look if it is infection vs. malabsorption
63 y/0 colostomy bag taken down. Whenever the pt has gone under an (abdominal) surgery, make sure he passes gas and bowel is working
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Earwax, also known by the medical term cerumen, is a yellowish, waxy substance secreted in the ear canal of humans and many other mammals. It plays a vital role in the human ear canal, assisting in cleaning and lubrication, and also provides some protection from bacteria, fungus, and insects. A comprehensive review of the physiology and pathophysiology of cerumen can be found in Roeser and Ballachanda.[1] Excess or impacted cerumen can press against the eardrum and/or occlude the external auditory canal and impair hearing.
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The tympanic membrane, colloquially known as the eardrum, is a thin membrane that separates the external ear from the middle ear. Its function is to transmit sound from the air to the ossicles inside the middle ear. The malleus bone bridges the gap between the eardrum and the other ossicles.
Rupture or perforation of the eardrum can lead to conductive hearing loss.
| Eardrum | |
|---|---|
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| Anatomy of the human ear. | |
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A speculum is a medical tool for investigating body cavities.
Its form is dependent on the body cavity for which it is designed. Ear specula resemble a funnel, and come in a variety of sizes.
Nasal specula have two relatively flat blades with handle. The instrument is hinged so that when the handles are squeezed together the blades spread laterally, allowing examination.
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Paroxysmal nocturnal dyspnea (PND) is a medical symptom wherein people with congestive heart failure develop difficulties breathing after laying flat. PND commonly occurs several hours after a person with heart failure has fallen asleep. PND resolves quickly once a person awakens and sits upright. It takes longer to develop than orthopnea, which is the inability to lie down flat due to pulmonary fluid accumulation.
PND is caused by increasing amounts of fluid entering the lung during sleep and filling the small, air-filled sacs (alveoli) in the lung responsible for absorbing oxygen from the atmosphere. This fluid typically rests in the legs during the day when the individual is walking around and redistributes throughout the body (including the lungs) when recumbent. PND is a sign of severe heart failure and was first described by Charles Lepois in the 1500s.
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Main Entry: dys·pnea
Variant(s): or chiefly British dys·pnoea /
dis(p)-n
-
/
Function: noun
: difficult or labored respiration -- compare EUPNEA
- dys·pne·ic or chiefly British dys·pnoe·ic /-n-ik/ adjective
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Main Entry: dys·pha·gia
Pronunciation: dis-f
-j(-)
Function: noun
: difficulty in swallowing
- dys·phag·ic /-faj-ik/ adjective
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Main Entry: me·le·na
Variant(s): or chiefly British me·lae·na /m-l-n/
Function: noun
: the passage of dark tarry stools (not dark FORMED stool)containing decomposing blood that is usually an indication of bleeding in the upper part of the alimentary canal and especially the esophagus, stomach, and duodenum -- compare HEMATOCHEZIA
Melena vs. hematochezia
Bleeding originating from the lower GI tract (such as the sigmoid colon and rectum) is generally associated with the passage of bright red blood, or hematochezia, particularly when brisk. Blood acts as a cathartic agent in the intestine, promoting its prompt passage. Only blood that originates from a high source (such as the small intestine), or bleeding from a lower source that occurs slowly enough to allow for oxidation, is associated with melena. For this reason, melena is often associated with hemorrhage in the stomach or duodenum (upper gastrointestinal tract), for example by a peptic ulcer.
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Hematochezia is the passage of bloody stools from the rectum.[1] It is commonly associated with lower gastrointestinal bleeding.
In adults, the most common causes are hemorrhoids and diverticulosis, both of which are relatively benign; however, it can also be caused by colorectal cancer, which is frequently fatal. In the neonate, hematochezia can be an initial symptom of necrotizing enterocolitis, a serious condition.
Hematochezia can be due to upper gastrointestinal bleeding. However, as the blood from upper GI bleeding is usually chemically modified by action of acid and enzymes, it presents more commonly as melena. Hematochezia from an upper GI source is an ominous sign, as it suggests a very brisk bleed which is life threatening.
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head
- inspection of head
- palpation for tenderness
ear
- check hearin, which ear can hear sound
- quickness for brevity?
air conduction
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Weber lateralization
In the Weber test of hearing, a tuning fork is struck and placed on the patient's forehead. The patient is asked to report in which ear the sound is heard louder.
This test cannot confirm normal hearing, because hearing defects affecting both ears equally will produce an apparently normal test result. To avoid this a Rinne test should always be performed first to establish in which ear bone conduction is loudest; if both ears have a positive Rinne (i.e. they are normal) the Weber test will give no additional information. In the case that one or both ears has a negative Rinne (indicating that conduction through bone is more effective that the normal route through the outer and middle ear) then Weber should be used to confirm the type of hearing defecit.
A patient with normal hearing, positive Rinne both sides, would hear the sound equally in both ears or may not even hear it at all if the room is noisy enough to mask the subtle sound of the tuning fork. A patient with very similar hearing lost bilaterally (e.g. Presbycusis) would give the same result.
A patient with a unilateral (one-sided) conductive hearing loss would hear the tuning fork loudest in the affected ear. This is because the conduction problem masks the ambient noise of the room, whilst the well-functioning middle ear picks the sound up via the bones of the skull causing it to be perceived as a louder sound than in the unaffected ear.
A patient with a unilateral sensorineural hearing loss would hear the sound loudest in the unaffected ear, because the affected ear is less effective at picking up sound even if is transmitted directly by conduction into the middle ear.
Conductive hearing loss can be mimicked by plugging one ear with a finger and performing the Rinne and Weber tests, which will help clarify the above.
This test, and its complement, the Rinne test, are quick screening tests and are no replacement for formal audiometry.
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The Rinne test of hearing compares perception of sounds, as transmitted by air or by sound conduction through the mastoid. This is achieved by placing a vibrating tuning fork (512 Hz) initially on the mastoid, then next to the ear and asking which sound is loudest. Air conduction uses the apparatus of the ear (pinna, eardrum and ossicles) to amplify and direct the sound whereas bone conduction bypasses some or all of these and allows the sound to be transmitted directly to the inner ear albeit at a reduced volume, or via the bones of the skull to the opposite ear.
In a normal ear, air conduction (AC) is better than bone conduction (BC)
- AC > BC, positive Rinne.
In conductive hearing loss, bone conduction is better than air
- BC > AC, negative Rinne.
In sensorineural hearing loss, bone conduction and air conduction are both equally depreciated, maintaining the relative difference of
- AC > BC, positive Rinne.
In sensorineural hearing loss patients there may be a false negative Rinne
- BC > AC,
if the normal ear is not masked, and bone conduction heard in the normal ear is reported as louder by the patient because conduction through the skull to the opposite ear is more effective than conduction through room air around the head.
A Rinne test should always be accompanied by a Weber test to confirm the nature of hearing loss.
This test, and its complement the Weber test, are quick screening tests and are no replacement for formal audiometry.
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mouth throat neck and nose
- any sores or blisters?
feel inside for tenderness
tongue depressor
kissing tonsils, biltarally swollen
white plaques
- neck lymph node (thyroid)
check trachea midline
neck supple
lymph node, submandible, tonsilar
- thyroid
let a pt swallow some water, feel thyroid below cartilage from behind the pt. It should move as he swallows.
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eye exam
glasses or contact?
ocular movement
confrontational testing
face same level
fundoscope exam
