Exam 1 / Week 5 HEENT Assessment

Question 1

HEAD & NECK: Which cranial nerves affect this area?

Answer 1

CN V (trigeminal > face strength & sensation
CN VII (facial) > symmetrical movement of face
CN XI (spinal accessory) > shoulder strength

Question 2

HEAD & NECK: List common questions used to assess this area.

Answer 2

Do you get headaches? If so, how often? Would you point to the exact location? Do you have any other symptoms related to your headaches, such as n/v? What do you do to relieve the pain? Have you ever had a head injury? Do you have any pain in your neck? Can you move your head & shoulders with ease? Have you noticed any unusual facial movements? Are any of your lymph nodes swollen? Does anyone in your family have thyroid disease?

Question 3

HEAD & NECK: How is the head palpated & inspected?

Answer 3

Expected Findings:

• • Skull: size as normocephalic; no depressions, deformities, masses or tenderness; overall contour & symmetry.
• • Face: symmetry of facial features; symmetry of expressions; no involuntary movements; proportionate features (no thickening as with acromegaly)
• • CN V M: test the strength of the muscle contraction by asking the pt to clench her teeth while you palpate the masseter and temporal muscles, and then the temporomandibular joint. The join movement should be smooth.
• • CN V S: test light touch by having the pt close eyes while you touch her face gently with a wisp of cotton. Ask pt to tell you when she feels the touch.)
• • CN VII M: test facial movement by having pt smile frown, puff out her checks, raise eyebrows, close eyes tightly, and show teeth.

Question 4

HEAD & NECK: How is the neck palpated & inspected?

Answer 4

Expected Findings&raquo_space;

• • Neck: muscles of the neck are symmetrical; check ROM so that moving head is done smoothly & w/o distress (1. chin to chest, flexion, 2. ear to shoulder, bilateral flexion, and 3. chin up, hyperextension.)
• • Shoulders: shoulders are equal in height and with average muscle mass
• • CN XI M: place your hands on the pt’s shoulders and ask her to shrug her shoulders against resistance.

Question 5

HEAD & NECK: How are the thyroid & trachea palpated & inspected?

Answer 5

Expected Findings&raquo_space;

• • Trachea: inspect and palpate for any deviation from midline; masses in the neck or mediastinum and pulmonary abnormalities cause lateral displacement
• • Thyroid: inspect the lower half of the neck to see any enlargement of the gland, normally it is not visible; ask pt to hyperextend the neck for better visualization; ask pt to sip water and you should feel the gland as it moves up with the trachea; palpate the gland on both sides of the trachea for size, masses, & smoothness.
• • If the thyroid is enlarged, asculate the gland using a stethoscope. A bruit indicates an increase in blood flow to the area, possibly due to hyperthyroidism.

Question 6

HEAD & NECK: How are the lymph nodes palpated & inspected?

Answer 6

Expected Findings&raquo_space;

• -Lymph nodes: Chains of them extend from the lower half of head down into the neck; palpate each one for enlargement; usually, they are difficult to feel and are not tender or visible
• • enlarged ones: use the pads of index and middle fingers and move the skin over the underlying tissue in a circular motion to try to detect them; compare from side to side; evaluate any enlarged ones for location, tenderness, size, shape, consistency, mobility, discreteness, and warmth

Question 7

HEAD & NECK: List the lymph nodes in the sequence you should palpate them.

Answer 7

1. Occipital (base of skull)
2. Postauricular (over the mastoid)
3. Preauricular (in front of the ear)
4. Tonsillar, retropharyngeal (angle of the mandible)
5. Submandibular (along the base of the mandible)
6. Submental (midline under chin)
7. Anterior cervical (along the sternocleidomastoid muscle)
8. Posterior cervical (posterior to the sternocleidomastoid muscle)
9. Supraclavicular (above the clavicles)

Question 8

EYES: Which cranial nerves affect this area?

Answer 8

CN II S (optic) > visual acuity, visual fields, and corneal light reflex
CN III M (oculomotor) > extraocular movements and the pupillary reaction to light
CN IV M (trochlear) > extraocular movements
CN VI M (abducens) > extraocular movements

Question 9

EYES: List common questions used to assess this area.

Answer 9

How is your vision? Have you noticed any changes? Do you ever have blurry or double vision? Do you ever see spots or halos? Do you have any eye pain, sensitivity to light, burning, itching, dryness, or excessively watery eyes? Do you have drainage or crusting from your eyes? Do you wear eyeglasses? Contact Lenses? When was your last eye exam? Does anyone in your family have any eye disorders? Do you have diabetes mellitus?

Question 10

EYES: Name what the Snellen and Rosenbaum charts are used to test.

Answer 10

– Visual acuity (CN II), distant vision.

Question 11

EYES: Name what the Ishihara Test is used to to test.

Answer 11

– Visual acuity (CN II), color blindness.

Question 12

EYES: Name what the hand-held car is used to test.

Answer 12

– Visual acuity (CN II), near vision.

Question 13

EYES: Name what the penlight or ophthalmoscope are used to test.

Answer 13

• • EOMs or extraocular movements (CN III, CN IV, CN VI),
• • External structures, and
• • The ophthalmoscope is also used for the internal structures

Question 14

EYES: Name what the eye covers are used to test.

Answer 14

• • Visual acuity (CN II), distant vision,
• • EOMs (CN III, CN IV, CN VI), and
• • Visual Fields (CN II)

Question 15

EYES: How do you use the Snellen Chart?

Answer 15

1. Have pt stand 20ft from the Snellen (E) chart
2. Evaluate both eyes and then each separately without correction
3. For each eye, cover the opposite eye
4. Ask the pt to read the smallest line of print visible
5. Note the smallest line the pt can read correctly
6. The first number is the distance (in feet) the pt stands from the chart (remember, it’s 20ft)
7. The second number is the distance at which a visually unimpaired eye can see the line clearly (which would be at 20ft)
   * * the Snellen chart can screen for myopia (impaired far vision)

Question 16

EYES: How do you use the Rosenbaum Eye Chart?

Answer 16

1. Hold it 14 inches from the pt’s face
2. Readings correlate with the Snellen Chart
   * * the Rosebaum chart can screen for presbyopia (impaired near vision or farsightedness)

Question 17

EYES: How do you screen for strabismus?

Answer 17

Use the cover/uncover test. While covering one eye, ask the pt to look in another direction. Remove the cover and expect both eyes to be gazing in the same direction.

Question 18

EYES: How do you screen for nystagmus?

Answer 18

Check the six cardinal directions of gaze. Move your finger in a wide “H” pattern about 8-10in from the pt’s eyes. Expect smooth, symmetric eye movements with no jerky or tremor-like movements.

Question 19

EYES: How do you check the visual fields?

Answer 19

Have the pt facing you at a distance of about 2ft. Run your fingers around an imaginary bowl around the pt’s head. Ask the pt to say when he sees your fingers as you bring them closer to the front of his face. Expect him to see your fingers when you see them.

Question 20

EYES: How are the external structures inspected?

Answer 20

Expect parallel eyes without bulging (exophthalmos) or crossing (strabismus); expect symmetrical eyebrows; expect complete closing and opening of eyelids that show the lower border and most of the upper portion of the iris without ptosis (the upper eyelid covering the pupil); expect eyelashed curving outward without inflammation; expect no edema or redness around the lacrimal glands; expect conjuctivae palpebral pink and bulbar transparent; expect sclerae white (light yellow if skin is naturally dark); expect clear corneas and lenses; expect PERRLA; expect irises round & illuminating fully when you shine a light across from side to side (partial illumination indicates glaucoma; and make note of the color of the iris

Question 21

EYES: What is PERRLA?

Answer 21

P: pupils clear
E: Equal and between 3-7mm in diameter
R: Round
RL: Reactive to light both directly & consensually when you direct light into one pupil & then the other
A: Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object

Question 22

EYES: How are the internal structures inspected?

Answer 22

1. Darken room and turn on ophthalmoscope, setting the diopter at 0
2. Use your right eye to examine the pt’s right eye and vice versa
3. Instruct pt to stare at a point somewhere behind you
4. Start slightly lateral; find and follow the red reflex to within a distance of 2-3cm from the pt’s eye! 2-3!
5. Expect to find… optic disk that is light pink or more yellow than the surrounding retina; retina w/o lesions that is pink; arteries veins are not nicked and at a 2:3 ratio; the macula briefly when the pt looks directly at the light

Question 23

EYES: What should you palpate?

Answer 23

Palpate the lacrimal apparatus to assess for tenderness and to express any discharge from the duct. Expect to find no tenderness, no discharge, and clear fluid (tears)

Question 24

EARS: Which cranial nerve affects this area?

Answer 24

CN VIII (auditory) > hearing

Question 25

EARS: List common questions used to assess this area.

Answer 25

How well do you hear? Have you noticed any changes in your hearing? Do you wear hearing aids? Have other people commented that you aren’t hearing what they say? Do you ever have ringing or buzzing in your ears, drainage, dizziness or pain? Do you have a history of ear infections?How do you clean your ears?

Question 26

EARS: How are the ears palpated & inspected?

Answer 26

• • external ear: check to find proper alignment (the top of the auricles meeting an imaginary horizontal line that extends from the outer canthus of the eye); the ear color matches the face color; no lesions, tenderness, foreign bodies, discharge or cerumen
• • internal ear: straighten the ear canal by pulling the auricle up and back for adults and older children (down and back from younger children)Use the otoscope w/o touching the ear canal to visualize the ear canal
• • expect that the tympanic membranes are pearly gray and intact; expect a light reflex that is visible and in a well-defined cone shape; expect umbo and manubrium landmarks that are readily visible; expect ear canals that are pink with fine hairs

Question 27

EARS: Describe the Whisper Test.

Answer 27

Technique: Occlude one ear and test the other to see if the client can hear whispered sounds without seeing your mouth move (tests CN VIII)
Expected Findings: Pt can hear you whisper softly from 1-2ft away

Question 28

EARS: Describe the Rinne Test.

Answer 28

Technique: Place a vibrating tuning fork firmly against the mastoid bone and note the time; have the pt state when he can no longer hear the sound and note the time; move the fork in front of the ear canal and when the client can no longer hear the fork, note the time.
Expected Findings: Air conduction (AC) should be greater than bone conduction (BC) at a 2:1 ratio.

Question 29

EARS: Describe the Weber Test.

Answer 29

Technique: Place a vibrating tuning fork on top of the pt’s head; ask whether the pt can hear the sound best in the right ear, left ear, or both ears equally.
Expected Findings: The pt hears sound equally in both ears (negative Weber Test)