The encounter, the oral presentation and documentation; the skin — structure, the descriptive vocabulary, abnormal findings of skin, hair and nails, and the examination itself; then the advanced ocular and ENT examinations.
| Term | What you need to know |
|---|---|
| Oral presentation — opening | Open with the past medical history and the chief complaint. Then pertinent positives and negatives from BOTH history and physical. Follow mostly the order you obtained them. Try not to read your notes. |
| Oral presentation — the test | A good presentation leads your facilitator to the same differential you formulated. It is a well-organized vignette, not the written note read aloud; the goal is to help listeners visualize the patient. |
| Focused vs comprehensive | A focused encounter narrows BOTH the history and the examination — history of present illness, review of systems, past medical history, social history, family history, medications and allergies are all focused. It is not a comprehensive encounter written up more briefly. |
| Focused encounter — required output | Differentials, laboratory and imaging studies, a diagnosis, and a treatment plan including patient education. Narrowing the data gathered does not narrow what you must conclude. |
| History and physical vs SOAP | The history and physical is comprehensive (whole history, head-to-toe). The SOAP note is problem-focused: Subjective (what the patient said), Objective (what you found, always with a general impression), Assessment (what you concluded), Plan (what you will do). |
| Documentation rules that cost marks | Describe findings — never 'normal', 'abnormal' or 'unremarkable'. NO abbreviations, with no exceptions. Keep subjective and objective in their own sections. If you did not do it, document why — never invent a finding. Never write a note with another student. |
| Communication | Adapt style and content for each patient. When someone else supplies the answers, ALWAYS look at and interact with the patient, not the person answering. Accept feedback and modify behavior; different facilitators give different feedback, and that is expected. |
| Term | What you need to know |
|---|---|
| Five functions | Protection of internal structures · prevention of entry of microorganisms · temperature regulation · excretion · production of vitamin D. |
| Sudoriferous (eccrine) glands | Secrete sweat to maintain body temperature. |
| Apocrine glands | Become active during PUBERTY; secrete pheromones. |
| Sebaceous glands | Surround hair follicles; secrete sebum to keep hair and skin moist. |
| Vellus vs terminal hair | Vellus is short, fine hair covering the body. Terminal is coarse — scalp, pubic, axillary, beard. |
| Term | What you need to know |
|---|---|
| Five features of any lesion | Distribution (location) · configuration (shape) · morphology (form and structure) · color · texture. |
| Distribution → diagnosis | Generalized/diffuse = allergic reactions. Regional = tinea capitis. Sun-exposed (photodistribution) = skin cancers. Dermatome = herpes zoster. Extensor = psoriasis. Flexor = intertrigo. Intertriginous = skin creases and folds. |
| Configuration terms | Annular = ring. Arciform = arcs or curves. Confluent = run together. Discrete = remain separate. Grouped = a cluster. Gyrate = twisted, coiled, spiral. Iris/target = bull's eye. Linear = line or stripe. Reticular = lacy or networked. Serpiginous = snake-like. |
| Herpetiform vs zosteriform | Herpetiform = grouped papules or vesicles arranged as in herpes SIMPLEX. Zosteriform = clustered in a DERMATOMAL distribution, as in herpes zoster. The pair most often swapped. |
| Primary vs secondary lesion | Primary forms first and results directly from the disease — identifying it is the key to the whole description. Secondary is a change in the primary over time, from disease progression, TREATMENT, or MANIPULATION (picking, scratching). |
| Term | What you need to know |
|---|---|
| The 1 cm hinge — three matched pairs | Flat: macule (<1 cm) / patch (>1 cm). Solid elevated: papule (<1 cm) / plaque (>1 cm). Fluid-filled: vesicle (<1 cm) / bulla (>1 cm). Six terms from three pairs — this is why a ruler is on the equipment list. |
| Nodule vs papule vs tumor | Nodule: elevated, firm, circumscribed, round or ellipsoid, DEEPER in the dermis than a papule, 1–2 cm (Bates: >0.5 cm). Tumor: solid mass >2 cm. Papule: solid, <1 cm. |
| Plaque | Elevated, flat-topped, firm, rough; plateau-like, occupying a large area compared with its elevation; >1 cm; may be coalesced papules. Example: psoriasis. |
| Wheal, pustule, cyst | Wheal: elevated irregular cutaneous edema, solid, TRANSIENT, variable diameter (the only transient one). Pustule: superficial elevation filled with PURULENT material, usually <1 cm. Cyst: elevated, circumscribed, ENCAPSULATED, in dermis or subcutis, liquid or semisolid (the only encapsulated one). |
| Erosion vs ulcer | Erosion: loss of superficial epidermis, does NOT involve dermis; moist but does NOT bleed. Ulcer: deeper loss of epidermis and/or dermis; MAY bleed and scar. Depth determines all three consequences at once. |
| Crust, fissure, scale, excoriation | Crust: cellular debris, dried serum and blood — a scab; antecedent lesion usually a vesicle, bulla or pustule. Fissure: linear crack (athlete's foot). Scale: thin flake of exfoliated epidermis (dandruff). Excoriation: abrasion or scratch mark, linear or rounded. |
| Scar vs keloid | Scar (cicatrix): fibrous tissue replacing destroyed tissue; hypertrophic = thick and pink, atrophic = thin and white; does NOT extend beyond the injured area. Keloid: a scar that GROWS BEYOND the wound. |
| Lichenification & collarette scale | Lichenification: thickening with skin line accentuation from chronic irritation (atopic dermatitis). Collarette scale: fine scale peripherally attached and centrally detached at a lesion's edge (pityriasis rosea). |
| Corn vs callus; warts | Corn: smaller, usually over a NON-weight-bearing area of the foot, conical keratin pointing toward the dermis. Callus: thickened epidermal keratin, usually on the sole at ball or heel. Verrucae (warts) are caused by human papillomavirus. |
| Term | What you need to know |
|---|---|
| Diascopy | Press clear glass or plastic against the skin and look at the lesion under pressure. Color FADES = vascular engorgement. Does NOT fade = hemorrhage in the skin. |
| Petechiae / purpura / ecchymosis | Same finding at three sizes, NONE blanching. Petechiae <3 mm. Purpura 3 mm–1 cm. Ecchymosis >1 cm, purple or purplish-blue, fades over time. |
| Angiomas & telangiectasia | Cherry angioma (Campbell De Morgan spots): dome shaped, bright red to violet/black, ± blanching. Telangiectasia: fine irregular vessels, blanches. Spider angioma: central red macule with radiating arms, blanches. |
| Triple response of Lewis | Firm stroking (dermatographism) produces: initial red line (capillary dilatation) → reflex flare with broadening erythema (arteriolar dilatation) → linear wheal (transudation of fluid, i.e. edema). |
| Pressure ulcer stages | I: INTACT skin, erythema failing to blanch, plus change in temperature, consistency, sensation, color. II: PARTIAL thickness loss (epidermis, dermis or both). III: FULL thickness, subcutaneous necrosis, may extend to but NOT through muscle. IV: full thickness with destruction of tissue, muscle and/or bone. |
| Tinea by site | Corporis (body) · pedis (foot) · barbae (beard) · cruris (groin) · capitis (scalp) · unguium (nails). Pedis: dry/scaling or macerated fissuring of interdigital spaces. Corporis: sharply demarcated round plaques with CENTRAL CLEARING. Capitis: round scaling patches of alopecia, hairs broken off close to scalp. |
| Skin malignancies | Basal cell carcinoma: face; translucent PEARLY nodule, depressed center, raised borders; may ulcerate; non-healing ulcer. Squamous cell carcinoma: face and sun-exposed; red scaling, crusting nodule or plaque that ulcerates and bleeds. Melanoma: irregularly colored plaque with sharp notches and pigment variation. |
| Melanoma warning letters | A asymmetry or shape · B border irregularity · C color variation · D diameter larger than 6 mm · E evolving, elevation · F family history · G growing. |
| Kaposi's sarcoma | The most frequent neoplasm in patients with acquired immunodeficiency syndrome. Light-colored lesions coalescing into darker ones; dark blue-purple macules, papules, nodules and plaques; widely disseminated on legs, trunk, arms, neck and head. |
| Patchy hair loss — three causes | Tinea capitis: SCALING patches, hairs broken close to scalp. Alopecia areata: round patches, 'EXCLAMATION POINT' hairs, chronic inflammatory disease of follicles, associated with autoimmune disorders. Trichotillomania: from an urge to pull, single or multiple patches. Also: androgenic alopecia = male pattern baldness; hirsutism = increased hair in women in a male pattern. |
| Nail findings | Koilonychia: spoon-shaped concave, plate thins and inverts. Onycholysis: PAINLESS separation of plate from bed starting DISTALLY (chemicals, immersion, fungal, psoriasis, tetracycline, trauma). Pitting: dystrophy of the plate. Terry's nails: proximal white, distal dark. Green = pseudomonas. Brown–black = MELANOMA. |
| Nail lines, hemorrhages, clubbing | Beau's lines: transverse DEPRESSIONS — halfway up the nail suggests illness about 3 MONTHS ago. Mee's lines: transverse lines. Splinter hemorrhages: distal capillary loop. Subungual hematoma: hemorrhage to the nail plate. Clubbing: nail base-to-finger angle GREATER THAN 180°, fingertip rounded and bulbous. Paronychia: soft tissue infection at cuticle or nail fold; acute is painful and purulent. |
| Term | What you need to know |
|---|---|
| IPPA | Inspection, palpation, percussion, auscultation — the same order for EVERY body system except the ABDOMINAL examination. Some systems do not use all four. |
| Equipment & environment | Ruler, light source, magnifying lens, gloves for open lesions. Patient in a gown so hair, anterior and posterior surfaces, palms and soles, nails and interdigital spaces can all be inspected. Good light, preferably NATURAL — artificial light may distort skin tone. |
| Six characteristics assessed | Color · moisture (dryness, sweating, oiliness) · temperature (warmth, coolness) · texture (roughness, smoothness) · mobility and turgor · lesions. |
| Temperature technique | Use the DORSAL aspect of the hands. |
| Mobility vs turgor | Mobility: normal skin lifts with ease; reduced mobility = EDEMA. Turgor: normal skin quickly resumes its shape; skin that remains elevated = DEHYDRATION. |
| Central vs peripheral cyanosis | Central: often inadequate oxygenation IN THE LUNGS. Peripheral: usually inadequate CIRCULATION. Same color, different organ. |
| Hair & scalp | Inspect color, distribution and quantity; palpate for texture. Separate the hair into sections to see the scalp, and inspect BEHIND THE EARS and the OCCIPUT. Should be clean — no lesions, discolorations, flaking or parasites. A magnifying glass aids inspection for lice (nits are tiny white ovoid granules adherent to hairs). |
| Pruritus is not a diagnosis | It is the sensation causing the desire to scratch. Generalized itching with no obvious reason: dry skin, aging, pregnancy, uremia, jaundice, lymphomas, leukemias, drug reaction, lice. |
| History — bugs, drugs, contact | Bugs: family members or contacts with the same, travel. Drugs: systemic medications, over-the-counter AND prescription. Contact: allergens and irritants from hobbies, occupation, environment. Core questions: where it first appeared, what it looked like, how it progressed, associated symptoms, what treatment was tried. |
| Term | What you need to know |
|---|---|
| The named virus in viral conjunctivitis | “I'm not going to test you on it, but adenovirus…” — she uses it for the great-mimicker story. NOTE: CMS I Exam 2 DOES test adenovirus. Different course. |
| The exophthalmometer | “I am not going to test you on the minutia of how to do that test… it was 20 to 22 millimeters… DON'T WORRY ABOUT IT.” BUT RECOGNIZING EXOPHTHALMOS IS IN — “about exophthalmos and how to recognize it.” |
| The strabismus diagram | “This is just a visual… that you don't have to memorize.” ESO-, EXO- and HYPERTROPIA as concepts stay in. |
| The corneal reflection test | “We've already done this, so I'm not gonna test you on it… we already did that in PD1.” |
| The Adie's pupil look-alikes | Dysautonomia/POTS, Shy-Drager, diabetes, amyloidosis — “it's not on my test this time.” BUT ADIE'S PUPIL ITSELF IS IN: “you should know Adie's pupil, that could be on my test.” |
| The Latin behind OD/OS/OU | “I don't care if you remember Oculus Sinister or Dexter.” BUT THE ABBREVIATIONS ARE IN — “those are terms that you must remember.” OD RIGHT · OS LEFT · OU BOTH. |
| Term | What you need to know |
|---|---|
| DIPLOPIA and the cranial nerves | HORIZONTAL (images SIDE BY SIDE) = palsy of CN III or VI. VERTICAL (images ON TOP of each other) = palsy of CN III or IV. Her shortcut: “THREE FOR BOTH OF THOSE” — CN III is in both patterns; side-by-side is where CN VI joins in. |
| The RED-EYE CHART — “be very familiar with that chart” | It is a PICTURE on the slide, so it is in no text copy of the deck. Written out in full in the study guide. Scan it by COLUMN: pattern of redness, pain, vision, discharge, pupil, cornea, significance. |
| RED TEXT ON A SLIDE | “See how this is in red — red's important too.” Said of: an ACUTE, SIGNIFICANTLY DILATED PUPIL IS A MEDICAL EMERGENCY, particularly with headache or neurologic signs — UNCAL HERNIATION or POSTERIOR COMMUNICATING ARTERY ANEURYSM. |
| THE REFERRAL LIST — “please know this list” | Her reason: “because you're going to be making those dispos.” EMERGENT (ophtho/ER IMMEDIATELY): SUDDEN VISION LOSS · RETINAL ARTERY OCCLUSION · CHEMICAL BURNS · RUPTURE · ACUTE ANGLE-CLOSURE GLAUCOMA · VITREOUS HEMORRHAGE. URGENT (ophtho in A DAY OR LESS): ACUTE GLAUCOMA · ORBITAL CELLULITIS · CORNEAL ULCER OR ABRASION · RETINAL DETACHMENT · MACULAR EDEMA OR HEMORRHAGE · HYPHEMA. |
| Term | What you need to know |
|---|---|
| The four axes | TIME COURSE · PRECIPITATING FACTORS · PALLIATIVE/EXACERBATING VARIABLES · VISION LOSS. |
| Laterality and floaters | BILATERAL visual loss → NEUROLOGIC, not ophthalmologic. MULTIPLE NEW flashes/floaters → RETINAL TEAR or VITREOUS HEMORRHAGE. A SINGLE floater → probably benign. |
| Tempo | RAPID deterioration → VASCULAR. GRADUAL → CATARACT and the like. |
| The anesthetic test | Pain RELIEVED by topical anesthetic → a SURFACE problem (corneal injury). NOT relieved → a DEEPER source. |
| Four symptom patterns | ACUTE/UNILATERAL/PAINLESS → retinal vascular occlusion, detachment, vitreous hemorrhage, macular degeneration. ACUTE/UNILATERAL/PAINFUL → cornea + anterior chamber: abrasion/ulcer, uveitis, traumatic hyphema, acute narrow angle glaucoma. ACUTE/BILATERAL/PAINFUL → THERMAL, RADIATION or CHEMICAL. GRADUAL/PAINLESS → simple glaucoma or cataract. |
| Eye pain, qualified | With BLINKING → abrasion or foreign body. GRITTY → conjunctivitis. + PHOTOPHOBIA → iris inflammation. + HEADACHE → acute narrow angle glaucoma. On EYE MOTION → optic neuritis. + TEMPORAL pain → temporal arteritis. |
| Discharge | WATERY or MUCOID → allergic or viral. PURULENT → bacterial. |
| Don't forget to ask | TETANUS STATUS in eye trauma. ACID OR ALKALI after a chemical splash. Systemic: DIABETES, HYPERTENSION and HIV — “HIV is going to affect basically any type of etiology.” |
| Term | What you need to know |
|---|---|
| Order of the exam | INSPECTION → external → cornea/lens/pupils → VISUAL ACUITY (“the vital sign of the eye”) → VISUAL FIELDS → OCULAR MOTILITY → PUPILLARY REACTIONS (CHECK BEFORE DILATING) → corneal reflection → special tests → slit lamp → pressure → ophthalmoscopy. |
| In trauma | DO NOT PALPATE THE GLOBE. |
| Lid and brow signs | SCALY brows → seborrheic dermatitis. LATERAL SPARSENESS → HYPOTHYROIDISM. PTOSIS → myasthenia gravis, CN III damage, or sympathetic damage (HORNER); senile = weak muscle + relaxed tissue + herniated fat weight. XANTHELASMA on the NASAL lid → lipid disorders. |
| HORDEOLUM vs CHALAZION on inspection | HORDEOLUM: PAINFUL, AT THE LID'S EDGE. CHALAZION: chronic, NON-painful, meibomian, generally NOT at the margin — POINTS INSIDE THE LID. |
| Sclera color | YELLOW → LIVER DISEASE. BLUE → OSTEOGENESIS IMPERFECTA. |
| Proptosis technique | STAND BEHIND THE SEATED PATIENT AND LOOK DOWN FROM ABOVE, drawing the lid slightly up. Causes: retrobulbar hemorrhage, orbital cellulitis, orbital tumor, GRAVES. |
| Nasolacrimal duct test | Look UP; press the lower lid near the MEDIAL CANTHUS just inside the bony rim; watch for regurgitation from the puncta. MUCOPURULENT FLUID = OBSTRUCTION. AVOID if significantly inflamed or tender. |
| Everting the upper lid | Look DOWN and relax → raise the lid so lashes protrude → grasp and pull DOWN AND FORWARD → stick AT LEAST 1 cm ABOVE THE MARGIN at the upper tarsal border → push down as you raise the edge. DO NOT PRESS ON THE EYEBALL. NEVER EVERT IF GLOBE RUPTURE IS SUSPECTED. |
| Subconjunctival hemorrhage on exam | PAIN ABSENT · VISION AND PUPIL UNAFFECTED · NO DISCHARGE · CORNEA CLEAR. GLOBE RUPTURE MORE LIKELY in trauma and when the hemorrhage ENCIRCLES THE ENTIRE CORNEA. |
| Injection pattern | DIFFUSE, MAXIMAL PERIPHERALLY → conjunctivitis. JUST AROUND THE CORNEA → KERATITIS, IRITIS or ACUTE GLAUCOMA. |
| Term | What you need to know |
|---|---|
| OD / OS / OU | OD = RIGHT eye. OS = LEFT eye. OU = BOTH. “Terms that you must remember.” |
| 20/200 | At 20 FEET the patient reads print a NORMAL eye reads at 200 FEET. THE LARGER THE SECOND NUMBER, THE WORSE THE VISION. Cannot read the chart → document COUNTING FINGERS, HAND MOTION, or LIGHT PERCEPTION. |
| PINHOLE TEST | Admits only light PERPENDICULAR to the lens, so it need not be bent → CORRECTS ANY REFRACTIVE ERROR. NOT corrected → consider CATARACT, OPTIC NERVE DISEASE or RETINAL DISEASE. |
| Confrontation fields | STATIC FINGER WIGGLE (arm's length, hands 2 ft apart lateral to the ears, into center of view, each quadrant) PLUS KINETIC RED TARGET (5 mm red-topped pin inward from beyond each quadrant — ask when it FIRST APPEARS RED). |
| Blind spot | 15 DEGREES TEMPORAL to the line of gaze. ENLARGED in GLAUCOMA, OPTIC NEURITIS and PAPILLEDEMA. A temporal defect in one eye → TEST FOR A NASAL DEFECT IN THE OTHER. |
| Nystagmus | A FEW BEATS ON LATERAL GAZE IS NORMAL. Bring the finger back into BINOCULAR vision — if it persists there, consider NEUROLOGIC disease. |
| Lid lag | Rim of SCLERA VISIBLE ABOVE THE IRIS on DOWNWARD gaze. Most often HYPERTHYROIDISM. |
| Term | What you need to know |
|---|---|
| Anisocoria | ½ to 1 mm difference is COMMON and BENIGN IF THE REACTIONS ARE NORMAL. ABNORMAL: difference > 1 mm, or a POORLY REACTIVE pupil. |
| SWINGING LIGHT TEST | Indication: ANISOCORIA. ABNORMAL = PARADOXICAL DILATION OF BOTH PUPILS when the light swings to the affected eye, WITH AN INTACT CONSENSUAL REFLEX = RELATIVE AFFERENT PUPILLARY DEFECT = MARCUS GUNN PUPIL = THE LESION IS THE OPTIC NERVE. Mechanism: reduced afferent input → reduced efferent output to BOTH pupils → net dilation. |
| ADIE'S TONIC | LARGE, regular, usually UNILATERAL. Light reaction SEVERELY REDUCED/ABSENT. NEAR REACTION PRESENT BUT VERY SLOW. Degeneration of the CILIARY GANGLIA and POSTGANGLIONIC PARASYMPATHETIC fibers. |
| ARGYLL ROBERTSON | SMALL, UNEQUAL, IRREGULAR. “ACCOMMODATES BUT DOESN'T REACT.” Classically TERTIARY SYPHILIS, today more often DIABETES; also LYME. Mydriatics dilate it only INCOMPLETELY. |
| HORNER SYNDROME | PTOSIS · MIOSIS · ANHIDROSIS of the ipsilateral face. THE SMALL PUPIL STILL REACTS BRISKLY to light and near — that is what separates it. Sympathetic supply to pupil AND levator interrupted. CONGENITAL: involved iris is LIGHTER (heterochromia). |
| CN III PALSY | DILATED pupil FIXED to BOTH light and near, with PTOSIS and LATERAL DEVIATION almost always present. |
| Three causes of a dilated pupil | Once local eye disease is excluded: (1) COMPRESSION/LESION OF CN III · (2) PARASYMPATHETIC DENERVATION from a ciliary ganglion lesion = ADIE'S · (3) PHARMACOLOGIC BLOCK of the sphincter. |
| Oblique lighting — crescent shadow | Light from the TEMPORAL side. NO SHADOW = normal, flat iris, OPEN angle. A SHADOW on the MEDIAL side = iris BOWED FORWARD = NARROW ANGLE = raised risk of NARROW-ANGLE GLAUCOMA. |
| Corneal scar vs cataract | SCAR: SUPERFICIAL grayish-white corneal opacity. CATARACT: DEEPER, visible ONLY THROUGH THE PUPIL. |
| Term | What you need to know |
|---|---|
| DO NOT DILATE if… | SERIAL NEUROLOGIC EXAMS are required · ELDERLY PATIENTS WHO HAVE HAD CATARACT SURGERY · SUSPECTED ACUTE ANGLE-CLOSURE GLAUCOMA. If you dilate: DOCUMENT THE TIME AND THE AGENTS. |
| NORMAL fundus | YELLOWISH-ORANGE TO CREAM · small disc vessels · SHARP disc margin · cup CENTRAL or slightly TEMPORAL, diameter LESS THAN HALF the disc. |
| PAPILLEDEMA | RAISED INTRACRANIAL PRESSURE. PINK, disc SWOLLEN with BLURRED MARGINS, CUP NOT VISIBLE, LOSS OF VESSEL PULSATIONS. |
| GLAUCOMATOUS CUPPING | Cup ENLARGED, MORE THAN HALF the disc diameter; retinal vessels SINK IN AND AROUND the disc. |
| OPTIC ATROPHY | WHITE disc, TINY DISC VESSELS ABSENT — death of optic nerve fibers. Seen in OPTIC NEURITIS, MULTIPLE SCLEROSIS, TEMPORAL ARTERITIS. |
| Trauma mechanics | LARGER objects transfer most energy to the ORBITAL RIM; SMALLER objects may strike the GLOBE directly. |
| ORBITAL (BLOW-OUT) FRACTURE | SUNKEN EYE · INFRAORBITAL HYPOESTHESIA (infraorbital nerve) · DIPLOPIA PARTICULARLY ON UPWARD GAZE · decreased motility · sometimes IPSILATERAL NOSEBLEED. Look for ECCHYMOSIS, POINT TENDERNESS, PALPABLE STEP-OFF. |
| ZYGOMATIC FRACTURE | FLATTENING OF THE MALAR EMINENCE, best seen from BEHIND the seated patient looking down. PAIN ON OPENING THE MOUTH because TEMPORALIS passes MEDIAL to the arch and inserts on the MANDIBLE. |
| HYPHEMA | Blood in the ANTERIOR CHAMBER from blunt trauma. Check ACUITY · PUPILS (crescent-like iris defect if torn) · RED REFLEX · INTRAOCULAR PRESSURE · SLIT LAMP. |
| CORNEAL ABRASION | EVERT THE UPPER LID — a foreign body in the upper tarsal conjunctiva scratches with every blink. A HAZY CORNEA SUGGESTS BACTERIAL INFECTION. TOPICAL ANESTHETIC IS FOR DIAGNOSIS, NOT TREATMENT. |
| CORNEAL ULCER | HERPES SIMPLEX ULCERS ARE NOT VERY PAINFUL. Ophthalmoscope at +40 DIOPTERS may reveal it, but FLUORESCEIN IS MORE SENSITIVE for early ulcers. Fluorescein is taken up by cornea DEVOID OF EPITHELIUM. |
| Term | What you need to know |
|---|---|
| Why this block leads | “The Weber and the Rinne tests are BOTH HIGH YIELD … the difference between sensorineural and conductive hearing loss is ALSO HIGH YIELD … IT WILL BE THREE POINTS ON TEST DAY.” |
| The two mnemonics, verbatim | “RINNE IS UNDER THE PINNA” — the pinna is the outside of the ear, the Rinne fork goes on the MASTOID under it. “WEBER TELLS YOU WHETHER” — whether it is the RIGHT or the LEFT. |
| WEBER — where and what for | Fork on the TOP OF THE HEAD or MID-FOREHEAD. Evaluates UNILATERAL loss by LATERALIZATION. Normal = MIDLINE or equal in both ears. |
| WEBER in CONDUCTIVE loss | Lateralizes to the IMPAIRED ear. WHY: the block screens out room noise on that side, so the bone-conducted tone has that ear to itself. |
| WEBER in SENSORINEURAL loss | Lateralizes to the GOOD ear. WHY: inner ear or cochlear nerve damage impairs transmission on the affected side however the sound arrives. |
| RINNE — how, in order | Fork on the MASTOID until the sound STOPS → move it CLOSE TO THE CANAL → ask if still heard. Bone conduction FIRST, air conduction SECOND. |
| RINNE normal | AIR > BONE. A sound beside the ear is louder than one against the skull. |
| RINNE in CONDUCTIVE loss | BONE ≥ AIR (abnormal). Vibration through bone BYPASSES the blocked external or middle ear and reaches an intact cochlea. |
| RINNE in SENSORINEURAL loss | AIR > BONE — THE NORMAL RATIO PREVAILS. Rinne compares two routes to the SAME cochlea; damage degrades BOTH, so the ratio survives. Counterintuitive, and that is the test working. |
| ★ THE WORKED CASE | Rinne right = NORMAL. Weber lateralizes RIGHT. Which ear has sensorineural loss? THE LEFT. Normal Rinne rules out conductive on the right; Weber goes AWAY from a sensorineural lesion. |
| What the forks CANNOT do | They do NOT distinguish normal from BILATERAL sensorineural loss, and NOT normal from MIXED loss. Both tests work by COMPARING — a symmetrical loss looks normal. |
| The fork itself | 512 Hz — THE SMALLER ONE. Quiet room. Tap or “pinch” the fork. |
| Term | What you need to know |
|---|---|
| Site | CONDUCTIVE: external or middle ear. SENSORINEURAL: inner ear (cochlea) or CN VIII / central pathways. |
| Mechanism | CONDUCTIVE: defective sound TRANSMISSION to the oval window. SENSORINEURAL: DESTRUCTION of hair cells or auditory nerve fibers. |
| Age of onset | CONDUCTIVE: childhood to about 40. SENSORINEURAL: MIDDLE OR LATER YEARS. |
| Visible on otoscopy? | CONDUCTIVE: usually VISIBLE — EXCEPT OTOSCLEROSIS. SENSORINEURAL: NOT visible. Otosclerosis is the conductive cause behind a normal-looking drum. |
| Noisy environments | CONDUCTIVE: hearing SEEMS TO IMPROVE (the block attenuates the background too). SENSORINEURAL: WORSENS. |
| ★ The patient’s own VOICE | CONDUCTIVE: voice stays SOFT — inner ear and cochlear nerve intact, so they hear themselves fine. SENSORINEURAL: voice may be LOUD — they cannot hear themselves. A feedback loop, and a free bedside sign. |
| Frequencies | SENSORINEURAL: HIGHER REGISTERS LOST, so sound is distorted. PRESBYCUSIS = high-frequency loss. |
| CONDUCTIVE causes | Cerumen · foreign bodies · effusions · EXOSTOSES/OSTEOMAS (benign bony canal growths) · tumors · TM perforation · otosclerosis. |
| SENSORINEURAL causes | Congenital · hereditary · PRESBYCUSIS · viral (RUBELLA, CYTOMEGALOVIRUS) · Ménière · NOISE · ACOUSTIC NEUROMA. |
| Whispered voice test | TWO FEET BEHIND the patient (no lip reading), OCCLUDE the other ear, THREE-item sequence in a quiet whisper, TWICE. NORMAL = 3 or more of 6 correct. ABNORMAL = 4 of 6 INCORRECT. |
| Other bedside screens | FINGER RUB and a WATCH. |
| Term | What you need to know |
|---|---|
| How to read it | DURATION column first, then HEARING. Those two separate all six. |
| BENIGN POSITIONAL VERTIGO | Sudden, on ROLLING ONTO THE AFFECTED SIDE or tilting the head up. SECONDS TO UNDER A MINUTE per episode; the CONDITION lasts a few weeks and may recur. Hearing NOT affected. Tinnitus ABSENT. |
| VESTIBULAR NEURONITIS (acute labyrinthitis) | Sudden. HOURS TO TWO WEEKS; may recur over 12–18 months. Hearing NOT affected. Tinnitus ABSENT. Nausea, vomiting, nystagmus. |
| MÉNIÈRE DISEASE | Sudden. SEVERAL HOURS TO A DAY OR MORE, recurrent. SENSORINEURAL loss that recurs and eventually PROGRESSES. Tinnitus PRESENT and FLUCTUATING. PRESSURE OR FULLNESS in the affected ear. |
| DRUG TOXICITY | Insidious or acute — LOOP DIURETICS, AMINOGLYCOSIDES, SALICYLATES, ALCOHOL. May or may not be reversible; partial adaptation. Hearing MAY be impaired. |
| ACOUSTIC NEUROMA | Insidious, from CN VIII compression (vestibular branch). Variable duration. Hearing IMPAIRED ON ONE SIDE. Tinnitus PRESENT. MAY INVOLVE CN V AND VII. |
| CENTRAL VERTIGO | Often sudden — BRAINSTEM LESION, ATHEROSCLEROSIS, MULTIPLE SCLEROSIS, VERTEBROBASILAR MIGRAINE, TIA. Variable but RARELY CONTINUOUS. Hearing NOT affected. Tinnitus ABSENT. OTHER BRAINSTEM DEFICITS — dysarthria, ataxia, crossed motor/sensory. |
| Hearing is the great divider | Of the six, only MÉNIÈRE, DRUG TOXICITY and ACOUSTIC NEUROMA touch hearing. |
| “DIZZINESS” splits FOUR ways | VERTIGO (spinning) · PRESYNCOPE (faint/lightheaded) · DISEQUILIBRIUM (unsteadiness/imbalance) · PSYCHIATRIC (anxiety, depression, alcohol/substances). The word means NOTHING until the patient explains it. |
| Tinnitus | Sound with NO EXTERNAL SOURCE. WITH hearing loss AND vertigo = MÉNIÈRE. |
| Term | What you need to know |
|---|---|
| Before the otoscope | Inspect and palpate the AURICLES, MASTOID and TRAGUS. |
| Otoscopy technique | Pull the auricle UP, BACK AND AWAY FROM THE HEAD. LARGEST speculum that fits. ULNAR ASPECT of the hand contacts the patient (anchors the instrument). INSUFFLATE. |
| Why the LARGEST speculum | Insufflation needs a SEAL. A small speculum leaks and the test becomes uninterpretable. |
| Leak check BEFORE inserting | Attach the speculum, put a FINGER OVER THE TIP, squeeze the bulb — you should FEEL PRESSURE BUILD if there is no leak. |
| Insufflation pressure | QUICK, FIRM BUT GENTLE. Reduced mobility → EFFUSION or THICKENED MEMBRANE. |
| Referred ear pain | TMJ · TEETH · CERVICAL SPINE. Carried by CN V, VII, IX, X. Four sensory nerves to one small structure. |
| Ototoxic drugs to ask about | AMINOGLYCOSIDES · ASPIRIN · NSAIDs · QUININE · FUROSEMIDE. |
| ACUTE otitis externa | Canal SWOLLEN, NARROW, MOIST, PALE, TENDER; may be erythematous. |
| CHRONIC otitis externa | Canal skin THICKENED, RED, ITCHY. Acute = PAIN, chronic = ITCH. |
| TM PERFORATION | CENTRAL = does NOT extend to the margin. MARGINAL = involves the margin. Usually secondary to OTITIS MEDIA; may drain through it. |
| TYMPANOSCLEROSIS | HYALINE DEPOSIT in the TM after severe otitis media or a healed perforation / tubes. USUALLY NOT CLINICALLY SIGNIFICANT. |
| SEROUS EFFUSION | AMBER fluid, sometimes BUBBLES. After URI or a change in ATMOSPHERIC PRESSURE. |
| OTITIS MEDIA on the drum | RED · LANDMARKS LOST · BULGING. Purulent effusion. STREP PNEUMONIAE and H. INFLUENZAE. |
| Bulging is GRADED | Normal → mild → moderate → severe. The landmarks disappear as it progresses; that transition is what makes the effusion convincing. |
| BULLOUS MYRINGITIS | PAINFUL HEMORRHAGIC VESICLES on the TM and/or canal. MAY BE VIRAL OR BACTERIAL. |
| Know normal first | “You have to see HUNDREDS of normal before you see anything abnormal … and then the abnormal will hit you in the face.” |
| Term | What you need to know |
|---|---|
| Turbinates | SUPERIOR, MIDDLE, INFERIOR. The MAXILLARY SINUS DRAINS AT THE MIDDLE TURBINATE. |
| Why aggression matters up here | “The roof of the mouth is the floor of your brain … anything that happened there CAN GO UP. Any infection in this area, you have to be a little more AGGRESSIVE.” |
| Recent DENTAL WORK | Can affect the MAXILLARY SINUSES — the sinus floor sits directly above the upper tooth roots. |
| Nasal drug history | RHINITIS MEDICAMENTOSA (topical decongestants) and COCAINE. Neither is volunteered. |
| Epistaxis causes | DIGITAL TRAUMA or other trauma · INFLAMMATION · DRY MUCOSA · FOREIGN BODY · TUMOR. RECURRENT, or WITH BLEEDING/BRUISING ELSEWHERE → SYSTEMIC problem. |
| Patency test | OCCLUDE ONE NOSTRIL AND BREATHE IN. UNILATERAL obstruction → FOREIGN BODY, TUMOR, DEVIATED SEPTUM. |
| NASAL POLYP associations | ALLERGIC RHINITIS · ASPIRIN SENSITIVITY · ASTHMA · CHRONIC SINUS INFECTION · CYSTIC FIBROSIS. |
| MUCOSA color | RED AND SWOLLEN → VIRAL rhinitis. PALE, BLUISH OR RED → ALLERGIC rhinitis. |
| PERFORATED septum | TRAUMA · SURGERY · DRUG USE. |
| Sinus palpation | Press UP on the FRONTAL sinuses AVOIDING THE EYES. Press UP on the MAXILLARY sinuses. |
| Transillumination | DARK ROOM. FRONTAL: light UP under the brow close to the nose. MAXILLARY: light DOWN just below the inner corner of the eye, MOUTH OPEN. No glow → thickened mucosa/secretions. NOT SENSITIVE OR SPECIFIC. |
| ★ ACUTE SINUSITIS — three rules | (1) Local tenderness, pain, fever, nasal discharge are SUGGESTIVE. (2) THE COLOR OF THE DISCHARGE IS NOT DIAGNOSTIC. (3) ACUTE BACTERIAL SINUSITIS IS UNLIKELY UNDER SEVEN DAYS — “it takes time to let it cook.” |
| ★ SEPTAL HEMATOMA | Injury disrupts vessels and PULLS THE LINING AWAY FROM THE CARTILAGE; blood collects between the two. URGENT DRAINAGE to prevent NECROSIS OF THE SEPTAL CARTILAGE — the cartilage has no blood supply of its own. “That blood HAS TO COME OUT.” |
| Don’t pull what you can’t name | A lesion everyone called a polyp turned out on imaging to be BRAIN TISSUE coming through. “You need to know what you’re looking at before you start pulling things.” |
| Term | What you need to know |
|---|---|
| ★ THE FOUR CENTOR CRITERIA | FEVER (above 100.4°F / 38°C) · TONSILLAR EXUDATES or swelling · SWOLLEN AND TENDER ANTERIOR CERVICAL NODES · ABSENCE OF COUGH. Three PRESENT and one ABSENT — that is the half people misremember. |
| Why ABSENCE of cough | A cough points TOWARD a viral cause, so its ABSENCE raises the probability of streptococcal infection. |
| ★ MODIFIED CENTOR — THE AGE POINTS | 3–14 years: +1. 15–44 years: 0. 45 AND OLDER: MINUS 1. This lives ONLY inside the slide’s PICTURE — the slide text is one caption line. |
| Score → risk of strep pharyngitis | ≤0 → 1–2.5% · 1 → 5–10% · 2 → 11–17% · 3 → 28–35% · ≥4 → 51–53%. |
| Score → action | ≤0: NO further testing or antibiotics. Middle: THROAT CULTURE or RAPID ANTIGEN TEST. ≥4: CONSIDER EMPIRIC TREATMENT. |
| UVULA deviation | Failure to rise WITH DEVIATION TO THE OPPOSITE SIDE → CN X PARALYSIS. The working side pulls unopposed, so the uvula points AWAY from the lesion. |
| TONGUE deviation | ASYMMETRIC PROTRUSION → CN XII LESION. |
| Tongue findings | SMOOTH, BEEFY RED → VITAMIN B12 DEFICIENCY. SORE AND SMOOTH → nutritional deficiency. GEOGRAPHIC TONGUE IS BENIGN. |
| TONGUE CANCER — where and who | LATERAL BORDER or UNDERSURFACE. INDURATED RED/WHITE lesions. MALES OVER 50. |
| Tongue palpation | Hold with GAUZE in one hand, palpate with the other, THEN SWITCH HANDS for the opposite side — the only way to reach both lateral borders. |
| Dentures | TAKE THEM OUT and look UNDERNEATH for ulcers and lesions. |
| Lip findings | ANGULAR CHEILITIS (corners) · ANGIOEDEMA · HERPES SIMPLEX. |
| TRENCH MOUTH | Necrotising ulcerative gingivitis = VINCENT’S ANGINA. “You can SMELL them across the room.” Bacteria DESTROY TISSUE as they go. From POOR DENTAL HYGIENE and drug use. |
| TORUS PALATINUS | BENIGN BONY GROWTH in the MIDLINE of the HARD PALATE. A normal variant, not a mass. |
| Hoarseness causes | VIRAL LARYNGITIS · VOICE OVERUSE · LARYNGEAL NERVE DAMAGE · REFLUX · SMOKING. |
| Term | What you need to know |
|---|---|
| ★ NODE CHAINS — in order, and NAME THEM ALOUD | PREAURICULAR · POSTAURICULAR · OCCIPITAL · TONSILLAR · SUBMANDIBULAR · SUBMENTAL · SUPERFICIAL (ANTERIOR) CERVICAL · POSTERIOR CERVICAL · DEEP CERVICAL · SUPRACLAVICULAR. “I need to know WHERE YOU’RE PUTTING YOUR FINGER” — the practical is graded on naming as you touch. |
| Palpation technique | PADS of the INDEX and MIDDLE fingers. |
| NORMAL node | ROUND OR OVOID · SMOOTH · MOBILE · NON-TENDER. |
| TENDER node | INFLAMMATION. |
| HARD or FIXED node | MALIGNANCY. Tender and soft is reactive; hard and fixed is not. |
| ★ LEFT SUPRACLAVICULAR node | METASTASIS FROM AN ABDOMINAL OR THORACIC MALIGNANCY. It drains territory far from the neck, so it redirects the whole search. |
| GENERALIZED lymphadenopathy | HIV/AIDS · EPSTEIN-BARR VIRUS · LYMPHOMA · LEUKEMIA · SARCOIDOSIS. |
| ★ LUDWIG’S ANGINA | SUBMANDIBULAR SWELLING AND ERYTHEMA = CELLULITIS OF THE FLOOR OF THE MOUTH. LIFE THREATENING — THE AIRWAY. Usually from LOWER TEETH. “It spreads FAST … you have to work with it QUICKLY.” |
| TRACHEAL deviation | MASSES · ATELECTASIS · LARGE PNEUMOTHORAX. |
| Thyroid landmark | Find the CRICOID CARTILAGE first — it locates the isthmus and lobes. |
| THYROID — diffuse enlargement splits on TEXTURE | SOFT → GRAVES DISEASE. FIRM → HASHIMOTO THYROIDITIS. TENDER → THYROIDITIS. |
| Other thyroid findings | ENDEMIC GOITER → IODINE DEFICIENCY. SINGLE NODULE → cyst or tumor. MULTINODULAR → metabolic process; RISK OF MALIGNANCY WITH FAMILY HISTORY. |
| HEADACHE patterns | MIGRAINE and TENSION are EPISODIC. MIGRAINE and CLUSTER are UNILATERAL. Migraine is in BOTH lists, so read the two features together. |
| HEADACHE red flags | SUDDEN AND SEVERE → SUBARACHNOID HEMORRHAGE. NEW, PROGRESSIVE AND PERSISTENT → MASS. Also consider MENINGITIS. |
| HEAD exam | FINE HAIR → HYPERTHYROIDISM. COARSE HAIR → HYPOTHYROIDISM. Look for LICE, SEBORRHEIC DERMATITIS, PSORIASIS, ATYPICAL NAEVI, ACTINIC KERATOSIS. SIZE: ENLARGED → HYDROCEPHALUS or PAGET DISEASE; SMALL → MICROCEPHALY. |