HEENT Flashcards
Head inspection
hair distribution, quantity scalp: scaling, nevi skull: size and contour face: expression and contour (asymmetry, swelling, masses) skin: color, pigmentation, hair distribution, lesions
Head palpation
hair texture, skull lumps, sinuses, skin texture and temperature, paresthesias always remember to try and gently reproduce symptoms
Parts of the eye: limbus
connection between the sclera and the edge of the iris through the conjuctiva, keeps stuff from bleeding into the anterior chamber. Where conjunctiva meets cornea
Parts of the eye: conjunctiva
protective membrane that covers all parts of the anterior globe, folding back on itself at superior and inferior fornix then extending onto the inner surface of upper and lower palpebra. It allows eye motion, moving with it. The epithelium over the cornea is very sensitive so when scratched there is significantly more eye pain and photophobia than if there is damage or a foreign body impacting the sclera
Parts of the eye: sclera
Whites of eyes
Parts of the eye: canthus
Lateral and medial, corners
Parts of the eye: iris and pupil
Iris = colored part Pupil = where light goes through
Eye inspection
Position and alignment of eyes Eyebrows: quantity and distribution Eyelids: edema, color, lesions, adequacy of closed eyelids (ptosis, exopthalamus, unilateral or bilateral) Check lacrimal gland for swelling Conjunctiva and sclera: color and vascular pattern Cornea and lens: opacity Iris: markings clearly defined Pupils: size, shape, reaction to light
Ptosis
Lid partially or fully closed; drooping without specific anatomical markers to define it. Typically noted when asymmetry exists.
Exopthalamus
Globe bulging forward so ,at rest, the lid is not able to reach the upper edge of the iris. Most typical for posterior fat pad growth stimulated in hyperthyroidism/Graves disease, doesn’t hurt
Visual acuity test
Very important part of exam! Central vision: Snellen eye chart; position patient 20 feet from the wall chart Patients should wear glasses if needed Test one eye at a time: Avoid squinting closed eye! Then test both together Near vision: hand-held card (can also use to test visual acuity at the bedside) use distance stated on card
Peripheral vision test
Screening: both eyes at same time; start in the temporal fields Further testing: If a defect is found, test one eye at a time
Extraocular movements
Six cardinal directions of gaze test each muscle and Convergence. “H” test
Nystagmus
Involuntary rapid, rhythmic movement of eye in any direction (horizontal, vertical, or rotatory)
Strabismus and Cover Test
Misalignment of eyes relative to each other. If untreated can cause amblyopia (visual loss) of one eye Cover test: Stare at one spot, Cover one eye, Holding gaze, cover other eye, If eye uncovered moves, some degree of strabismus exists
Subconjunctival hemorrhage
pain free, stops at limbus, no treatment
Corneal abrasion
Severe photophobia (light sensitivity) Fluoriscein stain Topical antibiotic +/- patching
Ears: auricle and pinna
external ear
Ear canal, tympanic membrane, malleus
can see during exam cannot see middle and inner ear
Eustachian tube
Comes in from behind the nose, equalizes air pressure, gives kids ear infections (either straight or angled down, so stuff runs right in, as we grow it angles up a little so adults do not get a lot of ear infections)
Ear inspection
Auricle for redness, lesions Ear canal: Discharge, foreign bodies, redness, swelling Tympanic membrane: Color, contour, mobility
Ear palpation
Auricle for lumps and tenderness
To see the ear canal and drum
Use an otoscope with the largest ear speculum that the canal will accommodate. Position the patient’s head so that you can see comfortably through the instrument. To straighten the ear canal, grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head. Holding the otoscope handle between your thumb and fingers, brace your hand against the patient’s face. Your hand and instrument follow unexpected movements by the patient. Insert the speculum gently into the ear canal, directing it somewhat down and forward.
What you should look for in otoscope
Visualizing the parts of the malleus and the cone of light helps define a misshapen tympanic membrane: effusion, scarring, partial retraction from perforation that never healed…. Malleus in a normal ear is visualized WELL Red = infection
Insufflation
Used to test tympanic membrane mobility: gently puff air in the ear canal looking for TM motion = insufflation Nonmobile TM: fluid, mass, sclerosis Hypermobile TM: ossicle bones disrupted
Auditory acuity
Test one ear at a time Finger rub with their eyes closed Whisper test, standing 1-2 feet behind patient, softly say “nine-four,” “baseball” “ice cream”
Air and bone conduction: Weber Test
Lateralization of sound (one side louder)? Is it equal? On top of head Look for lateralization: If occurs, use Rinne to further define the problem May be normal in equal, bilateral hearing loss
Air and bone conduction: Rinne Test
Compare time of air vs. bone conduction In normal hearing, Air conduction is heard after bone conduction is lost. AC>BC
Evaluation of hearing loss: conductive loss and sensorineural loss
The definition of conductive loss is bone conducting sound better than air. Sound waves are not reaching or being conducted through the middle ear bone apparatus. When the cochlear nerve is abnormal, this defines sensorineural hearing loss and both bone and air conduction is poor.
Weber/Rinne
Weber lateralizes right: right = loud/ left = soft IF: Rinne R: BC > AC or BC = AC = abnormal (negative) test L: AC > BC = normal (positive) test then Right ear is bad ear with conductive loss IF: Rinne R: AC > BC = normal L: AC > BC = normal then Right is good ear with sensorineural loss in Left ear
Sensorineural loss
Inner ear disorder involves cochlear nerve and neuronal impulse transmission to the brain. Causes include loud noise exposure (>85 db), inner ear infections, trauma, tumors, congenital and familial disorders, and aging
Conductive loss
External or middle ear disorder impairs sound conduction to inner ear. Causes include foreign body, otitis media, perforated eardrum, and otosclerosis of ossicles
Nose and sinuses: inspection
Asymmetry or deformity Inside of nose: Mucosa – color, swelling, bleeding, exudate, ulcers, or polyps Septum – deviation, inflammation, or perforation Turbinates – use otoscope or nasal speculum to view middle and inferior turbinates (not superior)
Palpation of sinuses
frontal, maxillary, ethmoid
Mouth and pharynx inspection
Lips: Note color, moisture, lumps, ulcers, cracking,or scaliness Oral mucosa: Note color, ulcers, and nodules Gums and teeth: Note color, presence, and position of teeth Roof of mouth: Note color Tongue and floor of mouth: Note color and texture, ulcers, nodules Pharynx: soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx Note color, symmetry, presence of exudate, swelling, ulceration, or tonsillar enlargement
Oral disease risk factors
Tobacco and alcohol use (cancers) Family history of oral cancers Lack of mouth guard use for sports Methamphetamine use (erosions) Bulemia (erosions) Significant GERD (erosions)
Screening oral exam: observation
Remove all dentures and appliances Teeth and oral hygiene Palate and gums Buccal mucosa Floor of mouth & tongue (lateral borders & undersurface) Posterior pharynx
Screening and oral exam: palpation
floor of mouth and neck
Screening and oral exam: record
Signs of caries (White spots, brown spots, pits) Signs of periodontal disease -Poor oral hygiene (presence of plaque) -Erythematous or receded gums -Loose teeth Signs of other oral disease -Soft tissues lesions -Tooth erosion
Neck inspection
Symmetry, masses, scars, enlarged glands or lymph nodes Trachea – position, alignment Thyroid gland - symmetry
Neck palpation
Lymph nodes (size, shape, mobility, consistency, tenderness): Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial anterior cervical, posterior cervical, supraclavicular
Thyroid gland
Flex neck slightly forward Place fingers of both hands with index fingers just below the cricoid cartilage Ask patient to swallow; feel for the thyroid (including isthmus) rising up under your finger pads (not always palpable) Palpate lateral to the trachea for the right and left lobes of the thyroid Note the size, shape, and consistency Identify any nodules or tenderness If enlarged, listen with bell over lateral lobes to detect a bruit
Tonsilitis
enlarged, red tonsils, white patches, want to sample around white patches when you swab, could be strep, staph, or mono
Thyromegaly
enlarged thyroid
Maxillary sinusitis
sinus infection, X-rays should just show black area, if white, might be infected (fluid-filled)
Lymphadenitis
swollen nodes, can be unilateral or bilateral
Parotosis
swollen nodes under ears
