HEENT Flashcards

Question

Symptoms of Menieres

Answer 1

vertigo, tinnitus and hearing loss

Answer 2

aminoglycosides, asa, nsaids, furosemide, some chemo

Answer 3

* Prenatal infections * Birth weight \<1500 gm * Hypoxia * Craniofacial anomalies * High bilirubin * Recurrent ear infections * Speech or language delay * Facial or ear injury * Foreign body in ear (children & geriatric- cognitive imp)

Answer 4

* Exposure to environmental or industrial noise * Use of recreational headphones * Use of ear protective equipment * Daycare or preschool * Allergies * Exposure to second-hand smoke * Piercings

Answer 5

Most otoscopes have a small air vent connection that allows the doctor to puff air in to the canal. Observing how much the eardrum moves with air pressure assesses its mobility, which varies depending on the pressure within the middle ear.

Answer 6

young children: pull pinna back and down Older: Pull auricle upward, backward, slightly away from head

Answer 7

Visualize tympanic membranes, noting the landmarks, light reflex, & pars tensa (landmarks include: umbo, malleus, short process)

Answer 8

1. Stand 2 feet behind patient 2. Occlude non-test ear with finger 3. Exhale 4. Whisper 3 numbers/letters (something that makes no sense so they can’t “guess”) 5. Patient repeats 6. Test each ear Sense of unilateral vs bilateral and what test to move on to

Answer 9

* Test for lateralization * Tuning Fork 256 Hz or 512 – at either extreme, not fine detail * Set into vibration, hold only base * Place base on top of head or midforehead. * If nothing heard, try again. Could not have worked - Could also be bilateral hearing loss. * Unilateral sensory: will hear in good ear

Answer 10

* Air Conduction (AC) vs Bone Conduction (BC) * Place base on mastoid bone * When patient can no longer hear sound, place fork close to ear * [Description: Rinne] “U” should face forward * AC\>BC normal * Conductive loss: BC = AC or BC\> AC (external, middle ear) * Sensorineural loss: AC \> BC (inner, cochlear nerve, centrl connx to brain)

Answer 11

**OE:** tug test +, may be hard to look in ear, painful **OM:** pain when press on mastoid process, erythema, may see bubbles, fluid

Answer 12

* Screening for adults 50 years of age and older Risk groups * Congenital or family hearing loss * Syphilis * Rubella * Meningitis * Exposure to hazardous noise level * Work * Soldiers

Answer 13

inner ear, cochlear nerve, central connections to brain trouble understanding speech – complain others are mumbling noisy environments make it worse

Answer 14

external or middle ear noisy environments may help

Answer 15

Dark room. Strong narrow light source. **Frontal**: light snugly deep under each brow, close to nose. Shield light w/hand. Look for dim red glow through air filled frontal sinus to forehead. **Maxillary**: pt tilts head back w/mouth opened wide. Shine light downward from just below inner aspect of each eye. Look through open mouth at hard palate. Reddish glow = normal air filled sinus.

Answer 16

parotid duct – opens onto buccal mucosa near upper second molar. Frequently marked by its own small papilla. Usually not visible unless blocked.

Answer 17

* 20 primary * First teeth 6-8 months * Start to lose 6 years * 32 Secondary

Answer 18

Oral thrush is easily removed. Leukoplakia is hard to remove - suggests immunocompromised

Answer 19

Vitamin deficiency

Answer 20

FVD, elderly

Answer 21

* Preauricular * Posterior auricular * Occipital * Submental * Submandibular * Tonsilar * Superficial cervical * Deep cervical * Posterior cervical * Supraclavicular

Answer 22

FIRM, FIXED, TENDER, UNILATERAL

Answer 23

Centralized scotoma or blind spot obliterated central vision, such as with macular degeneration. It can also be caused by a CVA or Traumatic Brain Injury (TBI) causing optic nerve damage.

Answer 24

Routine eye screening/examinations Ventilation/spray nozzles Safety goggles Sports goggles Age appropriate toys/monitoring Counseling: Fire/Smoking/Fireworks/optical radiation/tanning booths/sun exposure

Answer 25

Opthalmoscope/panoptic Cotton tip applicator Cotton wisp Exam gloves Snellen Eye Chart/Pedi-Allen Near Chart Rosenbaum Pocket Vision Screener Office: Direct opthalmoscope Slit lamp *(for corneal abrasion, foreign body...)* Color vision testing Florescein *(corneal abrasion)* Tonometry

Answer 26

may use for corneal abrasion, foreign body

Answer 27

blotting paper contains orange dye (flourescein stain). Contact lenses must be removed. provider touches surface of the eye with the flourescein stained paper and then ask the patient to blink, which spreads the dye over the corneal surface. The patient’s own lacrimal fluid will lubricate the eye. Next, the provider shines a cobalt blue light (can use slit lamp) on the patient’s eye **to detect any corneal abrasion**, which appears greenish under the light. Document the size, location and shape of the corneal injury, and of course which eye. The flourescein paper may sting a little bit and briefly discolor the sclera, but this does not require irrigation due to the test; tears will wash the dye out. Flourescein gtts are available, but most likely you will use the flourescein paper.

Answer 28

S/S: pain, gritty substance, hurts when blink, etc., photophobia, decreased visual acuity PE: tearing, Fluorescein stain to detect Tx: irrigate, topical antibiotics, possibly topical nsaids, possibly patching. Usually resolves 24-48h

Answer 29

area where blood vessels can be directly observed

Answer 30

located on the retina (creamy yellow spot surrounding the fovea and does not have sharp margins). Light narrows to a point on the macula, which is the center of vision.

Answer 31

a 2.5mm diameter that appears slightly dark in center of macula and is responsible for central vision. high concentration of cones but no rods, and this is where our vision is most sharp and is the location of most color vision. While the normal field of vision for each eye is about 135 degrees vertically and about 160 degrees horizontally, foveal field of vision represents a small conical area of only about 1 degree. BUTonly the fovea is able to perceive and send clear, sharply focused visual images to the brain.

Answer 32

Point of the optic nerve is the “blind spot.” (fundoscopy)

Answer 33

impaired far vision. Near sighted.

Answer 34

impaired near vision. Far sighted.

Answer 35

decreased accommodation – lens is harder w/age, less compliant

Answer 36

visual acuity from 20/70 – 20/200

Answer 37

better eye is 20/200 or less w/correction. Does not mean no vision.

Answer 38

Adolescents can get worse vision during growth spurt (Or better!)

Answer 39

2 lines of visual acuity difference or a visual acuity of 20/30 or lower determined by a Snellen chart Loss of visual acuity and binocular vision that is often irreversible after age 5

Answer 40

*may go unnoticed w/o screening* * Using Wright figures *(preliterate visual acuity chart)*, Snellen letters, HOTV chart * USPSTF and AAP recommend all preschool children (3-5 years) be screened for visual impairment (acuity and strabismus) as part of routine preventative care * Refer to ophthalmologist *

Answer 41

* Impairment of eye muscles manifesting as turning of eyes/crossed eyes * May be evident when patient is tired, during intense close work or reading * Babies have pseudostrabismus - a false strabismus as eyes appears crossed from extra skin covering the inner corners of eyes or wide bridge of nose

Answer 42

Esotropia-inward turning Exotropia-outward turning Hypertropia-upward turning Hypotropia-downward turning

Answer 43

Frequency-constant or intermittent Unilateral Alternating-sometimes right eye turns, sometimes left eye turns

Answer 44

see black and white; focuses on face; sluggish pupil response; can’t distinguish R, G, Y; acuity 20/400

Answer 45

fixes on objects; well developed pupil response 20/300

Answer 46

coordinates eye movements; distinguishes R-G, not Y-G; 20/150

Answer 47

improved coordination and focus, convergence, colors-R, G, Y

Answer 48

some accommodation; 20/50

Answer 49

acuity is 20/50

Answer 50

acuity is 20/30 with good color

Answer 51

acuity is 20/30, with accommodation

Answer 52

acuity is 20/20

Answer 53

A Stye ## Footnote An inflamed hordeolum will often calm and scar into a hard chalazion. A hordeolum is an acute purulent inflammation of the eyelid. It may be sterile or may show both inflammatory cells and bacteria, most commonly Staphylococcus aureus. An internal hordeolum represents inflammation of a meibomian gland just under the conjunctival side of the eyelid. An external hordeolum (stye) arises from an eyelash follicle or a lid-margin tear gland.

Answer 54

* may first present with eyelid swelling and erythema and then evolve into a painless, rubbery, nodular lesion. * commonly in patients with eyelid margin blepharitis and in those with rosacea. * Tx: Antibiotics are not indicated since chalazion is a granulomatous condition. Small chalazia often resolve without intervention. For larger lesions, frequent hot compresses may allow them to drain although typically most clear spontaneously in weeks to months. Symptomatic patients with recalcitrant lesions can be referred to an ophthalmologist for incision and curettage or direct glucocorticoid injection.

Answer 55

* cholesterol-filled, soft, yellow plaques that usually appear on the medial aspects of the eyelids bilaterally * most often occur in middle-aged and older adults-think hyperlipidemia * a classic feature of primary biliary cirrhosis, which is a condition often associated with marked hypercholesterolemia.

Answer 56

caused by a poxvirus and spread by direct contact or by fomites. It is usually seen as one or multiple small, pale, shiny nodules with central umbilication.

Answer 57

much less common but faster growing than basal cell carcinoma can arise de novo or from preexisting actinic keratosis and is more likely to metastasize.

Answer 58

a premalignant condition. It predisposes to squamous cell carcinoma. Biopsy, followed by surgical excision or cryotherapy, is recommended

Answer 59

* Prominent epicanthal fold may suggest Down’s syndrome * Normal variant with very young children and some races * Draw an imaginary line between the two medial canthi and observe for Mongolian slant

Answer 60

Sjogrens Syndrome: inflammation of exocrine glands (--\> dry eyes/mouth/etc) Schirmers test: put a piece of filter paper under the lower eyelid and measure how many tears are produced and absorbed. \>8mm, normal tear production, \<8mm, abnormally low tear production (need to be seen by an ophthalmologist to be evaluated for corneal ulcerations d/t lack of tears)

Answer 61

* Wide eyed stare * Protrusion of eyes * May have associated edema to eyelids and conjunctival injection * Often secondary to Graves’ hyperthyroidism, tumor, or inflammation of the orbit

Answer 62

* Provider is positioned 12 inches from patient, face to face * Provider’s hands are 2 feet apart * Patient gazes at your nose * Patient should point to your fingers as they are seen * Begin outside the visual range, wiggling 2 fingers in each outer quadrant of the visual field (temporal, superior, inferior) * F/up with holding 1 to 2 fingers, ask “how many fingers do you see?” * Normal test is viewing both sets of fingers simultaneously If defect noted: * assess boundaries * Test one eye at a time moving from defective area to good area * Repeat at several levels to define the border

Answer 63

Pupils equal, round, reactive to light, accommodation Reaction: direct & consensual

Answer 64

* Hold penlight at arms length in front of child * Gain child's attention blink/tap light * When child fixated on light * Examiner lines up light with her eyes * Note position of Corneal Light Reflex on each eye * Should fall on nasal portion of each cornea

Answer 65

* Have patient follow your finger or pencil as you sweep through the 6 cardinal gazes * Wide “H” beginning with patient’s extreme right, right upward, right downward, no pause, extreme middle left, left upward, left downward * Check nystagmus by pausing during upward and lateral gazes * Elders may need further distance * Checking CN III, IV, VI * Babies-twist body in 6 fields and observe eyes should follow *SO4, LR6, the rest are 3*

Answer 66

* Darkened room * Patient focuses on distant spot * No glasses * Start with diopter at 0 or 10 (if patient wears glasses); hold finger on disc * Use medium circle of light * Hold the opthalmoscope using proper technique * Patient focuses on distant point * Begin at a 15 degree angle, 15 inches from face and shine light into pupil * Locate the red reflex, light illuminates the retina * Move closer to focus on the retina (fundus) * Look for vessels (about 3-5cm from patient) * Once you find a blood vessel(s), try to adjust focus (diopters) * Locate the optic disc; if you have trouble seeing it, follow the blood vessels centrally, these become larger as you approach the disc * Check the optic disc margins, these should be sharp except for the nasal portion which may normally be blurred

Answer 67

Start at zero or higher if needed For nearsighted patients, start with disc in the red-rotate counterclockwise (minus) For farsighted patients, start with disc in the black-rotate clockwise (positive)

Answer 68

* Assess the color of the disc-yellow orange * Assess the **physiologic cup:disc ratio** (appears yellow white and cup is ~1/3 the size of the disc) * Examine the arteries at the disc and all 4 directions (2 arteries: 3 veins); check for **+ venous pulsations** * Assess for any lesions, hemorrhages, abnormalities * Check the **arteries: vein ratio and appearance** * Lastly, move more temporally and view the macula (darker spot in the center of retina); check fovea at center

Answer 69

Normal arterial wall is transparent, so vein crossing beneath artery can usually be seen. When the arterial walls lose their transparency, changes appear in the AV crossing 3 types of changes: **AV concealment/nicking **when vein appears to stop abruptly on either side of artery; **Tapering** when vein appears to taper on either side of artery; **Banking** when vein is twisted on idstal side of arter and forms a dark, wide knuckle

Answer 70

* Swelling of the optic disc and bulging of the physiologic cup * Characterized by loss of definition of the optic disc margin * Due to increased intracranial pressure (ICP) and pressure on the optic nerve * Found in meningitis, subarachnoid hemorrhage, trauma, lesions, tumor

Answer 71

* physiologic cup widens occupying most of the disc ratio; so if you see a widening of the cup, this is the most common cause. * open angle glaucoma is most common * Acute closed angle 5 % of cases: ocular emergency * Congenital glaucoma: autosomal recessive * Physical findings: marked elevated intraocular pressure, unreactive pupil, increased cupping of optic disc * Slit lamp exam Treatment topical pressure lowering agents, oral carbonic anhydrase inhibitors, laser surgery

Answer 72

* Causes central vision loss * Characterized by undigested cellular debris, known as Drusen deposits in the macula * Drusen may be central or scattered * Initially, patient is asymptomatic * As Drusen grow in accumulation, vision becomes blurred centrally and may be lost

Answer 73

* Yellow-white flecks scattered around the macular region are little mounds beneath the retinal pigment epithelium. They are tombstones of dead retinal pigment epithelial cells. Most common cause is age-related macular degeneration

Answer 74

Central Vision Impairment Look at grid from 14 in away. Shouldn't see wavy distorted lines. If you do, may be macular degeneration

Answer 75

Soft exudates-Whitish or grey irregular patches with soft borders like cotton. They result from infarcted nerve fibers. Debris is associated with hypertensive retinopathy and SLE.

Answer 76

These yellow flecks are called hard exudates. They are the lipid residues of serous leakage from damaged capillaries. The most common cause is diabetes. Other causes are retinal vein occlusion, angiomas (Von Hippel-Lindau Disease), other vascular dysplasias, and radiation-induced retinal vasculopathy. “macular star”

Answer 77

Separation of the retina and underlying choroidal circulation leading to ischemia and permanent blindness. ## Footnote *c/o flashing lighfs/floaters*

Answer 78

Must use light source Largest ear speculum. Tilt pt’s head back and insert speculum gently into vestibule of each nostril, avoiding contact w/sensitive nasal septum. Direct speculum posteriorly then upward in small steps, try to see inferior and middle turbinates, nasal septum, narrow nasal passage between.

Answer 79

scaling, fissures at corner of mouth

Answer 80

At base of tongue, ducts of the submandibular gland pass forward and medially. Open on papillae that lie on each sind of lingual frenulum.

Answer 81

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, cetntral retinal artery occlusion

Answer 82

usually in cornea or anterior chamber: corneal ulcer, uveitis, traumatic hyphema, acute glaucoma. Optic neuritis from MS. Immediate referral.

Answer 83

medications that change refraction e.g., cholinergics, anticholinergics, steroids

Answer 84

chemical, radiation exposures

Answer 85

Cataracts, macular degeneration

Answer 86

nuclear cataract, macular degeneration

Answer 87

open-angle glaucoma

Answer 88

hemianopsia and quadrantic defets