3 stations / 28 steps/ 9 script lines
Eyes and ENT
Two specialties that share a head. The histories here are the questions that decide whether the problem is in the eye or behind it; the exam follows the cranial nerve map in Neurology.
0 of 28 steps
Vision loss
- Neurological unilateral loss is optic nerve (ischemia, demyelination); a homonymous hemianopia is a post-chiasmal lesion the patient blames on one eye; ocular symptoms (injection, lid swelling) are usually eye disease.
- Onset and pain: sudden unilateral painless loss suggests ischemia; with headache, scalp tenderness, jaw claudication and polymyalgia symptoms, temporal arteritis; gradual loss over days that improves over weeks with pain on eye movement, optic neuritis; chronic progressive loss, compression.
- Location“Which eye is affected? Is the whole field or only part of it: upper, lower, temporal, nasal?”
- Associated“Any nausea or vomiting with eye pain? Halos around lights, redness, floaters, flashes, a curtain or shadow? Any numbness, weakness, speech or swallowing trouble, imbalance, dizziness, hearing change, double vision?”
- Past and family“Any previous injury to your head or eye? High blood pressure or cholesterol, diabetes, smoking? Anyone in the family who lost vision young, or had a stroke?”
Diplopia
- Binocular or monocular?“Does the double vision go away when you close one eye?”Neurological lesions cause binocular diplopia; monocular is ocular (corneal) or psychogenic. Diplopia essentially rules out a supratentorial lesion.
- Horizontal or vertical? Worse near (medial rectus) or far (lateral rectus)? Worse looking left or right?Horizontal, worse to the right and at distance: right CN VI palsy.
- Worse looking down and in, as on stairs? Head tilt that fixes it?Vertical diplopia on stairs with a head tilt away from the lesion: CN IV palsy; trauma is a common cause.
- Fluctuation and fatigability toward the end of the day, especially with ptosis: neuromuscular junction (myasthenia).
- Head trauma (orbital floor fracture restricting downward gaze) and vascular risk factors (microvascular palsies in older patients).
Eye pain, red eye, blurred vision
- Eye pain points to the anterior segment: dry eye, scleritis (with joint pain), corneal abrasion or ulcer, iritis (recurrent, systemic symptoms), angle closure glaucoma (severe pain over hours with nausea).“Is the pain in both eyes? Any recent exposure or travel? Redness? Better with blinking? Halos? Tearing or foggy vision? Photophobia? Has this happened before? Are the eyes firm to touch?”
- Red eye, approached from the lids inward: blepharitis, conjunctivitis (viral resolves in 2 to 3 weeks; bacterial usually gets a topical antibiotic, though most clears on its own), episcleritis.“Foreign body sensation? Discharge, and is it tears, mucus or pus? Puffy lids? A cold, cough or sore throat? Tired heavy lids? Crusts in the morning?”
- Painless blurred vision points to the posterior segment: central loss with macular disease; flashes, floaters or field defects with retinal tear or detachment.“One eye only? A shower of floating spots? Loss over one specific area? Distortion of straight lines? Recent trauma, or are you nearsighted?”
Rinne and Weber
| Row | Rinne (affected ear) | Weber |
|---|---|---|
| Normal | Air conduction louder than bone | No lateralization |
| Conductive loss (otitis media) | Bone conduction louder than air | Lateralizes to the affected ear |
| Sensorineural loss (CN VIII lesion) | Air louder than bone (normal) | Lateralizes to the unaffected ear |
Eye movement and pupil findings
| Row | Lesion |
|---|---|
| Eye down and out with ptosis and a dilated pupil | CN III with pupil involvement, typically compressive |
| Ptosis and down-and-out eye, pupil spared | CN III sparing the pupil, typically ischemic |
| Ptosis, miosis, anhidrosis | Horner syndrome, ipsilateral sympathetic pathway |
| Difficulty looking down and in, contralateral head tilt | CN IV palsy |
| Difficulty looking laterally | CN VI palsy |
| Ipsilateral adduction failure with nystagmus of the abducting eye | Internuclear ophthalmoplegia, medial longitudinal fasciculus |
Recall quiz
Localize the eye finding
Eye position and pupil in; the lesion out.
Score 0 / 6Streak 0
Shuffling the deck...
Demonstration videos are embedded from their creators’ own YouTube channels (Geeky Medics and Stanford Medicine 25) and remain theirs; each frame credits the channel and links out to it.