Ophthalmology and Otolaryngology

Case 2 – Sore Throat

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.


  • 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


  • 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


  • Auscultates in all lung fields
  • Comments on findings

Case 5 – Dizziness

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.


  • 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

Case 4 – Neck Mass

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.


  • 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


  • 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


  • 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

Case 3 – Hearing Difficulty

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.


  • 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


  • 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

Case 1 – Blurry Vision

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.


  • 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


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


  • 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


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