URI: upper respiratory infection caused either by bacteria or a virus, leading to congestion, sneezing, rhinorrhea, discharge, malaise. if bacterial in origin, a URI might be more likely to present with fever / chills and yellow/green mucopurulent discharge. if viral in origin a URI might present with clear rhinorrhea. diagnosis is by the jones criteria, rapid strep test, and microscopic smear of exudates.
asthma: can be extrinsic (allergic, to molds, pollens, etc), or intrinsic (infectious, emotional, etc.). usually results in coughing (worse at night), wheezing, dyspnea, sputum production. PE findings might include tachypnea, tachycardia, accessory muscle use, and if severe, pulsus paradoxus and muscle wasting. lung auscultation will reveal prolonged expiratory phase with expiratory wheezing, diminished breath sounds. a skin exam might also be performed to confirm signs of atopy (eczema, dermatitis).
sinusitis is an inflammation of the sinuses due to infection or allergies. it can result in a painful pressure in the sinus area from the swelling of the mucous membranes if associated with a URI. typical signs and symptoms might include swelling / tenderness over the affected sinus, malaise, toothache, severe frontal headache, swollen eyelids. on PE, one might find erythematous nasal mucosa and sinuses that do not transilluminate. labs might be useful to rule out periapical abscess (using xray) or to confirm chronic sinusitis (using CT scan).
bronchitis is an inflammation of the bronchial tree, either secondary to an infection, asthma, irritant, or primary/chronic. if infectious in origin, bronchitis is likely due to a bacterial URI, while common irritants might be organic solvents, ammonia, dust, chlorine. symptoms are similar to an infectious URI: coryza, malaise, f/c, myalgia, etc. the cough often progresses from a dry, non-productive, to a sputum producing cough. on a respiratory exam, one might hear scattered rhonchi, crackling/wheezing, moist rales.
pneumonia is an acute infection of the lung, and can be from a variety of different sources- bacterial, viral, or mycoplasmal. adults are more likely to get bacterial pneumonia, while young adults and children are more likely to get mycoplasmal or viral. risk factors include cigarette smoke, young/old age, immunocompromised, recurrent URI's, physical debilitation. patients might present with fever / chills, nausea / vomiting, pleurisy / dyspnea, productive cough with rusty colored sputum and an increased pulse and respiratory rate. a lung exam might reveal signs of lung consolidation: dullness to percussion, increased tactile fremitus, whispered pectriloquy, and bronchial breath sounds / crackles. ddx's might include bronchitis, goodpasture's, asthma, cystic fibrosis.
some notes on the different types of headaches. doing a good history is vital to determining the cause of the headache, as well as determining the location and radiation patterns. tension headaches are more likely to be described as a band-like pain around the occiput, whereas migraines are more frontal. pain around or in the eyes might be due to a cluster headache, and pain in the face is likely from trigeminal neuralgia. unilateral head pain on the side of the head could be from temporal arteritis. papilledema or A/V nicking on a fundoscopic can indicate serious conditions such as intracranial hemorrhage or malignant hypertension, respectively.
hay fever aka allergic rhinitis is inflammation of the mucosa of the eyes and nasal passageways, leading to rhinorrhea, itchy / burning eyes and nasal congestion. it is often due to seasonal allergens such as pollen and will present bilaterally. a skin test might be useful to check for signs of atopy in the form of dermatitis, etc. differentials might include sinusitis, acute rhinitis, vasomotor rhinitis, and cocaine use.
conjunctivitis is an inflammation of the conjunctiva of the eyes and can be bacterial, viral (pink eye), or allergic / irritant in nature. signs include conjunctival injection (superficial dilated vessels away from the iris), pruritis, discharge, hyperemic and swollen lids. if symptoms are bilateral, the origin is more likely to be infectious or allergic while unilateral symptoms suggest toxic/chemical/mechanical causes. a culture of secretions can be useful in differentiating the cause of conjunctivitis: bacterial related secretions would contain PMN's, viral would contain leukocytes, and allergic would contain eosinophils.
strep throat is the result of infection via type A beta-hemolytic strep. it manifests as swollen, sore throat with fever and L/A. the jones criteria, used to diagnose strep, requires at least 2 of the following: fever above 100.4F po, no cough, pseudomembrane, tonsillar exudate. strep can also be diagnosed via a rapid strep test or throat culture. ddx's might include pharyngitis, mono, peritonsilar abscess, and diptheria.
vertigo is more of a symptom and can be due to several different causes, including benign paroxysmal positional vertigo, meniere's vestibular neuronitis, and other CNS disorders. episodic vertigo is more likely to be BPPV, while vertigo that lasts for hours / days is more likely to be meniere's or vestibular neuronitis. vertigo can also be associated with symptoms such as nausea / vomiting, tinnitus, and nystagmus-- which if unilateral and horizontal indicates benign causes and if variable indicates CNS disorders.
questions
URI...
1. what is the etiology of a URI?
2. what are some typical signs / symptoms of a URI?
3. what are some features that might distinguish a URI of bacterial vs. viral origin?
4. what labs should be performed for the diagnosis of a URI?
asthma...
5. what are three major features of asthma?
6. what is the difference between intrinsic and extrinsic asthma?
7. what are the major signs and symptoms of asthma?
8. what are some typical PE findings for asthma?
9. what signs might indicate a severe case of asthma?
10. what are the common findings for a lung exam on a patient with asthma?
11. why might a skin exam be performed on a patient suspected of having asthma?
sinusitis...
12. what is sinusitis?
13. what are the typical signs and symptoms of sinusitis?
14. what are some typical PE findings for sinusitis?
15. which labs might be performed to aid in a diagnosis of sinusitis?
bronchitis...
16. what is bronchitis?
17. what are the most common etiological agents for bronchitis?
18. the symptoms of infectious bronchitis are similar to...
19. describe the progression of the cough in infectious bronchitis.
20. severe cases of bronchitis might also present with...
21. what might be heard on a respiratory exam for bronchitis?
22. where in the lung might these sounds be heard?
pneumonia...
23. what is pneumonia?
24. what are three different types of pneumonia?
25. which type is most common in adults? young adults / children?
26. what are some risk factors for pneumonia?
27. what are the signs and symptoms for pneumonia?
28. what are the signs one would expect to find on a lung exam of a pneumonia patient?
29. what are some ddx's for pneumonia?
headaches...
30. what are some causes of head pain?
31. where do tension headaches usually present? how is the sensation described?
32. a frontal headache is more likely what type of headache?
33. a periorbital or deep orbital pain is most likely due to what type of headache?
34. pain in the face is likely due to...
35. unilateral head pain on the side of the head is likely due to...
36. patients with temporal arteritis might also present with what concomitant symptom?
37. what are some physical exams that one should perform on a patient that presents with head pain?
hay fever...
38. what is hay fever?
39. what are two useful questions to ask a patient suspected of hay fever?
40. what are the signs and symptoms of hay fever?
41. why might a skin test be performed in patients suspected of hay fever?
42. what are the differentials for hay fever?
conjunctivitis...
43. "pink eye" is...
44. what are the signs and symptoms of conjunctivitis?
45. what do bilateral vs. unilateral symptoms suggest about the origins of conjunctivitis?
46. what PE exams would be useful in diagnosing conjunctivitis?
47. what labs would you order with a patient suspected of conjunctivitis?
strep throat...
48. what is the etiology of strep throat?
49. what are the signs/symptoms of strep throat?
50. what are the jones criteria for diagnosing strep throat?
51. what are the lab tests used to diagnose strep throat?
52. what are the ddx's for strep throat?
vertigo...
53. episodic vertigo is more likely to be...
54. vertigo that lasts hours or days is more likely to be...
55. vertigo that is sudden onset and lasts for minutes is more likely to be...
56. what are the signs and symptoms associated with vertigo?
57. how can the type of nystagmus differentiate between potential causes of vertigo?
answers
1. viruses or bacteria invading upper respiratory tract, causing inflammation of the mucosa.
2. congestion, sneezing, rhinorrhea, post-nasal drainage, malaise.
3. bacterial more likely to have fever / chills and yellow green mucopurulent discharge. viral more likely to have clear rhinorrhea.
4. rapid strep test if jones criteria met, microscopic smear of exudates.
5. airway obstruction
inflammation
irritability / hypersensitivity
6. extrinsic is to allergy to external factors such as mold, pollen, etc. intrinsic is non allergic- from infections or emotional or other internal causes.
7. coughing, especially at night
wheezing, shortness of breath, DOE
sputum production
8. tachypnea, tachycardia, diaphoresis, wheezing, accessory muscle use.
9. weight loss, wasting, pulsus paradoxus.
10. prolonged expiratory phase, expiratory wheezing and diminished breath sounds.
11. to look for signs of atopy: dermatitis, eczema, other allergic skin conditions.
12. inflammation of the paranasal sinuses due to infection or allergy.
13. swelling / tenderness
malaise
toothache
frontal headache
swollen eyelids
14. erythematous nasal mucosa, sinuses do not transilluminate.
15. CT scan for chronic sinusitis
xray of teeth apices to rule out periapical abscess
CBC
16. an infection of the bronchial tree, either secondary to an infection, asthma, irritant, or primary / chronic.
17. infectious: bacterial URI
irritant: organic solvents, ammonia, dusts, chlorine
18. infectious URI symptoms: coryza, malaise, fever/chills, myalgia, etc
19. begins as dry and non productive, then develops into a productive cough.
20. 101-102 degree fevers.
21. scattered rhonchi, crackling/wheezing, moist rales.
22. at the base for crackling / rales.
23. infection of the lung.
24. bacterial, viral, mycoplasma.
25. bacterial most common in adults, mycoplasma in young adults and children.
26. immunocompromised
young or old age
recurrent URI's
cigarette smoke
physical debilitation
27. fever / chills
pleurisy / dyspnea
productive cough with rusty sputum
tachycardia, tachypnea
N/V
malaise / myalgia
28. increased tactile fremitus
dullness to percussion
bronchial breath sounds
whispered pectriloquy
crackles
[touch dull bronchial whisper crackle]
[fremitus dullness whisper bronchial crackles] [touch the dull whisker to hear the bronchial crackles]
29. bronchitis
asthma
cystic fibrosis
goodpasture's
30. vasomotor instability
muscle tension
hypoglycemia
infection
trauma
mass lesion
cerebral hemorrhage
31. occiput, band-like.
32. migraine
33. cluster
34. trigeminal neuralgia.
35. temporal arteritis.
36. polymyalgia rheumatica.
37. vitals, M/S, eye exam, sinsuses, neurological exam.
38. also known as allergic rhinitis; an inflammatory process involving the nasal and throat mucosa, as well as the conjunctiva in response to various allergens.
39. do your symptoms appear seasonally? are they bilateral?
40. rhinorrhea
burning, itchy, watery eyes
nasal / sinus congestion
41. to check for signs of atopy: dermatitis, eczema.
42. sinusitis, acute rhinitis, vasomotor rhinitis, cocaine use.
43. viral conjunctivitis.
44. superficial dilated vessels in conjunctiva
pruritis
discharge
hyperemia, swelling of lids
45. bilateral more likely allergic / infectious. unilateral more likely toxic/chemical/mechanical.
46. vitals, lymph nodes, EENT, (heart, lungs)
47. culture of secretion: bacterial would contain PMN's, viral would contain lymphocytes, allergic would contain eosinophils.
48. pharyngitis caused by group A beta-hemolytic streptococcus.
49. sore throat
fever
no cough
cervical L/A
injected / erythematous mucous membranes
exudate / pseudomembrane
50. fever over 100.4 po, no cough, tonsilar exudate, pseudomembrane.
51. rapid strep test and throat culture.
52. viral / bacterial pharyngitis
infectious mononucleosis
diptheria
peritonsilar abscess
53. BPPV
54. meniere's, vestibular neuronitis
55. brain or vascular disease.
56. spinning sensation/disequilibirum
nystagmus
N/V
tinnitus
57. unilateral horizontal nystagmus is more likely benign, variable nystagmus likely due to a CNS disorder.
Showing posts with label vertigo. Show all posts
Showing posts with label vertigo. Show all posts
Wednesday, May 5, 2010
Saturday, May 2, 2009
organ systems III: vestibular system
the vestibular system is located in the inner ear and is involved in detecting head movement, maintaining balance and posture, and formation of the perception of one's physical boundaries. it is located within the petrous portion of the temporal bone and has several components: the bony labyrinth is the outer covering which contains the 3 mutually perpendicular semicircular canals and the vestibule. inside the semicircular canals are the semicircular ducts which contain endolymph and the crista receptors in the ampulla of each duct. inside the vestibule are the utricle and saccule, which contain the macula receptor.
the crista receptors inside the semicircular ducts are designed to sense angular acceleration- rotation of the head causes the fluid inside the semicircular ducts to shift due to the inertia of the fluid itself. the fluid pressing against the crista receptors causes a distortion of the cilia embedded within the crista, which causes a receptor potential. each semicircular canal is in a different orientation such that any given rotation will produce a different set of shifts in each duct, the combination of which is then integrated and processed downstream.
the macula receptors inside saccule and utricle are designed to sense linear acceleration. these are made of receptor cells with cilia embedded within a gelatinous otolith layer, on top of which there are calcium carbonate stones. when the head is tilted, the stones distort the otolith layer and therefore the cilia from the receptor cells, producing a receptor potential. occasionally the otoliths can detach and enter the semicircular ducts, causing benign paroxysmal positional vertigo.
the vestibular pathway starts at the vestibular nerve, which carries information to the vestibular nuclei in the pons. from there the vestibular nuclei projects to cranial nerves III, IV, VI in order to coordinate eye movement along with head movement (to enable tracking of an object in space- the vestibulo-ocular reflex), and also to the vestibulospinal tract, for control of muscles involved in posture and balance. damage to the vestibular pathway might result in vertigo, a loss of equilibrium and balance and a sense of falling.
information from the vestibular system is also projected to the vestibular cortex, which is located at the temporal-parietal junction, insula, somatosensory cortex, and the superior parietal cortex. in the parietal association cortex, vestibular information is integrated with other modalities such as somatosensory, visual, audition, etc. in order to form an integrated sense of one's environment and body. the vestibular cortex is also known to be involved in the sense of localization; ie, where one perceive's one's center of awareness to be. dysfunctions within the temporal-parietal junction in particular have been demonstrated to cause such hallucinations (of increasing intensity and of vestibular dysfunction) as autoscopy, where one sees one's own body in another space, heatoscopy, where one sees one's own body in another space and feels one's awareness might be located there as well, and out of body experiences, in which the person's center of awareness is completely removed from their body.
questions
anatomy and receptor physiology...
1. where is the vestibular system located?
2. the bony labyrinth is divided into...
3. what is the membranous labyrinth and what is it divided into?
4. what is endolymph secreted by? where does it drain?
5. what is perilymph secreted by? where does it drain?
6. what is meniere's disease?
7. what are the three semicircular ducts/canals? describe their orientation.
8. rotation of ducts with head causes...
9. what are crista and cupula?
10. how does the crista sense rotation?
11. describe the sensory receptor system within the saccule and utricle.
12. the macula is sensitive to what type of acceleration as opposed to the crista?
13. what happens in benign paroxysmal positional vertigo?
innervation...
14. vestibular nerve conducts to...
15. from where do the vestibular nuclei in the pons receive input?
16. where do the vestibular nuclei project to?
17. what is the vestibulo ocular reflex?
18. what is nystagmus?
19. what do the vestibulospinal tracts project to?
20. what is vertigo and what can it be caused by?
perception and sensation...
21. what does the parietal association cortex do?
22. how was the vestibular cortex mapped out?
23. where is the vestibular cortex?
24. which part of the vestibular cortex is mainly responsible for creating the sense of being in one's body?
25. what is autoscopy?
26. describe an out of body experience.
27. describe an autoscopic hallucination.
28. describe "heatoscopy".
29. which of these illusions has the most vestibular dysfunction? which has the least?
answers
1. within the petrous portion of the temporal bone.
2. the vestibule and the semi-circular canal.
3. membranous tube containing receptors for head movement; divided into semicircular ducts (in the semicircular canals) and saccule and utricle (within the vestibule).
4. secreted by cochlear duct and drains into dural sinuses via endolymphatic duct.
5. secreted by periosteum and drains into CSF via perilymphatic duct.
6. excess endolymph secretion or fluid pressure causing nausea/vomiting, vertigo/dizziness, abnormal saccadic eye movements.
7. anterior, horizontal, posterior. mutually perpendicular.
8. flow of endolymph within ducts.
9. the receptor organ in the ampula of each canal; the cupula is the gelatinous mass which the cilia of receptor cells are embedded in.
10. rotation of the head in the same alignment as the semicircular canals produces pressure against the crista because of the inertia of the endolymph.
11. maculae is the sensory device which is composed of ciliated macular receptor cells which have cilia embedded in the gelatinous otolithic membrane, which is then covered by calcium carbonate stones which produce shifts in the otolithic membrane when the head is tilted.
12. linear acceleration as opposed to angular acceleration.
13. when otoliths from utricle fall into the semicircular canals and produce "apparent motion" in the crista, resulting in dizziness, vertigo, imbalance, nausea
14. the vestibular nuclei in brain stem, cerebellum.
15. directly from the vestibular nerve or indirectly from the cerebellum.
16. CN III, IV, VI for control of eye movement.
17. a reflex that requires the cerebellum which causes movement of eyes opposite to rotation of head.
18. involuntary saccadic movements when the eyeball is at rest.
19. to the muscles that control posture and balance.
20. disorientation and a sense of spinning-- can be caused by a tumor in vestibular system or meniere's disease.
21. integrates somatosensory, proprioceptive, visual, auditory, vestibular input to form body schema- body, personal space, extra personal space.
22. by looking at brain responses to vestibular illusions in epilepsy, or to galvanic/caloric vestibular stimulation.
23. the temporal-parietal junction, insula, somatosensory cortex, superior parietal cortex.
24. the temporal-parietal junction.
25. the experience of perceiving one's own body in another place because of the lack of congruence among the sensory inputs integrated in the association cortices.
26. seeing one's own body from an elevated position, feeling that the center of awareness is located outside of the body (disembodiment).
27. seeing a double of oneself in extrapersonal space, with the center of awareness remaining inside the body.
28. seeing a double of oneself in extrapersonal space with the center of awareness being split between the body and the extrapersonal space.
29. out of body has the most TPJ dysfunction, then heatoscopy, then autoscopy.
the crista receptors inside the semicircular ducts are designed to sense angular acceleration- rotation of the head causes the fluid inside the semicircular ducts to shift due to the inertia of the fluid itself. the fluid pressing against the crista receptors causes a distortion of the cilia embedded within the crista, which causes a receptor potential. each semicircular canal is in a different orientation such that any given rotation will produce a different set of shifts in each duct, the combination of which is then integrated and processed downstream.
the macula receptors inside saccule and utricle are designed to sense linear acceleration. these are made of receptor cells with cilia embedded within a gelatinous otolith layer, on top of which there are calcium carbonate stones. when the head is tilted, the stones distort the otolith layer and therefore the cilia from the receptor cells, producing a receptor potential. occasionally the otoliths can detach and enter the semicircular ducts, causing benign paroxysmal positional vertigo.
the vestibular pathway starts at the vestibular nerve, which carries information to the vestibular nuclei in the pons. from there the vestibular nuclei projects to cranial nerves III, IV, VI in order to coordinate eye movement along with head movement (to enable tracking of an object in space- the vestibulo-ocular reflex), and also to the vestibulospinal tract, for control of muscles involved in posture and balance. damage to the vestibular pathway might result in vertigo, a loss of equilibrium and balance and a sense of falling.
information from the vestibular system is also projected to the vestibular cortex, which is located at the temporal-parietal junction, insula, somatosensory cortex, and the superior parietal cortex. in the parietal association cortex, vestibular information is integrated with other modalities such as somatosensory, visual, audition, etc. in order to form an integrated sense of one's environment and body. the vestibular cortex is also known to be involved in the sense of localization; ie, where one perceive's one's center of awareness to be. dysfunctions within the temporal-parietal junction in particular have been demonstrated to cause such hallucinations (of increasing intensity and of vestibular dysfunction) as autoscopy, where one sees one's own body in another space, heatoscopy, where one sees one's own body in another space and feels one's awareness might be located there as well, and out of body experiences, in which the person's center of awareness is completely removed from their body.
questions
anatomy and receptor physiology...
1. where is the vestibular system located?
2. the bony labyrinth is divided into...
3. what is the membranous labyrinth and what is it divided into?
4. what is endolymph secreted by? where does it drain?
5. what is perilymph secreted by? where does it drain?
6. what is meniere's disease?
7. what are the three semicircular ducts/canals? describe their orientation.
8. rotation of ducts with head causes...
9. what are crista and cupula?
10. how does the crista sense rotation?
11. describe the sensory receptor system within the saccule and utricle.
12. the macula is sensitive to what type of acceleration as opposed to the crista?
13. what happens in benign paroxysmal positional vertigo?
innervation...
14. vestibular nerve conducts to...
15. from where do the vestibular nuclei in the pons receive input?
16. where do the vestibular nuclei project to?
17. what is the vestibulo ocular reflex?
18. what is nystagmus?
19. what do the vestibulospinal tracts project to?
20. what is vertigo and what can it be caused by?
perception and sensation...
21. what does the parietal association cortex do?
22. how was the vestibular cortex mapped out?
23. where is the vestibular cortex?
24. which part of the vestibular cortex is mainly responsible for creating the sense of being in one's body?
25. what is autoscopy?
26. describe an out of body experience.
27. describe an autoscopic hallucination.
28. describe "heatoscopy".
29. which of these illusions has the most vestibular dysfunction? which has the least?
answers
1. within the petrous portion of the temporal bone.
2. the vestibule and the semi-circular canal.
3. membranous tube containing receptors for head movement; divided into semicircular ducts (in the semicircular canals) and saccule and utricle (within the vestibule).
4. secreted by cochlear duct and drains into dural sinuses via endolymphatic duct.
5. secreted by periosteum and drains into CSF via perilymphatic duct.
6. excess endolymph secretion or fluid pressure causing nausea/vomiting, vertigo/dizziness, abnormal saccadic eye movements.
7. anterior, horizontal, posterior. mutually perpendicular.
8. flow of endolymph within ducts.
9. the receptor organ in the ampula of each canal; the cupula is the gelatinous mass which the cilia of receptor cells are embedded in.
10. rotation of the head in the same alignment as the semicircular canals produces pressure against the crista because of the inertia of the endolymph.
11. maculae is the sensory device which is composed of ciliated macular receptor cells which have cilia embedded in the gelatinous otolithic membrane, which is then covered by calcium carbonate stones which produce shifts in the otolithic membrane when the head is tilted.
12. linear acceleration as opposed to angular acceleration.
13. when otoliths from utricle fall into the semicircular canals and produce "apparent motion" in the crista, resulting in dizziness, vertigo, imbalance, nausea
14. the vestibular nuclei in brain stem, cerebellum.
15. directly from the vestibular nerve or indirectly from the cerebellum.
16. CN III, IV, VI for control of eye movement.
17. a reflex that requires the cerebellum which causes movement of eyes opposite to rotation of head.
18. involuntary saccadic movements when the eyeball is at rest.
19. to the muscles that control posture and balance.
20. disorientation and a sense of spinning-- can be caused by a tumor in vestibular system or meniere's disease.
21. integrates somatosensory, proprioceptive, visual, auditory, vestibular input to form body schema- body, personal space, extra personal space.
22. by looking at brain responses to vestibular illusions in epilepsy, or to galvanic/caloric vestibular stimulation.
23. the temporal-parietal junction, insula, somatosensory cortex, superior parietal cortex.
24. the temporal-parietal junction.
25. the experience of perceiving one's own body in another place because of the lack of congruence among the sensory inputs integrated in the association cortices.
26. seeing one's own body from an elevated position, feeling that the center of awareness is located outside of the body (disembodiment).
27. seeing a double of oneself in extrapersonal space, with the center of awareness remaining inside the body.
28. seeing a double of oneself in extrapersonal space with the center of awareness being split between the body and the extrapersonal space.
29. out of body has the most TPJ dysfunction, then heatoscopy, then autoscopy.
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