Sensory Ella09

Chapter 14
Sensor y System
Eyes, Ear s,
Nose, Mouth and
T hroat
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

Copyright © 2003, Elsevier Science (USA). All rights reserved.
Chapter 14
Eyes
 Structure and Function

 Subjective Data—Health History Questions
 Objective Data—The Physical Exam
 Abnormal Findings
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 14-1
Chapter 14
Eyes
Structure and Function

External Anatomy
 Palpebral fissure- the elliptical open space between the eye
lid
 Limbus- the border between the cornea and sclera
 Tarsal plates- connective tissue
 Meibomian glands
 Conjunctiva- palpebral and bulbar
 Lacrimal apparatus- lacrimal glands secreting tears drain to
puncta
 Extraocular muscles
Structure and Function, cont.
Internal Anatomy
 Inner layer- sclera
 A rough protective white covering
 Continuous anteriorly with the smooth transparent cornea,
covers the iris and pupil
 Sensitive to touch- corneal reflex
 CNV and CN VII

Chapter 14
Eyes

Internal Anatomy
 Middle layer—choroid
– Muscle of ciliary body control the thickness of the lens and production of
aqueous humor in the anterior chamber
– iris- varying the opening of its centre, control amount of light go to the retina
– Pupil- CNIII: parasympathetic nerve (constriction), sympathetic nerve (dilation)
– Lens- biconvex
– Anterior chamber
• posterior to the cornea and in front of the iris and lens.
• The intraocular pressure: a balance between the amount of aqueous
produced and resistance to it’s outflow at the angle of anterior chamber
Internal Anatomy
 Inner layer—retina
– Optic disc
– Retinal vessels
– Macula
• Fovea centralis
• Area of sharpest and keenest vision
• Receives and transforms the light stimulus into nerve
impulses through the optic nerve and the optic tract to
the visual cortex of the occipital lobe

Chapter 14
Eyes

 Visual pathways and visual fields
– Refraction of light rays
– Crossing of fibers at optic chiasm
 Visual reflexes
– Pupillary light reflex
• Direct light reflex
• Consensual light reflex
– Fixation
– Accommodation
3
1
Increase intraocular pressure

Developmental consideration
 Infants and children
– 3 to 4 months can fixate on a single image
– 80% are born farsignted
– Eye ball reaches adult size by 8 years
 Aging adult
– Presbyopia
• Lens loses elasticity
– Cataract
– Glaucoma

Chapter 14
Eyes
Subjective Data—
Health History Questions
 Vision difficulty (decreased acuity, blurring, blind spots,
halo around the light)
 Pain, photophobia
 Strabismus (will cause amblyopia exanopsia), diplopia
 Redness, swelling
 Watering, discharge
 Past history of ocular problems
 Glaucoma
 Use of glasses or contact lenses
 Self-care behaviors
Chapter 14
Eyes
Objective Data—
The Physical Exam
 Preparation
– Position
 Equipment needed
– Snellen eye chart
• 20/20- you can read 20 feet what the normal eye could have
read at 20 feet
• numerator: distance
• denominator: the distance the normal eye could have read
– Handheld visual screener
– Opaque card or occluder
– Penlight
– Applicator stick
– Ophthalmoscope
Chapter 14
Eyes
Objective Data—
The Physical Exam, cont.
 Test central visual acuity
– Snellen eye chart
– Near vision
 Test visual fields

– Confrontation test
 Inspect extraocular muscle function

– Corneal light reflex (Hirschberg test)
– Cover test
– Diagnostic positions test
Chapter 14
Eyes
Objective Data—
 Inspect external ocular structures
– General
– Eyebrows
– Eyelids and lashes
– Eyeballs
– Conjunctiva and sclera
• Pinguecula -thickening of bulbar conjunctiva
• Arcus senilis- cloudy cornea as lipid deposition
• Xanthelasma- raised yellow plaques on the lids
– Eversion of the upper lid
– Lacrimal apparatus
Pinguecula -thickening of bulbar conjunctiva
Pinguecula
Arcus senilis
Arcus senilis- cloudy cornea as lipid deposition

•Xanthelasma- raised yellow plaques on the lids
Chapter 14
Eyes
Objective Data—
 Inspect anterior eyeball structures
– Cornea and lens
– Iris and pupil
• Size and shape
• Pupillary light reflex
• Accommodation
Far vision- pupil dilate Near vision- pupil
constrict

Chapter 14
Eyes
Objective Data—
 Inspect the ocular fundus
– Use of the ophthalmoscope
– Red reflex
– Optic disc
• Color
• Shape
– Retinal vessels
• Number
• Color
• A:V ratio
• Caliber
– General background of the fundus
– Macula
Chapter 14
Eyes
Abnormal Findings
Abnormalities in the Eyelids
 Periorbital edema
 Exophthalmos (protruding eyes)
 Enophthalmos (sunken eyes)
 Ptosis (drooping upper lid)
 Upward palpebral slant
 Ectropion (lower lid is loose)
 Entropion (the lower lid roll in)
Ptosis (drooping upper lid)
Pseudostrabimus
Ectropion (lower lid is loose)
Chapter 14
Eyes
Abnormal Findings
Lesions on the Eyelids
 Blepharitis (inflammation of the eyelids)

 Chalazion (infection or retention cyst of a meibomian
gland)
 Hordeolum (stye) (hair follicle staphylococcus
infection)
 Dacryocystitis (inflammation of the lacrimal sac)
 Dacryoadenitis (inflammation of the lacrimal gland)
 Basal cell carcinoma
Chalazion (infection or retention cyst of a meibomian gland)
Chapter 14
Eyes
Abnormal Findings
 Vascular disorders of the  Abnormalities of the
external eye cornea and iris
– Conjunctivitis – Pterygium
– Subconjunctival • Chronic exposure to
hemorrhage hot, dry, sandy
– Iritis (circumcorneal • pinguecula
redness) – Corneal abrasion
– Acute glaucoma – Hyphema (blood in
• Circumcorneal redness anterior chamber)
around the iris – Hypopyon (purulent
• Dilated pupil matter in anterior
• Halo around light chamber)
• Sudden eye pain
Pterygium
Chronic exposure to hot, dry, sandy
from pinguecula

–Iritis (circumcorneal redness)
Chapter 14
Eyes
Abnormal Findings
Abnormalities in the Pupil
 Unequal pupil size—anisocoria

 Monocular blindness
 Constricted and fixed pupils—miosis
 Dilated and fixed pupils—mydriasis
 Argyll Robertson pupil (no reaction to light, does constrict
with accomdation
 Tonic pupil (Adie’s pupil)
 Cranial nerve III damage (no reaction to light,
accommodation, pitosis, eye deviatind down)
 Horner’s syndrome (unilateral, small pupil does react to
light and accommodation, ptosis and absence of sweat- a
lesion of sympathetic nerve)
Chapter 14
Eyes
Abnormal Findings
Opacities in the Lens
 Senile cataracts
– Central gray opacity—nuclear cataract
– Star-shaped opacity—cortical cataract
Chapter 14
Eyes
Abnormal Findings
 Abnormalities in the  Abnormalities in the
optic disc retinal vessels
– Optic atrophy (disc – Arteriovenous crossing
pallor) – Narrowed arteries
– Papilledema (choked – Vessel nicking
disc) – Silver wire arteries
– Excessive cup:disc – Copper wire arteries
ratio
Chapter 14
Eyes
Abnormal Findings
Abnormalities in the
General Background
 Diabetic retinopathy
 Microaneurysms
 Dot-shaped hemorrhages
 Flame-shaped hemorrhages
 Soft exudates
 Hard exudates
Chapter 15
Ear s

Chapter 15
Ears

Chapter 15
Ears

 External ear
– Auricle or pinna
– External auditory canal
– Tympanic membrane
 Middle ear
– Malleus, incus, and stapes
– Eustachian tube- equalization of pressure
– Functions
 Inner ear
– Vestibule and semicircular canals
– Cochlea
Chapter 15
Ears

 Hearing
– Auditory system has three levels
• Peripheral
• Brainstem
• Cerebral cortex
– Pathways of hearing
• Air conduction
• Bone conduction
– Hearing loss
• Conductive
• Sensorineural (perceptive)
• Equilibrium
Chapter 15
Ears
Subjective Data—
 Earaches
 Infections
 Discharge
 Hearing loss
 Environmental noise
 Tinnitus
 Vertigo
 Self-care behaviors
Note to examiner
 Person lip reading
 Frowning
 Posturing of head
 Misunderstands your questions
 Act irritable
 Person’s speech sound garbled
 Inappropriately loud voice
 Flat ,monotonus tone of voice

Chapter 15
Ears
Objective Data—
The Physical Exam
 Preparation
– Position
– Cleaning the ear canal
– Otoscope with bright light
– Pneumatic bulb attachment (sometimes needed with
infants or young children)
– Tuning forks in 512 and 1024 Hz
Chapter 15
Ears
Objective Data—
External Ear – Inspect and Palpate
 Size and shape
 Skin condition
 Tenderness
 External auditory meatus
Otoscopic Examination
 Position the head and ear
 Method of holding and inserting otoscope
 External canal
– Color
– Swelling – Lesions
– Discharge
Chapter 15
Ears
Objective Data—
Otoscopic Examination, cont.
 Tympanic membrane
– Color and characteristics
– Position
– Integrity of membrane
 Test hearing acuity
– Conversational speech
– Voice test
– Tuning fork tests
• Weber test
• Rinne test
 Vestibular apparatus
– Romberg test
Chapter 15
Ears
Abnormal Findings
Abnormalities of the External Ear
 Frostbite
 Otitis externa (“swimmer’s ear”)
 Brachial remnant and ear deformity
 Cerebrospinal fluid otorrhea
Chapter 15
Ears
Abnormal Findings
Lumps and Lesions on
the External Ear
 Darwin’s tubercle
 Sebaceous cyst
 Tophi
 Chondrodermatitis nodularis helicis
 Keloid
 Carcinoma
Darwin’s tubercle
Chapter 15
Ears
Abnormal Findings
Abnormalities in the Ear Canal
 Excessive cerumen
 Otitis externa
 Osteoma- nodule obscures the drum, benign
 Foreign body
 Exostosis- small, bony hard ,round nodules
 Furuncle- painful, redened, infected hair follicle
 Polyp
Chapter 15
Ears
Abnormal Findings
Abnormalities of
the Tympanic Membrane
 Retracted drum
 Serous otitis media
 Acute purulent otitis media
 Perforation
 Insertion of tympanostomy tubes
 Cholesteatoma
 Scarred drum
 Blue drum (hemotympanum)
 Bullous myringitis
 Fungal infection (otomycosis)
Chapter 15
Ears
Abnormal Findings
Tuning Fork Tests
 Conductive hearing loss

– Results with Weber test
– Results with Rinne test
 Sensorineural hearing loss

– Results with Weber test
– Results with Rinne test
Chapter 16
Nose, Mouth, and Throat

Chapter 16

Chapter 16

 Nose
– Function in the respiratory system
– External nose
– Nasal cavity
– Septum
– Turbinates
– Paranasal sinuses
• Frontal
• Maxillary
• Ethmoid
• Sphenoid
Chapter 16

 Mouth
– Function in the digestive and respiratory systems
– Hard and soft palates
– Uvula
– Tongue
– Salivary glands
• Parotid
• Submandibular
• Sublingual
– Teeth
Chapter 16

 Throat
– Oropharynx
– Tonsils
– Nasopharynx
Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Slide 16-3a
Chapter 16
Subjective Data—
 Nose
– Discharge
– Frequent colds (upper respiratory infections)
– Sinus pain
– Trauma
– Epistaxis (nosebleeds)
– Allergies
– Altered smell
Chapter 16
Subjective Data—
Health History Questions, cont.
 Mouth and throat
– Sores or lesions
– Sore throat
– Bleeding gums
– Toothache
– Hoarseness
– Dysphagia
– Altered taste
– Smoking and/or alcohol consumption
– Self-care behaviors
• Dental care pattern
• Dentures or appliances
Chapter 16
Objective Data—
The Physical Exam
 Preparation
– Positioning
– Otoscope with short, wide-tipped nasal speculum attachment
– Pen light
– Two tongue blades
– Cotton gauze pad (4 x 4 inches)
– Gloves
– Long-stem light attachment for otoscope (occasionally)
Chapter 16
Objective Data—
Mouth—Inspect Throat—Inspect
 Lips  Tonsils grading
 Teeth and gums  Use of tongue blade
 Tongue  Posterior pharyngeal wall
 U-shaped area under the
tongue
 Buccal mucosa
 Palate
– Hard and soft palate
– Torus palatinus
– Uvula
Chapter 16
Objective Data—
Nose—Inspect and Palpate
 External nose
 Test patency of nostrils
 Nasal cavity
– Holding the otoscope
– Nasal septum
– Turbinates
Sinus Areas—Palpate
 Frontal and maxillary sinuses
 Transillumination
Chapter 16
Abnormal Findings
Abnormalities of the Nose
 Choanal atresia  Allergic rhinitis

 Foreign body  Sinusitis
 Epistaxis  Polyps
 Perforated septum  Furuncle
 Acute rhinitis  Carcinoma
Chapter 16
Abnormal Findings
Abnormalities of the Lips
 Cleft lip
 Herpes simplex I
 Angular cheilitis (stomatitis, perleche)
 Carcinoma
 Retention “cyst” (mucocele)
Chapter 16
Abnormal Findings
 Abnormalities of the  Abnormalities of the
teeth and gums buccal mucosa
– Baby bottle tooth – Aphthous ulcers
decay – Koplik’s spots
– Malocclusion – Leukoplakia
– Dental caries – Candidiasis or
– Epulis monilial infection
– Gingival hyperplasia
– Gingivitis
malocclusion
Aphthous ulcers
Chapter 16
Abnormal Findings
 Abnormalities of the  Abnormalities of the
tongue oropharynx
– Geographic tongue – Cleft palate
(migratory glossitis) – Bifid uvula
– Smooth, glossy – Oral Kaposi’s
tongue sarcoma
(atrophic glossitis) – Acute tonsillitis and
– Black hairy tongue pharyngitis
– Enlarged tongue
(macroglossia)
– Carcinoma
Black hairy tongue

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Chapter 14

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Structure and Function

Structure and Function

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

Structure and Function, cont.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

Structure and Function, cont.

Increase intraocular pressure

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Test visual fields

 Inspect extraocular muscle function

Arcus senilis- cloudy cornea as lipid deposition

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Blepharitis (inflammation of the eyelids)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Unequal pupil size—anisocoria

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Structure and Function

Structure and Function

Structure and Function, cont.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Conductive hearing loss

 Sensorineural hearing loss

Nose, Mouth, and Throat

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition.

 Structure and Function

Structure and Function

Structure and Function, cont.

Structure and Function, cont.

 Choanal atresia  Allergic rhinitis

 Perforated septum  Furuncle

 Acute rhinitis  Carcinoma

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