HEENT Flashcards
temporal arteries
palpate & auscultate
Snellen Chart
CNII
- chart tests central vision
- 20 feet from chart
- Glasses (except reading) should be worn
- Test one eye at a time, repeat
- Have patient cover eye with card. Don’t press eye, can lose vision for a period.
- Read the smallest line of print reading more than half of letters
- Record OD (right eye), OS (left eye). OU (both eyes) 20/20, 20/30, and corrected to designate use of glasses
- If miss one character can say, “20/30 -1” – or office standard
Rosenbaum Chart
(CN II).
- Use Rosenbaum chart to assist with screening of presbyopic patients, age 45+ or those wearing bifocals
- Hold the card 14 inches from patient’s eyes or at a reasonable distance for the patient
- Test each eye separately with and without glasses
- Presbyobic patients may read through the bifocal
- Record the line with the smallest letters/figures
- Pediatric near allen test – for kids. Can use other symbols than letters as well!
Cover/Uncover Test
tests for strabismus
- Observation of binocular eye movement
- Fix gaze on far object
- Cover one eye and observe
- Alternate eye
- Check covered eye for refixation movement
- Alternating esotropia-covering fixating eye, the opposite eye moves outward
- Alternating exotropia-outturned eye refixates inward when opposite eye is covered
Inspect eyelids for…
symmetry, ptosis, edema, erythema
Entropian: describe & examination technique
common in elderly
- Inward turning of the lid margin
- Lower lashes may not be apparent as these are engulfed in the margin causing irritation to the conjunctiva and lower cornea
- Examination technique-squeeze eyes together and open
Inspect sclera and conjunctiva for …
- color
- discharge
- pterygium
- corneal arcus/
- foreign body
- hemorrhage.
Note and inspect both the bulbar and palpebral conjunctiva
bulbar conjunctive: covers most of anterior eyeball
palpebral conjunctiva: lines the eyelids
pterygium
- Elevated, external thickening of the bulbar conjunctiva
- Extends into corneal surface
- May obstruct vision: wedge shaped area
Ectropion
- The lower lid margin is turned outward and exposes the palpebral conjunctiva
- When the punctum of the lower lid turns outward, the eye drains improperly
- Common geriatric finding
Headache: Primary vs Secondary
- Primary (90%): Migraine, tension, cluster, chronic
- Secondary: structural, systemic, infectious
Common Primary Headache Types
Cluster, Tension, Migraine
Cluster: tends to be unilateral, retroorbital
Tension: tends to be bilateral, temporal
Migraine: Tends to be unilateral, assoc w/ other symptoms, e.g., aura, photophobia, NA, cravings for food, euphoria, dizziness
Headache + nausea/vomiting, consider…
migraine,
tumor, subarachnoid hemorrhage, … (increased ICP)
Valsalva aggravates headache, consider…
acute sinusitis, mass lesion/ICP
Coughing, sneezing aggravates headache, consider…
increased ICP
Headache Warning SIgns
- Progressively frequent or severe over 3-month
- Sudden onset like “thunderclap” or “worse headache of my life” (SA hemorrhage, esp >50 w/following Sx)
- New onset > 50 years
- Aggravated or relieved by position change
- Precipitated by Valsalva maneuver
- Recent trauma
- Associated papilledema, neck stiffness or neurologic deficits
Not necessarily together but signal need for further imaging
Could be increased ICP, bleed, progressive concussion, malignancy, etc. = don’t wait
7 bones of skull
- 2 Frontal
- 2 Parietal
- 2 Temporal
- 1 Occipital
Skull: anatomy of newborn
- Bones connected by Sutures
- Posterior fontanel closes by 2 months
- Anterior fontanel closes by 24 months
Facial anatomy: fused & movable bones
Fused bones
- Frontal
- Zygomatic
- Nasal
- Ethmoid
- Lacrimal
- Sphenoid
- Maxillary
Movable Bones
- Mandible
Facial landmarks
- Palpebral fissures
- Nasolabial folds
Look for symmetry
Facial innervation
Trigeminal (CNV): Muscles of mouth & jaw
Facial (CN VII): Muscles of eyebrows, forehead, cheeks, lips
Trigeminal nerve: areas of innervation (sensory)
Enlarged skull may indicate…
hydrocephalus or paget’s dz of bone
Vertigo vs dizziness
Vertigo is rotational, not just losing balance
Causes of vertigo
Peripheral: in labyrinths of inner ear, peripheral lesions of CNVIII, indicates vestibular disease. BPPV, labyrinthitis, menieres
**Central: **CNVIII pathways or nuclei in brain. Ataxia, diplopia, dysarthria, vertigo. Central neurologic causes in cerebellum or brainstem (CVD, posterior fossa tumor)
Migraine
Symptoms of Menieres
vertigo, tinnitus and hearing loss
Ototoxic drugs
aminoglycosides, asa, nsaids, furosemide, some chemo
Children and PMH: high risk for hearing loss
- 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)
Personal/social history & risk for hearing loss
- 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
Insufflation of ear
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.
Anatomy of ear
Otoscope technique: young children vs older children & adults
young children: pull pinna back and down
Older: Pull auricle upward, backward, slightly away from head
Tympanic Membrane
Visualize tympanic membranes, noting the landmarks, light reflex, & pars tensa (landmarks include: umbo, malleus, short process)
Whispered Voice test
- Stand 2 feet behind patient
- Occlude non-test ear with finger
- Exhale
- Whisper 3 numbers/letters (something that makes no sense so they can’t “guess”)
- Patient repeats
- Test each ear
Sense of unilateral vs bilateral and what test to move on to
Weber test
- 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
Rinne Test
- 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)
Otitis Externa vs Otitis Media
OE: tug test +, may be hard to look in ear, painful
OM: pain when press on mastoid process, erythema, may see bubbles, fluid
TM: perforation, myringotomy tubes
US Preventive Task Force: Risk Groups for Hearing Loss
- 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
Sensorineural Hearing Loss
inner ear, cochlear nerve, central connections to brain
trouble understanding speech – complain others are mumbling
noisy environments make it worse
Conductive Hearing Loss
external or middle ear
noisy environments may help
nasal anatomy
The Sinuses
Transillumination
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.
Stensen’s Ducts
parotid duct – opens onto buccal mucosa near upper second molar. Frequently marked by its own small papilla. Usually not visible unless blocked.
Number of teeth
- 20 primary
- First teeth 6-8 months
- Start to lose 6 years
- 32 Secondary
Oral Thrush vs Leukoplakia
Oral thrush is easily removed. Leukoplakia is hard to remove - suggests immunocompromised
Smooth tongue
Vitamin deficiency
Fissured Tongue
FVD, elderly
Muscle groups of neck
Major vessels of neck
Head & Neck Lymph nodes
- Preauricular
- Posterior auricular
- Occipital
- Submental
- Submandibular
- Tonsilar
- Superficial cervical
- Deep cervical
- Posterior cervical
- Supraclavicular
Traits of problem lymph nodes
FIRM, FIXED, TENDER, UNILATERAL
physiologic enlarged thyroid
Pregnancy
Scotoma
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.
Routine Health Maintenance for Eyes
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
Equipment for Eye Exam
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
Slit lamp
may use for corneal abrasion, foreign body
Flourescein Stain
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.
Corneal Abrasion
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
Direct vs indirect ophthalmoscopy
Fundus (eye)
area where blood vessels can be directly observed
macula
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.
Fovea
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.
“Blind Spot” the eye
Point of the optic nerve is the “blind spot.” (fundoscopy)
myopia
impaired far vision. Near sighted.
Hyperopia
impaired near vision. Far sighted.
Presbyopia
decreased accommodation – lens is harder w/age, less compliant
Low Vision
visual acuity from 20/70 – 20/200
Legal blindness
better eye is 20/200 or less w/correction. Does not mean no vision.
adolescents & vision changes
Adolescents can get worse vision during growth spurt (Or better!)
Pediatric Amblyobia: definition
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
Pediatric Amblyobia: recommendations
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
*
Strabismus
- 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
Strabismus: Types
Esotropia-inward turning
Exotropia-outward turning
Hypertropia-upward turning
Hypotropia-downward turning
Strabismus: Classification
Frequency-constant or intermittent
Unilateral
Alternating-sometimes right eye turns, sometimes left eye turns
Newborn vision
see black and white; focuses on face; sluggish pupil response; can’t distinguish R, G, Y; acuity 20/400
1 month vision
fixes on objects; well developed pupil response 20/300
2 months vision
coordinates eye movements; distinguishes R-G, not Y-G; 20/150
3 months: vision
improved coordination and focus, convergence, colors-R, G, Y
6 months vision
some accommodation; 20/50
12 months vision
acuity is 20/50
2 years vision
acuity is 20/30 with good color
3 years vision
20/20
5 years vision
acuity is 20/30, with accommodation
6 years vision
acuity is 20/20
Eye Structures
Anatomy of episclera and sclera
Eye anatomy cross section
Hordeolum
A Stye
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.
Chalazion
- 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.
Xanthelasma
- 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.
Molluscum contagiosum
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.
Squamous cell carcinoma
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.
Actinic keratosis
a premalignant condition. It predisposes to squamous cell carcinoma. Biopsy, followed by surgical excision or cryotherapy, is recommended
Epicanthal fold
- 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
Palpebral or Mongolian Slant
Lacrimal Glands & Sjogren’s Syndrome
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)
Exophthalmos
- 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
Visual fields by confrontation
- 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
PERRLA
Pupils equal, round, reactive to light, accommodation
Reaction: direct & consensual
Corneal light reflex
- 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
EOMs
- 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
Opthalmoscopic Exam: process
- 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
Opthalmoscopic Exam: for nearsighted/farsighted patients
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)
Opthalmoscopic Exam: what to assess
- 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
AV Crossing & changes
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
Papilledema
- 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
Glaucoma
- 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
Macular Degeneration
- 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
Drusen deposits
- 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
Amsler Grid
Central Vision Impairment
Look at grid from 14 in away. Shouldn’t see wavy distorted lines. If you do, may be macular degeneration
Cotton Wool Patches
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.
Hard Exudates
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”
Location of cataracts
Immature vs mature cataract
Retinal Detachment
Separation of the retina and underlying choroidal circulation leading to ischemia and permanent blindness.
c/o flashing lighfs/floaters
Inspect internal nose
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.
cheilosis
scaling, fissures at corner of mouth
Wharton’s ducts
At base of tongue, ducts of the submandibular gland pass forward and medially. Open on papillae that lie on each sind of lingual frenulum.
sudden unilateral painless vision loss
vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, cetntral retinal artery occlusion
Sudden unilateral painful vision loss
usually in cornea or anterior chamber: corneal ulcer, uveitis, traumatic hyphema, acute glaucoma. Optic neuritis from MS. Immediate referral.
sudden bilateral painless vision loss
medications that change refraction e.g., cholinergics, anticholinergics, steroids
sudden bilateral painful vision loss
chemical, radiation exposures
gradual bilateral vision loss
Cataracts, macular degeneration
slow central vision loss
nuclear cataract, macular degeneration
peripheral vision loss
open-angle glaucoma
one-sided vision loss
hemianopsia and quadrantic defets
