough neurologic examination is
warranted.
- Is the visual loss unilateral? If so, is it painful or painless? If it is associated with headache, jaw pain or
claudication, it may be associated with giant-cel arteritis. If painless, it may be associated with a vascular
occlusion, retinal detachment, or hemorrhage.
- Is the visual loss bilateral? (Sudden bilateral visual loss is rare.) If so, is it painful? If bilateral and
painless, consider vascular etiologies, stroke, or non-physiologic causes. If bilateral and painful, consider
intoxication, trauma, chemical or radiation exposures.
- Is the onset of bilateral visual loss gradual? Gradual vision loss usualy arises from cataracts, glaucoma,
or macular degeneration.
- Location of visual loss may also be helpful. Is there blurring of the entire field of vision or only parts of it?
Slow central loss may occur with nuclear cataract (p. 387) and macular degeneration (p. 377). Peripheral
loss can be seen in advanced open-angle glaucoma (p. 381) with unilateral loss with hemianopsia and
quadrantic defects (p. 384). Though they may be asymmetric, these conditions are often bilateral disease
processes.
- If the visual field defect is partial, is it central, peripheral, or on only one side?
- Is the visual field defect bilateral?
- Are there any patterns that we can help localize the lesion? Are there specks in the vision or areas
where the patient cannot see (scotomas)? If so, do they move around in the visual field with shifts in gaze
or are they fixed?
- Moving specks or strands suggest vitreous floaters; fixed defects, or scotomas, suggest lesions in the
retina, visual pathway, or brain.
- Are there lights flashing across the field of vision?
- Vitreous floaters may accompany this symptom.
- Flashing lights with new vitreous floaters suggest traction on the retina with detachment of the vitreous
body from the retina. Prompt consultation is indicated to rule out retinal tears or detachments.
- Does the patient wear glasses? Contact lenses? Has the patient undergone refractive surgery?
Visual acuity p.365-366
- Test the acuity of central vision by using a Snellen eye chart in a well-lit area, if possible. Position the
patient 20 ft from the chart. Patients who wear glasses other than for reading should put them on. Ask the
2
,patient to cover one eye with a card (to prevent looking through the fingers) and to read the smallest line
of print possible. Coaxing to attempt the next line may improve performance.
- A patient who cannot read the largest letter can be positioned closer to the chart; note the intervening
distance. Identify the smallest line of print where the patient can identify more than half the letters.
- For patients who cannot identify the English alphabet, there are other options to test vision. Tumbling
“E’s” can be used, in which the patient points to the direction of the open face of the letter “E.” Allen cards
display standardized pictures that can be recognized by children over the age of 2 years.
- Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of the patient
from the chart, and the second, the distance at which a normal eye can read the line of letters.
- The larger the second number, the worse the vision.
- Myopia (nearsightedness) causes focusing problems for distance vision, whereas hyperopia
(farsightedness) describes eyesight that is blurry on objects nearby. Astigmatism is an imperfection of the
cornea or lens causing distortion while looking at near and far objects.
- Presbyopia causes focusing problems for near vision, found in middle-aged and older adults. A person
with presbyopia often sees better when the card is farther away.
- In the United States, a person is usualy considered legaly blind when vision in the better eye, corrected
by glasses, is 20/200 or less. Legal blindness also results from a constricted field of vision, which is 20
degrees or less in the better eye.
Cornea and lens p.369 Table 12-5
With oblique lighting, inspect the cornea of each eye for opacities. Note any opacities in the lens that
may be visible through the pupil.
- Corneal Arcus. A thin grayish-white arc or circle not quite at the edge of the cornea. Accompanies
normal aging but also seen in younger adults, especialy African Americans. In young adults, suggests
possible hyperlipoproteinemia. Usualy benign.
- Corneal Scar. A superficial grayish-white opacity in the cornea, secondary to an old injury or to
inflammation. Size and shape are variable. Do not confuse with the opaque lens of a cataract, visible on a
deeper plane and only through the pupil.
- Cataracts. Opacity of the lenses visible through the pupil. Risk factors are older age, smoking, diabetes,
corticosteroid use.
- Nuclear Cataract. A nuclear cataract looks gray when seen by a flashlight. If the pupil is widely dilated,
the gray opacity is surrounded by a black rim.
- Kayser–Fleischer Ring. A golden to red brown ring, sometimes shading to green or blue, from copper
deposition in the periphery of the cornea found in Wilson disease. Due to a rare autosomal recessive
mutation of the ATO7B gene on chromosome 13 causing abnormal copper transport, reduced biliary
copper excretion, and abnormal accumulation of copper in the liver and tissues throughout the body.
Patients present with liver disease, renal failure, and neurologic symptoms of tremor, dystonia, and a
variety of psychiatric disorders.
- Pterygium. A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface
of the cornea, usualy from the nasal side. Reddening and irritation may occur. May interfere with vision as
it encroaches on the pupil.
- Peripheral Cataract. Produces spoke-like shadows that point—gray against black, as seen with a
flashlight, or black against red with an ophthalmoscope. A dilated pupil, as shown here, facilitates this
observation.
Near reaction p.359 p.371
- Near Reaction. When a person shifts gaze from a far object to a near object, the pupils constrict; like
the light reaction, is mediated by the oculomotor nerve (CN III). Coincident with this pupillary constriction,
but not part of it, are (1) convergence of the eyes, a bilateral medial rectus movement; and (2)
3
, accommodation, an increased convexity of the lenses caused by contraction of the ciliary muscles; In
accommodation, the change in shape of the lenses brings near objects into focus; physically, this takes
place behind the iris and is not visible to the examiner.
- Hold your finger or pencil about 10 cm from the patient’s eye. Test one eye at a time.
- Ask the patient to look alternately at it and into the distance directly behind it. Watch for pupillary
constriction with near effort and convergence of the eyes. The third component of the near reaction,
accommodation of the lens that brings the near object into focus, is not visible.
- Testing the near reaction is helpful in diagnosing Argyll Robertson, tonic (Adie) pupils, and other
neurologic syndromes.
Chapter 13 (Ears and Nose)
Peripheral vertigo Table 13-1
Conductive vs sensorineural hearing loss: Weber and Rinne test p.407-408
- Note that older adults with presbycusis (sensorineural hearing loss related to age-appropriate
changes in the auditory system) have higher frequency hearing loss, making them more likely to
miss sibilant consonants (producing the sound of or a sound resembling that of the s or the sh),
which have higher frequency sounds than vowels. The hearing loss is typicaly gradual,
progressive, and bilateral.
- Note also that tuning fork tests do not distinguish normal hearing from bilateral sensorineural loss
or from mixed conductive sensorineural loss. Sensitivity of the Weber test is about 55%;
specificity for sensorineural loss is about 79%, and for conductive loss, 92%. Sensitivity and
specificity of the Rinne test are 60% to 90% and 95% to 98%.
- Test for lateralization (Weber test). Set the fork into light vibration by briskly stroking the prongs
(the “U”) between the thumb and index finger or by tapping the prongs on your forearm just in
front of your elbow. Place the base of the lightly vibrating tuning fork firmly on top of the patient’s
head or on the midforehead. Ask where the patient hears the sound best: “On one side or both
sides?” Normally, the vibration is heard in the midline or equally in both ears. If nothing is heard,
4
Chapter 11 (Head and Neck)
Cervical lymph nodes p.343-345
You can usually examine both sides at once, noting both the presence of lymph nodes as well as
asymmetry. For the submental nodes, however, it is helpful to feel with one hand while bracing the top of
the head with the other.
1. Submental—palpate in the midline a few centimeters behind the tip of the mandible.
2. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually
smaller and smoother than the lobulated submandibular gland against which they lie.
3. Preauricular—palpate in front of the ear.
4. Posterior auricular—palpate behind the ear and superficial to the mastoid process.
5. Tonsillar (jugulodigastric)—palpate at the angle of the mandible.
6. Occipital—palpate at the base of the skull posteriorly.
7. Anterior superficial cervical—palpate for these nodes anterior and superficial to the SCM muscle.
8. Posterior cervical—palpate along the anterior edge of the trapezius by flexing the patient’s neck
slightly forward toward the side being examined.
9. Deep cervical chain—deep in the SCM muscle and often inaccessible to examination. Hook your
thumb and fingers around either side of the SCM muscle to find them.
10. Supraclavicular—palpate deep in the angle formed by the clavicle and the SCM muscle
-A small hard tender “tonsillar node” high and deep between the mandible and the SCM is probably an
elongated temporal styloid process.
- Enlargement of a supraclavicular node, especialy on the left (Virchow’s node), suggests possible
metastasis from a thoracic or an abdominal malignancy.
-Tender nodes suggest inflammation; hard or fixed nodes (fixed to underlying structures and not movable
on palpation) suggest malignancy.
-Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such
as HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.
Thyroid gland p.346-347
-Inspection. Inspect the neck for the thyroid gland. Tip the patient’s head slightly back. Using tangential
lighting directed downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage
to identify the contours of the gland.
-Observe the patient swallowing. Ask the patient to sip some water and to extend the neck again and
swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetry. The thyroid
cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then fall to their resting
positions.
-Palpate the thyroid gland. Find your landmarks—the notched thyroid cartilage and the cricoid cartilage
below it. Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings;
Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate
laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed SCM
muscle.
-Retrosternal goiters can cause hoarseness, shortness of breath, stridor, or dysphagia from tracheal
compression; neck hyperextension and arm elevation may cause flushing from compression of the
thoracic inlet from the gland itself or from clavicular movement (Pemberton sign). More than 85% of
goiters are benign.
- The thyroid is soft in Graves disease and may be nodular; it is firm in Hashimoto thyroiditis (though not
always uniformly) and malignancy.
1
,- The thyroid is tender in thyroiditis
- A localized systolic or continuous bruit may be heard in hyperthyroidism from Graves disease or toxic
multinodular goiter.
- For palpable solitary nodules, ultrasound and possible fine needle aspiration are advised. Ultrasound
usualy reveals multiple additional nonpalpable nodules; only 5% of nodules are malignant.
Chapter 12 (Eyes)
Vision changes p.362-363; Begin with open-ended questions such as “Have you had any trouble with
your eyes?”
- Is vision worse during close work or at distances? Difficulty with close work suggests hyperopia
(farsightedness) or presbyopia (aging vision), and, difficulty with distance vision, suggest myopia
(nearsightedness).
- Is there blurred vision? If yes, is the onset sudden or gradual? If sudden and unilateral, is the visual loss
painless or painful? Is it associated with headache?
- If sudden visual loss is unilateral and painless, consider vitreous hemorrhage from diabetes or trauma,
macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.
- If painful, causes are usualy in the cornea and anterior chamber such as corneal ulcer, uveitis, traumatic
hyphema, and acute angle closure glaucoma. Optic neuritis from multiple sclerosis may also be painful.
Immediate referral is warranted. If associated with headache, a thorough neurologic examination is
warranted.
- Is the visual loss unilateral? If so, is it painful or painless? If it is associated with headache, jaw pain or
claudication, it may be associated with giant-cel arteritis. If painless, it may be associated with a vascular
occlusion, retinal detachment, or hemorrhage.
- Is the visual loss bilateral? (Sudden bilateral visual loss is rare.) If so, is it painful? If bilateral and
painless, consider vascular etiologies, stroke, or non-physiologic causes. If bilateral and painful, consider
intoxication, trauma, chemical or radiation exposures.
- Is the onset of bilateral visual loss gradual? Gradual vision loss usualy arises from cataracts, glaucoma,
or macular degeneration.
- Location of visual loss may also be helpful. Is there blurring of the entire field of vision or only parts of it?
Slow central loss may occur with nuclear cataract (p. 387) and macular degeneration (p. 377). Peripheral
loss can be seen in advanced open-angle glaucoma (p. 381) with unilateral loss with hemianopsia and
quadrantic defects (p. 384). Though they may be asymmetric, these conditions are often bilateral disease
processes.
- If the visual field defect is partial, is it central, peripheral, or on only one side?
- Is the visual field defect bilateral?
- Are there any patterns that we can help localize the lesion? Are there specks in the vision or areas
where the patient cannot see (scotomas)? If so, do they move around in the visual field with shifts in gaze
or are they fixed?
- Moving specks or strands suggest vitreous floaters; fixed defects, or scotomas, suggest lesions in the
retina, visual pathway, or brain.
- Are there lights flashing across the field of vision?
- Vitreous floaters may accompany this symptom.
- Flashing lights with new vitreous floaters suggest traction on the retina with detachment of the vitreous
body from the retina. Prompt consultation is indicated to rule out retinal tears or detachments.
- Does the patient wear glasses? Contact lenses? Has the patient undergone refractive surgery?
Visual acuity p.365-366
- Test the acuity of central vision by using a Snellen eye chart in a well-lit area, if possible. Position the
patient 20 ft from the chart. Patients who wear glasses other than for reading should put them on. Ask the
2
,patient to cover one eye with a card (to prevent looking through the fingers) and to read the smallest line
of print possible. Coaxing to attempt the next line may improve performance.
- A patient who cannot read the largest letter can be positioned closer to the chart; note the intervening
distance. Identify the smallest line of print where the patient can identify more than half the letters.
- For patients who cannot identify the English alphabet, there are other options to test vision. Tumbling
“E’s” can be used, in which the patient points to the direction of the open face of the letter “E.” Allen cards
display standardized pictures that can be recognized by children over the age of 2 years.
- Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of the patient
from the chart, and the second, the distance at which a normal eye can read the line of letters.
- The larger the second number, the worse the vision.
- Myopia (nearsightedness) causes focusing problems for distance vision, whereas hyperopia
(farsightedness) describes eyesight that is blurry on objects nearby. Astigmatism is an imperfection of the
cornea or lens causing distortion while looking at near and far objects.
- Presbyopia causes focusing problems for near vision, found in middle-aged and older adults. A person
with presbyopia often sees better when the card is farther away.
- In the United States, a person is usualy considered legaly blind when vision in the better eye, corrected
by glasses, is 20/200 or less. Legal blindness also results from a constricted field of vision, which is 20
degrees or less in the better eye.
Cornea and lens p.369 Table 12-5
With oblique lighting, inspect the cornea of each eye for opacities. Note any opacities in the lens that
may be visible through the pupil.
- Corneal Arcus. A thin grayish-white arc or circle not quite at the edge of the cornea. Accompanies
normal aging but also seen in younger adults, especialy African Americans. In young adults, suggests
possible hyperlipoproteinemia. Usualy benign.
- Corneal Scar. A superficial grayish-white opacity in the cornea, secondary to an old injury or to
inflammation. Size and shape are variable. Do not confuse with the opaque lens of a cataract, visible on a
deeper plane and only through the pupil.
- Cataracts. Opacity of the lenses visible through the pupil. Risk factors are older age, smoking, diabetes,
corticosteroid use.
- Nuclear Cataract. A nuclear cataract looks gray when seen by a flashlight. If the pupil is widely dilated,
the gray opacity is surrounded by a black rim.
- Kayser–Fleischer Ring. A golden to red brown ring, sometimes shading to green or blue, from copper
deposition in the periphery of the cornea found in Wilson disease. Due to a rare autosomal recessive
mutation of the ATO7B gene on chromosome 13 causing abnormal copper transport, reduced biliary
copper excretion, and abnormal accumulation of copper in the liver and tissues throughout the body.
Patients present with liver disease, renal failure, and neurologic symptoms of tremor, dystonia, and a
variety of psychiatric disorders.
- Pterygium. A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface
of the cornea, usualy from the nasal side. Reddening and irritation may occur. May interfere with vision as
it encroaches on the pupil.
- Peripheral Cataract. Produces spoke-like shadows that point—gray against black, as seen with a
flashlight, or black against red with an ophthalmoscope. A dilated pupil, as shown here, facilitates this
observation.
Near reaction p.359 p.371
- Near Reaction. When a person shifts gaze from a far object to a near object, the pupils constrict; like
the light reaction, is mediated by the oculomotor nerve (CN III). Coincident with this pupillary constriction,
but not part of it, are (1) convergence of the eyes, a bilateral medial rectus movement; and (2)
3
, accommodation, an increased convexity of the lenses caused by contraction of the ciliary muscles; In
accommodation, the change in shape of the lenses brings near objects into focus; physically, this takes
place behind the iris and is not visible to the examiner.
- Hold your finger or pencil about 10 cm from the patient’s eye. Test one eye at a time.
- Ask the patient to look alternately at it and into the distance directly behind it. Watch for pupillary
constriction with near effort and convergence of the eyes. The third component of the near reaction,
accommodation of the lens that brings the near object into focus, is not visible.
- Testing the near reaction is helpful in diagnosing Argyll Robertson, tonic (Adie) pupils, and other
neurologic syndromes.
Chapter 13 (Ears and Nose)
Peripheral vertigo Table 13-1
Conductive vs sensorineural hearing loss: Weber and Rinne test p.407-408
- Note that older adults with presbycusis (sensorineural hearing loss related to age-appropriate
changes in the auditory system) have higher frequency hearing loss, making them more likely to
miss sibilant consonants (producing the sound of or a sound resembling that of the s or the sh),
which have higher frequency sounds than vowels. The hearing loss is typicaly gradual,
progressive, and bilateral.
- Note also that tuning fork tests do not distinguish normal hearing from bilateral sensorineural loss
or from mixed conductive sensorineural loss. Sensitivity of the Weber test is about 55%;
specificity for sensorineural loss is about 79%, and for conductive loss, 92%. Sensitivity and
specificity of the Rinne test are 60% to 90% and 95% to 98%.
- Test for lateralization (Weber test). Set the fork into light vibration by briskly stroking the prongs
(the “U”) between the thumb and index finger or by tapping the prongs on your forearm just in
front of your elbow. Place the base of the lightly vibrating tuning fork firmly on top of the patient’s
head or on the midforehead. Ask where the patient hears the sound best: “On one side or both
sides?” Normally, the vibration is heard in the midline or equally in both ears. If nothing is heard,
4
