Head

Diseases Description Examples of abnomalities

Headache One of the most common
symptoms in clinical practice, with
a lifetime prevalence of 30% in the
general population
Three most important attributes of
headache
> severity
> chronologic pattern >associated
symptoms
overuse of analgesics,
ergotamines, or triptans mya
cause headache
Types:
*Tension headache-often arise in the temporal areas, predominant,
episodic and tend to peak over several hours.
*Thunderclap headaches reaching maximal intensity over several
minutes occur in 70% of patients with subarachnoid hemorrhage
*Unilateral headache- occurs in migraine and cluster headaches,
cluster headaches may be retro-orbital.
Classified as:
-primary-without an identified underlying disease
e.g. migraine, tension, cluster, and chronic daily headaches
-secondary-with an identified underlying disease
e.g. meningitis, subarachnoid hemorrhage (severe and of sudden
onset) mass lesion, tumor, or abscess.

Note: Nausea and vomiting are common with migraine, but also
occur with brain tumors and subarachnoid hemorrhage.

Valsava maneuvers
>leaning forward-sinusitis
>lying down-mass lesion

Women aging 35yrs+ avoid use of estrogen–progestin contracepives

Migraine -unilateral
-primary
-nausea & vomiting
-60%-70% have a symptom
prodome prior to onset
-experience visual aura:
>spark photopsis (flashes of light)
>fortifications (zig-zag arcs of light)
 > scotomas (areas of visual loss
with surrounding normal vision).
-Genetic inheritance is present in
30% to 50% of patients with
migraine.
Eyes
Hyperopia -Difficulty with close work,
farsightedness
presbyopia (aging vision)
myopia with distances, nearsightedness
vitreous hemorrhage sudden visual loss is unilateral If PAINLESS
-diabetes/ trauma
-macular degeneration
-retinal detachment
-retinal occlusion
-central retinal artery occlusion

If PAINFUL:
-affects cornea, anterior chamber
-corneal ulcer, uveitis, traumatic hyphema, and acute angle closure
glaucoma

If bilateral If PAINLESS
-consider vascular etiologies such as giant-cell arteritis or
nonphysiologic causes.

If PAINFUL
-consider chemical or radiation exposures.

Optic neuritis from multiple sclerosis

cataracts or macular degeneration -Gradual vision loss
-Slow central loss
advanced open-angle glaucoma -peripheral loss
hemianopsia and quadrantic -one-sided loss
defects
fixed defects, or scotomas -suggest lesions in the retina or Note: Moving specks are vitrous floaters
visual pathways.

detachment of the vitreous body - Flashing lights with new vitreous -Prompt consultation is indicated
from the retina floaters

subconjunctival hemorrhage -red painless eye

viral conjunctivitis - red eye with a gritty sensation
hyphema, episcleritis, acute angle - red painful eye
closure glaucoma, herpes keratitis,
foreign body, fungal keratitis, and
sarcoid uveitis.
Diplopia lesions in the brainstem or -horizontal diplopia: palsy of CN III or VI
cerebellum -vertical diplopia: palsy of CN III or IV
-weakness or paralysis of one or
more extraocular muscles. Note: Diplopia in one eye, with the other closed, suggests a problem
in the cornea or lens.
Ears
sensorineural loss -have trouble understanding Medications that affect hearing:
speech -aminoglycosides, aspirin, NSAIDs, quinine, and furosemide.
-often complaining that others
mumble
conductive loss -noisy envi- ronments may help
otitis externa -Pain occurs in the external canal Note: Acute otitis externa and acute or chronic otitis media with
-inflammation of the external ear perforation usually present with yellow-green discharge.
cana
otitis media infection of the middle ear
Tinnitus - is a perceived sound that has no -When associated with hearing loss and vertigo, suspect Ménière
external stimulus disease
 -is a common symptom, increasing - popping sounds originate in the temporomandibular joint
in frequency with age.

Vertigo -is the sensation of true rotational benign positional vertigo, labyrinthitis, vestibular neuri- tis, and
movement of the patient or the Ménière disease.
surroundings.
-room is spinning and tilting
-represents vestibular disease,
usually from peripheral causes in
the inner ear
Presyncope -Feel as if falling or pass out Symptoms similar to:
-Feeling light- headed, weak in the arrhythmia, orthostatic hypotension, or vasovagal stimulation.
legs, or about to faint points t
Disequilibrium -unsteady or losing balance
Ataxia, diplopia, and dysarthria -signal central neurologic causes in
the cerebellum or brainstem such
as cerebral vascular disease or
posterior fossa tumor
presbycusis -Aging is the most important risk risk factors
factor -congenital or familial hearing loss, syphilis, rubella, meningitis,
- degenerating hair cells in the ear diabetes, recurring inner ear infections, exposure to ototoxic agents,
lead to gradually progressive frequent use of headphones, and exposure to hazardous noise levels
hearing loss, particularly for high- at work, leisure, or on the battlefield.
frequency sounds.
Nose and Sinuses
Rhinorrhea -drainage from the nose
-nasal congestion, a sense of
stuffiness or obstruction.
-Causes include viral infections,
allergic rhinitis (“hay fever”), and
vasomotor rhinitis. Itching favors
an allergic cause.
allergic rhinitis. -Seasonal onset or environmental Noe: Drug-induced rhinitis occurs in excessive use of topical
triggers decongestants, or use of cocaine.

Acute bacterial
sinusitis/rhinosinusitis
viral rhinitis
deviated nasal septum, nasal
polyp, foreign body, Wegener
granuloma, or carcinoma.
Epistaxis
-may be pale, bluish, or red
is unlikely until viral URI symptoms
persist more than 7 days; both
purulent drainage and facial pain
should be present for diagnosis
(sensitivity and specificity are
above 50%)
mucosa is reddened and swollen
nasal congestion only on one side
is bleeding from the nasal Local causes of epistaxis include trauma (especially nose-picking),
passages. Bleeding can also inflammation, drying and crusting of the nasal mucosa, tumors, and
originate in the paranasal sinuses foreign bodies.
or nasopharynx.
Types:
Hemoptysi-coughing blood
Hematemesi-vomited blood

Anticoagulants, NSAIDs, vascular malformations, and coagulopathies

Mouth, Throat, and Neck
- Tobacco and alcohol account for about 75% of oral cavity cancers
Sore throat or pharyngitis is a frequent complaint, usually
associated with an acute URI.
However, sometimes a sore throat
is the only symptom.
sore tongue may result from local lesions as
well as from systemic illness
gingivitis bleeding gums
Hoarseness -change in voice quality, rough,
harsh, or lower pitched than usual.
can contribute to epistaxis.
Diagnosis for streptococcal and Fusobacterium necrophorum
pharyngitis:
fever history, tonsillar exudates, swollen tender anterior cervical
adenopathy, and absence of cough
aphthous ulcers and sore smooth tongue of nutritional deficiency
Acute:
-consider voice overuse
-acute viral laryngitis
 -neck trauma.

If hoarseness lasts over 2 weeks, refer for laryngoscopy and consider

causes such:
-hypothyroidism
-reflux, vocal cord nodules

head and neck cancers:

-thyroid masses
-neurologic disorders
-Parkinson disease
-amyotrophic lateral sclerosis
-myasthenia gravis.
periodontal disease bleeding, pus, recession of the Risk factors:
gums, and bad breath. low income, male gender, smoking, diabetes, and poor oral hygiene

note: Inspect the mucous membranes, the palate, the oral floor, and
the surfaces of the tongue for ulcers and leukoplakia, warning signs
for oral cancer and HIV disease
pharyngitis Accompaied by Enlarged tender
lymph nodes
goiter thyroid function may be increased,
decreased, or normal
hypothyroidism Intolerance to cold, weight gain,
dry skin, and slowed heart rate
point
hyperthyroidism intolerance to heat, weight loss,
moist velvety skin, and palpitations
point
Eyes
cataracts clouding of the lens
macular degeneration mottling of the macula, variations
in retinal pigmentation, subretinal
hemorrhage or exudates
glaucoma change in color and size of the
optic disc
Primary open-angle glaucoma -gradual loss of vision in the
(POAG) peripheral visual fields, resulting
from loss of retinal ganglion cell
axons

- pal- lor and increasing size of the

optic cup
Head
hyperthyroidism Fine hair
hypothyroidism coarse hair
seborrheic dermatitis or psoriasis Presence of redness and scaling
pilar cysts Soft lumps
melanoma Pigmented melanoma
hydrocephalus or Paget disease of Enlarged skull
bone.
Hirsutism (excessive facial hair) polycystic ovary syndrome
Eyes
Anatomy and Physiology
palpebral fissure The opening between the eyelids
conjunctiva clear mucous membrane with two
easily visible components
bulbar conjunctiva covers most of the anterior The two parts of the conjunctiva merge in a folded recess that
eyeball, adhering loosely to the permits movement of the eyeball.
underlying tissue.
palpebral conjunctiva lines the eyelids
levator palpebrae the muscle that raises the upper
eyelid, is innervated by the
oculomotor nerve, CN III
tarsal plates firm strips of connective tissue
meibomian glands parallel row
Conjuctival glands tear fluid protects the conjunctiva
Lacrimal glands and cornea from drying, inhibits lies mostly within the bony orbit, superior and lateral to the eyeball
microbial growth, and gives a
smooth optical surface to the cor-
nea.
levator palpebrae the muscle that raises the upper
eyelid, is innervated by the
oculomotor nerve, CN II.I
lacrimal puncta two tiny holes where tear fluid The tears then pass into the lacrimal sac and on into the nose through
spreads across the eye and drains the nasolacrimal duct.
medially
aqueous humor -A clear liquid that fills the
anterior and posterior chambers of
the eye
-produced by the ciliary body
-drains out through the canal of
Schlemm.
optic fundus The posterior portion of the eye Structures here include: retina, choroid, fovea, macula, optic disc,
that is seen through the and retinal vessels.
ophthalmoscope
fovea darkened circular area
macula surrounds the fovea, but has no
discernible margins
vitreous body transparent mass of gelatinous
material that fills the eyeball
behind the lens and helps to
maintain the shape of the eye
visual field is the entire area seen by an eye
when it looks at a central point
Nerve impulses stimulated by light, are conducted
through the retina, optic nerve (CN
II)
optic radiation curving tract
Pupillary Reactions
Light Reaction
near reaction
Autonomic Stimulation
six cardinal directions
CN IV (trochlear nerve) damage
size changes in response to light
and to the effort of focusing on a
near object
Direct reaction: light beam shining retina, optic nerve (CN II), and optic tract, which diverges in the
onto one retina causes pupillary midbrain. Impulses back to the constrictor mus cles of the iris of each
constriction in both that eye eye are transmit- ted through the oculomotor nerve, CNIII
Consensual reaction to light:
contralateral eye
-mediated by the oculomotor
nerve (CN III)
when a person shifts gaze from a convergence of the eyes- medial rectus movement
far object to a near object, the
pupils constrict accommodation- increased convexity of the lenses caused by
contraction of the ciliary muscles.
-mediated by the oculomotor
nerve (CN III)
Parasympathetics: Pupillary
constriction
Sympathetics: Pupillary dilation
and raising of upper eyelid
(superior tarsal muscle)
(CN III)- right inferior rectus, down
and right, prinicipally responsible
for moving the right eye
(CN IV)- superior oblique,
prinicipally respo for movig the left
eye
due to:
head trauma

Presbyopia
glaucoma, optic neuropathy, optic
neuritis, and glioma
stroke and chiasmal tumors
left homonymous hemianopsia
glaucoma, optic neuritis, and
papilledema
esotropia
exotropia
Graves disease or ocular tumors
seborrheic dermatitis
hypothyroidism
Down syndrome
blepharitis
conjunctival inflammation or
corneal irritation, or impaired
congenital causes
central lesions
causes dysfunction of the superior
oblique muscle
leads to:
diplopia (double vision)
causes focusing problems for near legally blind when vision in the better eye, corrected by glasses, is
vision, found in middle-aged and 20/200 or less.
older adults. A presbyopic person
often sees better when the card is Legal blindness also results from a constricted field of vision: 20° or
farther away. less in the better eye.
Causes of anterior pathway
defects
Posterior pathway defects
when the patient’s left eye
repeatedly does not see your fin-
gers until they have crossed the
line of gaze
An enlarged blind spot occurs in
con- ditions affecting the optic
nerve
inward deviation
outward deviation
abnormal protrusion
Scaliness
-lateral sparseness
-Convergence is poor
Upslanting palpebral fissures
Red inflamed lid margins
Excessive tearing may be from
increased production
drainage, caused by ectropion, and
nasolacrimal duct obstruction
Sjögren syndrome
Jaundice
nodular episcleritis
acute narrow-angle glaucoma
open-angle glaucoma
Miosis
mydriasis
Simple anisocoria
direct reaction
consensual reaction
near reaction
Sustained nystagmus within the
binocular field of gaze
lid lag of hyperthyroidism
proptosis
Dryness from impaired secretion
A yellow sclera
Local redness
-crescentic shadow present increases the risk for acute narrow-angle glaucoma a sudden increase
-very narrow angle with the in IOP when drainage of the aqueous humor is blocked
cornea
common form of glaucoma, the
normal spatial relation between
iris and cornea is preserved and
the iris is fully lit.
refers to constriction of the pupils
dilation Contraindications for mydriatic drops include
(1) head injury and coma, since continuing observations of pupillary
reactions are essential
(2) any suspicion of narrow-angle glaucoma.
difference in pupillary diameter of
0.4 mm or greater without a
known pathologic cause
pupillary constriction in the same
eye
pupillary constriction in the
opposite eye
helpful in diagnosing Argyll
Robertson and tonic (Adie) pupils
is seen in congeni- tal disorders,
labyrinthitis, cerebellar disorders,
and drug toxicity
a rim of sclera is visible above the
iris with downward gaze.
abnormal protrusion of the eye- Unilateral- consider an orbital tumor
balls in hyperthyroidism, leading to Retrobulbar- hemorrhage from trauma.
 a characteristic “stare” on frontal
gaze.
Absence of a red reflex -suggests an opacity of the lens
(cataract)
-the vitreous (or even an artificial
eye)
-detached retina
-in children, a retinoblastoma may
obscure this reflex.
hippus spasm of the pupil
refractive error light rays from a distance do not
focus on the retina.
myopia they focus anterior to the retina Retinal structures in a myopic eye look larger than normal
hyperopia posterior
chronic open-angle glaucoma Enlarged cup
high intracranial pressures (above -Loss of SVPs
190mmH2O -glaucoma and retinal vein
occlusion
diabetic and hypertensive irregular patches
retinopathy
Macular degeneration -cause of poor central vision in Types
older adults 1. dry atrophic (more common but less severe)
2. wet exudative
3. neovascular

Cellular debris, called drusen, may be hard and sharply defined, or

soft and confluent with altered pigmentation
Vitreous floaters are dark specks or strands seen
between the fundus and the lens
cataract -opacity in lens
-densities present in the lens
Ear
Anatomy and Physiology
external ear captures sound waves for External ear causes include ceru- men impaction, infection (otitis
transmission into the middle and externa), trauma, squamous cell carci- noma, and benign bony
inner ear growths such as exostoses or osteomas.

Comprises:
*Auricle-consists chiefly of
cartilage covered by skin and has a
firm elastic consistency.
>helix-prominet curved outer
ridge
>anti-helix- Parallel and anterior
to the helix is another curved
prominence
>lobule- Inferi orly is the fleshy
projection of the earlobe
>tragus- nodular protrusion that
points backward over the entrance
to the canal
*ear canal- curves inward and is
approximately 24 mm long.
Cartilage encases its outer two
thirds. Cerumen.
>tympanic membrane-or
eardrum, marking the medial limit
of the external ear
Middle Ear Ossicles: Above the short process lies a small portion of the eardrum called the
1. malleus pars flaccida. The remainder of the drum is the pars tensa.
2. incus
3. stapes- transform sound Middle ear disorders include otitis media, congen- ital conditions,
vibrations into mechanical cholesteatomas and otosclerosis, tumors, and perforation of the
waves for the inner ear tympanic membrane.
eustachian tube: connects the
middle ear to the nasopharynx.
Inner Ear
acute otitis externa (inflammation
of the ear canal)
otitis media
exostoses
acute otitis externa
chronic otitis externa
A serous effusion, a thickened
drum, or purulent otitis media
Presbycusis
unilateral conductive hearing loss
unilateral sensorineural hearing
loss
sensorineural hearing loss
conductive hearing loss
local infection such as a furuncle
1. cochlea Disorders of the inner ear cause sen- sorineural hearing loss from
2. semicircular canals congeni- tal and hereditary conditions, presbycusis, viral infections
3. distal end of the auditory such as rubella and cytomegalovirus, Ménière disease, noise
nerve (vestibulocochlear exposure, ototoxic drug exposure, and acoustic neuroma.
nerve) or CN VIII-
transmits nerve impulses
Movement of the auricle and
tragus (the “tug test”) is painful
Tenderness, not painful
Nontender nodular swellings
covered by normal skin deep in the
ear canals
the canal is often swollen,
narrowed, moist, pale, and tender.
It may be reddened.
skin of the canal is often
thickened, red, and itchy
decrease mobility If there is a perforation, there will be no mobility
Note: older adults with presbycusis have higher frequency hearing
loss, making them more likely to miss consonants, which have higher
fre- quency sounds than vowels
otosclerosis, otitis media,
perforation of the eardrum, and
cerumen
sound is heard in the good ear
sound is heard longer through air
sound is heard through bone as
long as or longer than it is through
air
Tenderness of the nasal tip,
particularly if there is a small
erythematous and swollen area.
Nasal polyps are pale saclike growths of seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus
inflamed tissue that can obstruct infections, and cystic fibrosis.
the air passage or sinuses
Malignant tumors of the nasal cavity
occur rarely, associated with exposure to tobacco or chronically
inhaled toxins.
acute bacterial rhonosinusitis Local tenderness, together with involving the frontal or maxillary sinuses
symptoms such as facial pain,
pres- sure or fullness, purulent
nasal dis- charge, nasal
obstructions, and smell disorder,
especially when present for >7
days
labial frenulum connects each lip
with the gingiva
Mouth
denture stomatitis (denture sore -Bright red edematous mucosa
mouth) underneath a denture
- ulcers or papillary granulation
tissue.
anemia central cyanosis or pallor
gingivitis - Redness of the gingiva
- black line might indicate lead
poisoning.
Torus palatinus is a startling but benign midline Asymmetric protrusion suggests a lesion of CN XII (tongue points
lump toward the side of the lesion).
squamous cell carcinomas on the Men aged >50 years, smokers, and
side or base of the tongue heavy users of chewing tobacco
and alcohol are at highest risk for
cancers of the tongue and oral
cavity
erythroplakia and leukoplakia Any persistent nod ule or ulcer,
red or white, is suspect, especially

CN X paralysis
Neck
Generalized lymphadenopathy
mediastinal mass, atelectasis,
or a large pneumothorax
Stridor
Retrosternal goiters
Graves disease
if indurated, with discolored
lesions
the soft palate fails to rise and the
uvula deviates to the opposite side
(points “away from the lesion”).
seen in multiple infectious,
inflammatory, or malignant
conditions such as HIV or AIDS,
infectious mononucleosis,
lymphoma, leukemia, and
sarcoidosis.
Masses in the neck may cause
tracheal deviation to one side
- is an ominous, high-pitched
musical sound from severe
subglottic or tracheal obstruction
that signals a respiratory
emergency
Causes: epiglottitis,foreign body,
goiter, and stenosis from
placement of an artifi- cial airway
can cause hoarseness, shortness of below the suprasternal notch, it is often not palpable
breath, stridor, or dysphagia from
tracheal compression; neck
hyperextension and arm eleva-
tion may cause flushing from com-
pression of the thoracic inlet from
the gland itself or from clavicular
movement (Pemberton sign)
The thyroid is soft and may be
nodular

Hashimoto thyroiditis
thyroiditis
Hyperthyroidism
& bruit may be heard
Toxic multinodular goiter
Jugular venous distention
Graves opthalmopathy
Marcus Gunn pupil
Primary Headaches
CLUSTER
- A localized systolic or continuous
bruit may be heard
Thyroid is firm
Tender thyroid
A localized systolic or continuous
hall- mark of heart failure
- Exophthalmos
-Diplopia and tearing, grittiness,
and pain from corneal exposure
- Eyelid retraction (91%)
- extraocular muscle dysfunction
(43%)
-ocular pain (30%)
-lacrimation (23%)
demonstrates an afferent pupillary
defec
TENSION MIGRAINE

Process unclear—possibly
hypothalamic then
trigeminoautonomic activation
Process:
Process unclear—possibly
heightened CNS pain sensitivity.
Involves pericranial muscle
tenderness; etiology also unclear
Neuronal dysfunction, possibly of brainstem origin, involving low
serotonin level, spreading cortical depression and trigeminovascular
activation; types: with aura, without aura, variants

Lifetime prevalance:
<1%, more common in men. Most common headache (40%); 10% of headaches; prevalence 18% of U.S. adults; affects ∼15% of
prevalence about 50% women, 6% of men

Location:
Unilateral, usually behind or Usually bilateral; may be Unilateral in ∼70%; bifrontal or global in ∼30%
around the eye or temple generalized or localized to the
back of the head and upper neck
or to the frontotemporal area

Quality and severity:

Sharp, continuous, intense; severe Steady; pressing or tightening; Throbbing or aching, pain, moderate to severe in intensity; preceded
in intensity nonthrobbing pain; mild to by an aura in up to 30%
moderate intensity

Abrupt; peaks within minutes
15 minutes to 3 hours
Episodic, clustered in time, with
several each day for 4–8 weeks
and then relief for 6–12 months
Unilateral autonomic symptoms:
lacrimation, rhinorrhea, miosis,
ptosis, eyelid edema, conjunctival
infection
During attack, sensitivity to alcohol
may increase
Timing
Onset: Gradual
Duration: 30 minutes to 7 days
Course: Episodic; may be chronic
Associated Symptoms:
Sometimes photophobia,
phonophobia; scalp tenderness;
nausea absent
Triggers/ Factors That Aggravate
or Provoke:
Sustained muscle tension, as in
driving or typing; stress; sleep
disturbances
Fairly rapid, reaching a peak in 1–2 hours
4–72 hours
Recurrent—usually monthly, but weekly in
∼10%; peak incidence early to mid- adolescence
Prodrome: nausea, vomiting, photophobia, phonophobia; aura in
30%; either visual (flickering, zig-zagging lines), or motor
(paresthesias of hand, arm, or face, or language dysfunction)
Alcohol, certain foods, or stress may provoke; also menses, high
altitude; aggravated by noise and bright light

Factors That Relieve:

Possibly massage, relaxation Quiet, dark room; sleep; sometimes transient relief from pressure on
the involved artery
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