Exam 1 - HEENT Exam Flashcards
Head ROS
Head: headaches, head injury.
Eyes ROS
Eyes: vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double vision, spots, specks, flashing lights, glaucoma, cataracts.
Ears ROS
Ears: hearing acuity, last hearing examination, tinnitus, vertigo, earaches, infection, discharge.
Nose (sinuses) ROS
Nose/Sinuses: frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble.
Throat (mouth) ROS
Mouth/Throat: condition of teeth and gums, bleeding gums, last dental examination, sore tongue, frequent sore throats, hoarseness.
Neck: lumps in the neck, swollen glands, goiter, pain or stiffness in the neck.
Head Exam PE
Scalp/Skull: contour, scaliness, lesions, lumps, tenderness
Hair: texture, color, distribution, quantity
Face: symmetry, color, expression, edema, involuntary movement
External Eye Exam PE
Check Visual Acuity
>Use Snellen card 14 inches from nose or eye chart
External Eye
Eyebrow/lashes: flakiness, loss of hair
Eyelid: swelling, lid position, lid closure, tenderness
Lacrimal apparatus: duct, sac, tenderness, tearing
Conjunctiva/sclera color
Pull lower lids down to fully visualize conjunctiva
Cornea: opacities, surface characteristics
Use tangential lighting to assess LIGHT REFLEX
Iris: shape, color consistencies
Pupil: shape, bilateral size, reaction to light (both direct and consensual), corneal light reflection
Swinging flashlight test
EOMs (6 cardinal fields of gaze), lid lag, nystagmus, convergence, accommodation
Visual Fields: by confrontation (one eye at a time)
How do you check visual acuity?
Snellen Card (14 inches from nose)
2 types of conjunctiva
Palpebral (lines the inner lid)
Bulbar (globe/sclera)
Meets the cornea at the limbus
Tarsal plates (thick tissue)
Keep the eyes from getting stuck together; protect and lubricates eye.
Meibomian Glands
Meibomian glands are the tiny oil glands which line the margin of the eyelids (the edges which touch when the eyelids are closed).
These glands secrete oil which coats the surface of our eyes and keeps the water component of our tears from evaporating (drying out).
Water and oil layer of the eye make up the:
tear film
Six Cardinal Directions of Gaze
Normal conjugate movements
Nystagmus
Lid lag
Convergence
Aqueous humor - where is it produced?
Anterior portion of eye cavity; fluid produced by ciliary body
Flow through pupil to anterior chamber
Out through canal of schlemm
Aqueous humor - what is its function?
Controls pressure in eye
What controls pupil size?
The muscles of the iris
What controls lens thickness?
Muscles of the ciliary body
What does visual fields test?
Visual Fields assesses peripheral vision
By confrontation
Face-to-face at eye level with patient
Patient covers right eye, you cover your left eye
Wiggle your right fingers from lateral sides to center
Patient states when your fingers can be seen
Fundoscopic exam
Darken the room and have the patient look off in the distance. Switch on the ophthalmoscope light, turn the lens disc to the large round beam of white light. Turn lens disc to the 0 diopter.
Hold the ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye
Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision
Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex
Follow the red reflex and move inward toward the nasal aspect of the visual field
Red Reflex
reddish-orange reflection of light from the eye’s retina that is observed when using an ophthalmoscope or retinoscope from approximately 15inches away.
Once red reflex has been established, follow the vessels to the optic disk. What do you look for?
Sharpness or clarity of the disc outline Color of the disc Size of the central physiologic cup Compare to the patient’s other fundus Look for papilledema Swelling of the optic disc/bulging of the cup
What do you look at in the retina?
Examine the Retina
Examine arteries/veins
Arteries- smaller, lighter red
Veins- larger, dark red
Check for hemorrhages, A-V nicking, cotton-wool spots
Ear Exam PE
Gross hearing acuity
External ear: deformities, lumps, lesions and tragal tenderness, mastoid tenderness.
Otoscopy: pull auricle up and back; condition of external canal landmarks: umbo, color of drum.
Cone of light, valsalva (pinch nose, close mouth and exhale). Check for mobility of TM.
External nose PE
External exam: symmetry, lesions, discharge, tenderness Nasal patency (each nostril) Have patient occlude each nostril and breathe in
Internal Eye Exam PE
Internal Eye: funduscopic exam (left eye, left hand, patient’s left eye) (right eye, right hand, patient’s right eye). Do this by dimming the room light
Red reflex: cornea, lens, aqueous/vitreous humors
Retinal structures
Optic disc: clarity, color, fovea. Cup to disc ratio = 1:2
Vessels: color, size, light reflex, artery vs. vein
Internal Nose PE
Rhinoscopy: polyps, deviated septum, mucosa color, discharge
Must insert nasal speculum into nostril using a lighted scope
Paranasal sinuses: maxillary and frontal tenderness
Overview of nose exam
Inspection
Anterior and inferior surface – asymmetry or deformity
Inside of nose
Mucosa – color, swelling, bleeding, exudate, ulcers, or polyps
Septum – deviation, inflammation, or perforation
Turbinates – use otoscope to view middle and inferior turbinates
Palpation of sinuses – frontal and maxillary
Mouth and Throat PE
Lips: color, symmetry, moisture, lesions, pigmentation
Oral mucosa: moisture, color, lesions, odor
Use gloves, tongue blade and light source
Gums and teeth: number, color, surface characteristics
Roof of mouth, uvula
Pharynx and tonsils: landmarks, swelling, color, exudate
Is the oropharynx patent?
Parotid ducts (Stensen’s ducts)
Tongue: symmetry, color, surface characteristics
Floor of mouth, Wharton’s ducts, frenulum
Palpate oral cavity (gloved, bimanual)
Full neck exam PE
Symmetry and Range of Motion with Flexion, Extension, Rotation, Lateral Bending
Lymph nodes: size, shape, mobility, tenderness, consistency
Trachea: location, symmetry
Thyroid gland: inspect anterior for symmetry, rises with swallowing.
Palpate from posterior for tenderness and enlargement with patients neck flexed and turned slightly left and right.
Lymph nodes
Lymph nodes: size, shape, mobility, tenderness, consistency
List nodes: (1) preauricular; (2) postauricular; (3) occipital; (4) tonsillar; (5) submandibular; (6) submental; (7) superficial cervical; (8) posterior cervical; (9) deep cervical chain; (10) supraclavicular
Thyroid Exam
Flex patient’s neck slightly forward
Place fingers of both of your hands so that your index fingers are just below the cricoid cartilage
Ask patient to swallow; feel for the thyroid isthmus rising up under your finger pads
Displace trachea to the right and palpate laterally for the right lobe of the thyroid; repeat on the left side
Note the size, shape, and consistency
Identify any nodules or tenderness
Example ROS Doc
Head: Denies headaches or head injury.
Eyes: Last vision exam 6 mos ago, wears glasses to correct myopia. Positive eye dryness. Denies pain, redness, excessive tearing, double vision, spots, specks, flashing lights, glaucoma or cataracts.
Ears: Unknown last hearing exam. Hearing acuity good. Denies tinnitus, vertigo, earaches, infections or discharge.
Nose/Sinuses: Denies frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds or sinus trouble.
Mouth/Throat: Last dental exam 4 months ago. Fair condition of teeth and gums. Wears upper and lower partial plates in good repair. Intermittent hoarseness x 2 months. Denies bleeding gums, sore tongue, or frequent sore throats.
Neck: Denies swollen glands, goiter, lumps, pain or stiffness.
Example PE doc
Head- AT/NC. Full head of thinning, brittle hair. Symmetrical facies, pale complexion, good expression. No involuntary movements.
Eyes- Visual acuity 20/40 OU with correction. Thinning eyebrows, eyelashes without flakiness. Puffy eyelids without tenderness, good position, full closure. Lacrimal duct without tenderness, no excess tearing, no discharge. Conjunctiva pick, moist. Injected sclera bilaterally. Corneas smooth without opacities. Irises with consistent shape and brown color. PERRLA, positive light reflection. No lid lag or nystagmus. EOMI. Visual fields intact, full confrontation. Positive red reflex, optic disc clarity color fovea, vessels.
Example PE doc 2
Ears- Decreased hearing to whispered voice, L>R. No external deformities, masses, lesions tragal tenderness, mastoid tenderness. Canals without erythema, 10%, non occluding cerumen buildup. Bilateral TMs pearly grey, with positive cone of light, visible landmarks. Positive motion with valsalva.
Nose- Nose symmetric with patent nares. Septum midline. No lesions, polyps, discharge, or tenderness. Mucosa pink, moist. Frontal and maxillary sinuses without tenderness.
Example PE doc 3
Mouth/Throat- Lips symmetric with consistent pale color, dry, without lesions or changes in pigmentation. Oral mucosa pale but moist, without lesions or odor. Gums pale without lesions. 30 teeth in good repair, no caries noted. Roof of mouth pale and moist, without swelling or exudates. Pharynx patent, tonsillar pillars, tonsils symmetric without swelling or exudates. Stensen’s duct visualized without signs of obstruction. Tongue symmetric, pale pink in color, without lesions or masses. Floor of mouth without lesions or masses. Frenulum intact, Wharton’s ducts visible without signs of obstruction.
Example PE doc 4
Neck-symmetrical, supple with limited ROM with flexion and extension. Preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, seep cervical chain and supraclavicular nodes mobile, non tender. Trachea midline. Thyroid symmetrical without tenderness or bruits, rises upon swallowing.
