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71

Labyrinth and the Liminal Student

Background The transition period from undergraduate training to postgraduate “foundation” practice is brief – often only a matter of a few days - but its impact is profound. What was previously a well supported, structured learning environment is suddenly a strange and potentially frightening place where critical decision-making skills, authority and professionalism seem suddenly more relevant than all of the knowledge amassed in undergraduate training. Foundation doctors indicate that the undergraduate experience does little to prepare them for the shock of actual practice. Summary of work An emerging initiative within the University of Edinburgh’s College of Medicine and Veterinary Medicine is to adopt the easy-to-use authoring tools and principals associated with Game Informed Learning to afford collaborative groups of later year undergraduates and foundation doctors the scope to create learning objects for undergraduates. Conclusions Using in-house developed instruments such as the branching scenario authoring tool “Labyrinth”, these groups draw on their recent experience of this transition period to create learning objects that not only directly address perceived gaps in the range of learning support activities available to undergraduates but also, using the principals of game-informed learning to situate the activities within realistic contexts, and plausible scenarios which offer an indication of what practice will feel like. Take-home message Learning tools to ease the transition between medical student and doctor.  
Jennifer Willder
over 9 years ago
10
1
74

Focus On: Treatment of Epistaxis

Epistaxis is one of the most common ear, nose, and throat emergencies, with an estimated 60% lifetime incidence rate for an individual person.  
American College Of Emergency Medicine
almost 9 years ago
29749
7
362

Cranial Nerve Examination - Abnormal

Cranial Nerve 1- Olfaction This patient has difficulty identifying the smells presented. Loss of smell is anosmia. The most common cause is a cold (as in this patient) or nasal allergies. Other causes include trauma or a meningioma affecting the olfactory tracts. Anosmia is also seen in Kallman syndrome because of agenesis of the olfactory bulbs. Cranial Nerve 2- Visual acuity This patientâs visual acuity is being tested with a Rosenbaum chart. First the left eye is tested, then the right eye. He is tested with his glasses on so this represents corrected visual acuity. He has 20/70 vision in the left eye and 20/40 in the right. His decreased visual acuity is from optic nerve damage. Cranial Nerve II- Visual field The patient's visual fields are being tested with gross confrontation. A right sided visual field deficit for both eyes is shown. This is a right hemianopia from a lesion behind the optic chiasm involving the left optic tract, radiation or striate cortex. Cranial Nerve II- Fundoscopy The first photograph is of a fundus showing papilledema. The findings of papilledema include 1. Loss of venous pulsation 2. Swelling of the optic nerve head so there is loss of the disc margin 3. Venous engorgement 4. Disc hyperemi 5. Loss of the physiologic cup an 6. Flame shaped hemorrhages. This photograph shows all the signs except the hemorrhages and loss of venous pulsations. The second photograph shows optic atrophy, which is pallor of the optic disc resulting form damage to the optic nerve from pressure, ischemia, or demyelination. Images Courtesy Dr. Kathleen Digre, University of Uta Cranial Nerves 2 & 3- Pupillary Light Refle The swinging flashlight test is used to show a relative afferent pupillary defect or a Marcus Gunn pupil of the left eye. The left eye has perceived less light stimulus (a defect in the sensory or afferent pathway) then the opposite eye so the pupil dilates with the same light stimulus that caused constriction when the normal eye was stimulated. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Inspection & Ocular Alignmen This patient with ocular myasthenia gravis has bilateral ptosis, left greater than right. There is also ocular misalignment because of weakness of the eye muscles especially of the left eye. Note the reflection of the light source doesn't fall on the same location of each eyeball. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Versions • The first patient shown has incomplete abduction of her left eye from a 6th nerve palsy. • The second patient has a left 3rd nerve palsy resulting in ptosis, dilated pupil, limited adduction, elevation, and depression of the left eye. Second Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Duction Each eye is examined with the other covered (this is called ductions). The patient is unable to adduct either the left or the right eye. If you watch closely you can see nystagmus upon abduction of each eye. When both eyes are tested together (testing versions) you can see the bilateral adduction defect with nystagmus of the abducting eye. This is bilateral internuclear ophthalmoplegia often caused by a demyelinating lesion effecting the MLF bilaterally. The adduction defect occurs because there is disruption of the MLF (internuclear) connections between the abducens nucleus and the lower motor neurons in the oculomotor nucleus that innervate the medial rectus muscle. Saccades Smooth Pursui The patient shown has progressive supranuclear palsy. As part of this disease there is disruption of fixation by square wave jerks and impairment of smooth pursuit movements. Saccadic eye movements are also impaired. Although not shown in this video, vertical saccadic eye movements are usually the initial deficit in this disorder. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Utah Optokinetic Nystagmu This patient has poor optokinetic nystagmus when the tape is moved to the right or left. The patient lacks the input from the parietal-occipital gaze centers to initiate smooth pursuit movements therefore her visual tracking of the objects on the tape is inconsistent and erratic. Patients who have a lesion of the parietal-occipital gaze center will have absent optokinetic nystagmus when the tape is moved toward the side of the lesion. Vestibulo-ocular refle The vestibulo-ocular reflex should be present in a comatose patient with intact brainstem function. This is called intact "Doll’s eyes" because in the old fashion dolls the eyes were weighted with lead so when the head was turned one way the eyes turned in the opposite direction. Absent "Doll’s eyes" or vestibulo-ocular reflex indicates brainstem dysfunction at the midbrain-pontine level. Vergenc Light-near dissociation occurs when the pupils don't react to light but constrict with convergence as part of the near reflex. This is what happens in the Argyll-Robertson pupil (usually seen with neurosyphilis) where there is a pretectal lesion affecting the retinomesencephalic afferents controlling the light reflex but sparing the occipitomesencephalic pathways for the near reflex. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerve 5- Sensor There is a sensory deficit for both light touch and pain on the left side of the face for all divisions of the 5th nerve. Note that the deficit is first recognized just to the left of the midline and not exactly at the midline. Patients with psychogenic sensory loss often identify the sensory change as beginning right at the midline. Cranial Nerves 5 & 7 - Corneal refle A patient with an absent corneal reflex either has a CN 5 sensory deficit or a CN 7 motor deficit. The corneal reflex is particularly helpful in assessing brainstem function in the unconscious patient. An absent corneal reflex in this setting would indicate brainstem dysfunction. Cranial Nerve 5- Motor • The first patient shown has weakness of the pterygoids and the jaw deviates towards the side of the weakness. • The second patient shown has a positive jaw jerk which indicates an upper motor lesion affecting the 5th cranial nerve. First Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 7- Motor • The first patient has weakness of all the muscles of facial expression on the right side of the face indicating a lesion of the facial nucleus or the peripheral 7th nerve. • The second patient has weakness of the lower half of his left face including the orbicularis oculi muscle but sparing the forehead. This is consistent with a central 7th or upper motor neuron lesion. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 7- Sensory, Tast The patient has difficulty correctly identifying taste on the right side of the tongue indicating a lesion of the sensory limb of the 7th nerve. Cranial Nerve 8- Auditory Acuity, Weber & Rinne Test This patient has decreased hearing acuity of the right ear. The Weber test lateralizes to the right ear and bone conduction is greater than air conduction on the right. He has a conductive hearing loss. Cranial Nerve 8- Vestibula Patients with vestibular disease typically complain of vertigo – the illusion of a spinning movement. Nystagmus is the principle finding in vestibular disease. It is horizontal and torsional with the slow phase of the nystagmus toward the abnormal side in peripheral vestibular nerve disease. Visual fixation can suppress the nystagmus. In central causes of vertigo (located in the brainstem) the nystagmus can be horizontal, upbeat, downbeat, or torsional and is not suppressed by visual fixation. Cranial Nerve 9 & 10- Moto When the patient says "ah" there is excessive nasal air escape. The palate elevates more on the left side and the uvula deviates toward the left side because the right side is weak. This patient has a deficit of the right 9th & 10th cranial nerves. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 9 & 10- Sensory and Motor: Gag Refle Using a tongue blade, the left side of the patient's palate is touched which results in a gag reflex with the left side of the palate elevating more then the right and the uvula deviating to the left consistent with a right CN 9 & 10 deficit. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 11- Moto When the patient contracts the muscles of the neck the left sternocleidomastoid muscle is easily seen but the right is absent. Looking at the back of the patient, the left trapezius muscle is outlined and present but the right is atrophic and hard to identify. These findings indicate a lesion of the right 11th cranial nerve. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 12- Moto Notice the atrophy and fasciculation of the right side of this patient's tongue. The tongue deviates to the right as well because of weakness of the right intrinsic tongue muscles. These findings are present because of a lesion of the right 12th cranial nerve.  
Neurologic Exam
over 8 years ago
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2
138

ENT Examination

Guide to doing a clinical exam on the ears, nose and throat by the clinical skills tutors at the University of Liverpool  
Mary
over 6 years ago
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7
154

Ear Anatomy

The outer, middle and inner ear. The structures that are present, hope you like it!! Facebook: http://www.facebook.com/ArmandoHasudungan IMAGE: https://docs.google.com/open?id=0B8Ss3-wJfHrpcER1Q2lpX2g0WGs  
Nicole Chalmers
over 5 years ago
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8
167

Anatomy of the Ear and Physiology of Hearing

A walk-through of ear anatomy using an illustrated diagram.  
Nicole Chalmers
over 5 years ago
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1
26

Upper Respiratory Tract Infections

Upper Respiratory Tract Infections These account for up to 80% of all RTI’s in children. They can involve the ears, nose, throat and sinuses. They are rarely serious and will not often require hospitalisation. They can become an issue when: A very young child has an RTI that causes a severely ‘blocked nose’ as this can affect feeding. This may result in hospitalisation. There are associated febrile convulsions The RTI causes an exacerbation of asthma  
almostadoctor.com - free medical student revision notes
over 5 years ago
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1894

Ear Anatomy & Physiology

Ms. Klemme discusses basic ear anatomy and an introduction to the hearing pathway.  
YouTube
over 5 years ago
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8
268

Ear Organ of Corti

An animation of the organ in the inner ear of mammals that contain auditory inner and outer haircells.  
YouTube
over 5 years ago
Static.www.bmj
1
36

Hoarseness in a 79 year old woman

A 79 year old woman was referred to our ear, nose, and throat outpatient clinic with a history of hoarse voice. This symptom had been present for around three months. It initially fluctuated in severity but eventually became constant. There was no associated pain, weight loss, cough, dysphagia, odynophagia, or other upper airway symptoms. She had not recently had surgery or experienced trauma. Her medical history was of chronic obstructive pulmonary disease, and she was an ex-smoker.  
bmj.com
about 5 years ago
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1
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A 68 year old woman with deteriorating hearing

A 68 year old woman presented to the ear, nose, and throat (ENT) clinic with gradually worsening bilateral hearing loss over at least the past five years. This was associated with some non-intrusive tinnitus but no other otological symptoms, history of vertigo, or associated systemic problems. She found that she was increasing the TV volume to a level that her family found uncomfortable, and she had started to avoid social situations because she struggled to hear conversation among the background noise. Her medical history was unremarkable except for well controlled hypertension, for which she was taking amlodipine. She also had no history of excessive noise exposure, no previous otological problems, and no family history of note.  
bmj.com
about 5 years ago
1
1
20

WHO | Many countries lack capacity to prevent and treat hearing loss

Many of the countries who responded to a new WHO survey lack the capacity to prevent and care for hearing loss, according to a report published on International Ear Care Day, 3 March.  
who.int
about 5 years ago
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1
27

A 68 year old woman with deteriorating hearing

A 68 year old woman presented to the ear, nose, and throat (ENT) clinic with gradually worsening bilateral hearing loss over at least the past five years. This was associated with some non-intrusive tinnitus but no other otological symptoms, history of vertigo, or associated systemic problems. She found that she was increasing the TV volume to a level that her family found uncomfortable, and she had started to avoid social situations because she struggled to hear conversation among the background noise. Her medical history was unremarkable except for well controlled hypertension, for which she was taking amlodipine. She also had no history of excessive noise exposure, no previous otological problems, and no family history of note.  
bmj.com
about 5 years ago
Preview
1
57

A 68 year old woman with deteriorating hearing

A 68 year old woman presented to the ear, nose, and throat (ENT) clinic with gradually worsening bilateral hearing loss over at least the past five years. This was associated with some non-intrusive tinnitus but no other otological symptoms, history of vertigo, or associated systemic problems. She found that she was increasing the TV volume to a level that her family found uncomfortable, and she had started to avoid social situations because she struggled to hear conversation among the background noise. Her medical history was unremarkable except for well controlled hypertension, for which she was taking amlodipine. She also had no history of excessive noise exposure, no previous otological problems, and no family history of note.  
bmj.com
about 5 years ago
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1
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Cochlear implants for children and adults with severe to profound deafness | 2-Clinical-need-and-practice | Guidance and guidelines | NICE

2.1 Hearing loss may be caused by interference with the transmission of sound from the outer to the inner ear (conductive hearing loss) or damage within the cochlea, the auditory nerve or auditory centres in the brain (sensorineural hearing loss). In adults the most common cause of sensorineural hearing loss is presbycusis. This is a progressive condition caused by the loss of function of hair cells in the inner ear, leading to deafness. Hearing loss in adults may also be caused by excessive exposure to noise, or by ototoxic drugs, metabolic disorders, infections or genetic factors. Severe to profound hearing loss in children may have a genetic aetiology, or have prenatal, perinatal or postnatal causes. These include conditions such as meningitis and viral infection of the inner ear (for example, rubella or measles), as well as premature birth and congenital infections. Deafness that occurs before the development of language is described as prelingual, whereas deafness that occurs after the development of language is described as postlingual.  
publications.nice.org.uk
about 5 years ago
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2
102

A&P Biol 227: Anatomy of the Ear

A fantastical adventure through the winding roads and convoluted canals of the ear.  
YouTube
about 5 years ago
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6
149

Auditory Transduction (2002)

This 7-minute video by Brandon Pletsch takes viewers on a step-by-step voyage through the inside of the ear, to the acoustic accompaniment of classical music...  
YouTube
about 5 years ago
Logo
2
35

otoscopy.php

NB in textbooks and on this website, images of the ear are usually taken with an endoscope which has a wide angle lens on the end. This gives us an image which contains the whole tympanic membrane and much of the ear canal. When using an otoscope, you will NEVER get a view as good as this, not because it is your fault, but because of the optics of most endoscopes. It is unlikely that you will in fact be able to see the whole drum in one position. To see all aspects of the drum you will need to change position and move the tip of the otoscope.  
entbristol.co.uk
about 5 years ago
8
1
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Resources

RESOURCES: Here are some useful presentations to download / see prior to your Oncology attachment. They are also good revision tools; plus there are prizes to be won!! Prizes to be won: Steven Carstairs Research Prize and Edinburgh EAR Congress Research Prize are offered through the Royal College of Radiologists. This year's closing date has…  
Cancer Dundee Blog
almost 5 years ago
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1
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A&P Biol 227: Anatomy of the Ear

A fantastical adventure through the winding roads and convoluted canals of the ear.  
YouTube
almost 5 years ago