Ophthalmology and Otolaryngology

You are seeing Tom, a 10 year old boy, in your outpatient clinic today for a sore throat. Take a focused history of his complaint and perform the relevant physical examination.

History

• Onset of sore throat
• Severity
• Alleviating factors
• Aggravating factors
• Change in voice
• Presence of fever
• Odynophagia
• Associated cough, sputum production
• Shortness of breath
• Neck tenderness and swelling
• Otalgia
• Recent upper respiratory illness
• Personal history of throat infections
• Infectious contacts
• Allergies to medication
• Vaccination history
• Development history

Physical Examination

Oropharynx

• Uses tongue depressor and light to examine oropharynx
• Comments on the presence of erythema and exudates in oropharynx
• Comments on other findings in the oropharynx e.g. enlarged tonsils, lesions, deviated uvula

Node Examination

• Palpates the lymph nodes of the head and neck
• Names the nodal regions which are being palpated
• Comments on the size, texture, mobility, and location of nodes that are identified
• Asks patient about tenderness during examination

Respiratory

• Auscultates in all lung fields
• Comments on findings

You are seeing Mr. Rodriguez, a 31 year old man, because he often feels dizzy. Take a focused history and perform the Dix-Hall Pike maneuver.

History

• Clarifies symptoms are descriptive of vertigo (‘the room spinning around’)
• Duration of dizziness
• Frequency
• Associated activity, especially head turning
• Other precipitants
• Aural fullness (none)
• Decreased hearing from one ear
• Tinnitus (none)
• Otalgia (none)
• Syncopal episodes
• Chest pain or shortness of breath
• Nausea or vomiting
• Vision changes
• Sensory deficits (none)
• Motor deficits (none)
• Trauma to either ear
• Previous episodes of otitis media
• Smoking and alcohol history
• Effect on daily activities

Dix-Hallpike Maneuver

• Explains procedure to patient, and what they might expect
• Asks patient to lie down and tilts head back and towards one side
• Repeats maneuver on opposite side
• Comments that they are looking for geotropic nystagmus towards affected ear
• Comments on reversal when leaning toward non-affected ear

You are seeing Mrs. Nguyen, a 52 year old woman, because she noticed a large swelling on her neck. Take a focused history and perform a focused head and neck examination.

History

• Clarifies location of mass (patient thinks it’s on the her right side of her neck)
• Onset of mass
• Progression in size
• Pain
• Dysphagia
• Odynophagia
• Change in voice
• Symptoms suggestive of hyperthyroidism
• Symptoms suggestive of hypothyroidism
• Systemic symptoms – weight loss, night sweats, anorexia
• Infectious symptoms – nausea/vomiting, fever, diarrhea
• Past medical history
• Personal history of malignancy
• Exposure to head and neck irradiation
• Exposure to tobacco, smoking, alcohol, and betel nuts
• Asks patient about ethnic origin (South East Asia)
• Personal history of thyroid disease
• Family history of thyroid disease
• Family history of head and neck cancer

Physical Examination

Inspection

• Comments on location of mass and any neck asymmetry
• Comments on stigmata of hyperthyroidism in head and neck (exophthalmos, lid lag, etc.)
• Comments on stigmata of hypothyroidism in head and neck (skin and hair changes)
• Comments on size of thyroid and observes thyroid as patient swallows

Palpation

• Comments on quality, size, and mobility of mass (mass is hard, irregular, and tethered)
• Comments on size of mass (~2 cm in diameter)
• Palpates all lymph node regions of the head and neck
• Names the regions which are being palpated
• Comments on the size, texture, mobility, and location of nodes that are identified
• Asks patient if palpation is tender
• Palpates both lobes of the thyroid; comments on size and nodularity
• Auscultates thyroid and comments on absence of bruits

You are seeing Mr. Syed, a 73 year old man, in your outpatient clinic. He says that his family members have told him that they have a difficult time communicating with him because he has poor hearing. Take a focused history, and perform the pertinent physical examination maneuvers.

History

• Inquires whether patient is aware of hearing loss (he agrees)
• Onset of hearing difficulty
• Settings in which difficulty is worst (noisy crowds)
• Whether hearing difficulty is worse with specific frequency (patient unsure)
• Otalgia
• Exudation from ear, including pus and blood (none)
• Phonophobia
• Tinnitus
• Vertigo
• Associated neurologic deficits elsewhere in the body
• Vision loss
• Headache
• Use of ear plugs
• Trauma to the ear, including digital
• Past history of cerumen
• Use of any hearing aids
• Past history of hearing difficulty
• Past exposure to noise (including occupational history)

Physical Examination

Inspection

• Comments on the gross appearance of both ears
• Uses otoscope to examine the auditory canal, commenting on its appearance
• Examines tympanic membrane and comments on its appearance

Special Tests

• Performs the Rinne Test bilaterally
• Performs the Weber Test
• Interprets the results of these two tests
• Performs whisper test bilaterally

You are seeing Mrs. Woods, a 74 year old woman, in your ambulatory clinic today. She states that her vision has become blurry. Take a focused history of this complaint and perform the relevant physical examination.

History

• Onset and duration of blurry vision
• Progression of blurry vision
• Foreign body sensation, or history of foreign body in affected eye
• Awareness of a red eye (none)
• Visual field defects
• Change in acuity
• Double vision
• Eye pain
• Pain with eye movement
• Presence of flashes and floaters
• Photophobia
• Excessive or poor lacrimation
• Association with any extra-ocular symptoms: rashes, arthritis, urethritis
• Change in colour vision
• Distinguish between blurred vision vs. metamorphopsia (distorted vision)
• Use of corrective lenses
• Exposure to environmental irritants
• History of diabetes, hypertension, cardiac disease, and stroke (risk factors for CRVO, CRAO)
• History of cataract removal
• Past ocular disease, including trauma
• Smoking and alcohol history
• Medications and allergies
• Family history of eye diseases, e.g. glaucoma, retinal detachment
• Inquires if patient is driving since onset of vision changes
• Effect on daily living

Physical Examination

Inspection

• Comments on absence of ptosis
• Comments on appearance of lid, eyelashes, lacrimal glands
• Comments on appearance of conjunctiva and sclera

CN II

• Asks patient about prescription for corrective lenses before beginning examination
• Checks visual acuity using Snellen Chart at 14 inches or 20 feet
• Assesses pupillary response to light
• Assesses pupillary accommodation
• Assesses for RAPD/Marcus Gunn pupils
• Assesses visual fields by confrontation
• Performs fundoscopy and comments on findings, specifically the disc-to-cup ratio
• States that color vision testing should be performed
• States that a slit lamp examination should be performed

CN III, IV, & VI

• Comments on absence of nystagmus
• Assesses all six cardinal movements of the extraocular muscles
• Asks patients about diplopia in all directions of gaze