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Physical Diagnosis > HEENT > Flashcards

HEENT Flashcards

1
Q

What is the equipment needed for a HEENT exam?

A
  • stethoscope
  • opthalmoscope
  • otoscope (+/- pneumatic bulb)
  • snellen or rosenbaum eye chart
  • tuning fork (256 Hz vs 512 Hz)
  • tongue blade
  • cotton tipped applicator
  • gloves, gauze
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2
Q

ROS Head

A

headache, vertigo, syncope, head trauma

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3
Q

ROS eyes

A

visual acuity changes, blurred vision, diplopia, photophobia

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4
Q

ROS ears

A

change in acuity, discharge, pain, tinnitus, recurrent ear infections

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5
Q

ROS nose

A

obstruction, discharge, epistaxis, pain

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6
Q

ROS Mouth

A

toothaches, bleeding gums, sore throat, dysphagia, hoarseness, change in taste

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7
Q

ROS neck

A

pain, stiffness, swelling/ masses

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8
Q

Normally the head and scapl are

A

normocephaic, atraumatic

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9
Q

inspection (face, skull, hair, scalp)

A
  • trauma
  • symmetry
  • skin lesions
  • scales
  • hair distribution
  • etc
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10
Q

palpation (face, skull, hair, scalp)

A
  • Lumps
  • bumps
  • tenderness
  • lesions
  • describe regions based on underlying bone
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11
Q

head and scalp percussion

A

sinuses

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12
Q

head and scalp auscultation

A

vascular sounds

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13
Q

CN visual acuity

A

CN2

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14
Q

CN hearing

A

CN8

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15
Q

CN EOMs

A

CN3, 4, 6

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16
Q

CN facial expression

A

CN 7

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17
Q

CN mastication, clench

A

CN5 motor

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18
Q

CN sharp/dull face touch

A

CN5 sensory

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19
Q

CN soft palate/ uvula “Ah”

A

CN 9, 10

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20
Q

CN movement of tongue

A

CN12

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21
Q

CN head and shoulder movement

A

CN 11

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22
Q

Inspect hair for

A
  • lice, nits
  • hair loss
  • quantity, distribution, texture
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23
Q

alopecia areata

A

autoimmune condition causing hair loss “patchy”

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24
Q

seborrheic dermatitis

A
  • “dandruff”
  • greasy
  • yellowish
  • scaly
  • can be on scalp, nasolabial folds, eyebrows, forehead
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25
Q

psoriasis

A
  • autoimmune dermatologic condition
  • silvery white sharply dermarcated plaques and coarse scale
  • can be quite thick, usually not associated with hair loss
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26
Q

tinea capitis

A
  • fungal infection of scalp
  • scaly patches or plaques with or without inflammation
  • kerion- raised boggy secondarily infected fungal lesion of hair
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27
Q

inspect face for

A
  • landmarks for asymetry
  • lesions, rashes, swelling
  • characterisitic “facies associated with disease states
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28
Q

acromegaly

A
  • increase of growth hormone
  • enlargement of bone and soft tissues
  • elongated head with bony prominence of the forehead, nose, and lower jaw
  • enlarged nose, lips, and ear soft tissues
  • coarsened facial features
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29
Q

myxedema

A
  • severe hypothyroidism
  • dull, puffy facies
  • pronounced edema around the eyes that does not pit with pressure
  • dry, coarse, thinned hair and eyebrows
  • dry skin
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30
Q

neprotic syndrome

A
  • edematous face
  • pale
  • swelling first appears around eyes in the morning
  • slitlike eyes with severe edema
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31
Q

cushings syndrome

A
  • increased adrenal hormone
  • round moon face
  • red cheeks
  • excessive hair growth on mustache, sideburn areas, and chin
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32
Q

parotid gland enlargement

A
  • chronic bilateral
  • may be associated with obesity, diabetes, cirrhosis
  • swellings anterior to the ear lobes and above the angles of the jaw
  • gradual unilateral enlargement suggests neoplasm
  • acute enlargement seen in mumps
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33
Q

parkinsons

A
  • decreased facial mobility blunts expression
  • mask face
  • decreased blinking
  • characteristic stare
  • neck and trunk flex forward
  • patient peers upwards
  • oily skin
  • drooling
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34
Q

palpate bones for

A

tendernous

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35
Q

where do you palpate/ percuss

A

over maxillary and frontal sinuses

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36
Q

Temporomandibular Joint palpation

A
  • palpate joint
  • listen and feel for clicks
  • check ROM
    • open/close, move side to side
  • palpate massetere muscles (CN5)
    • clench teeth
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37
Q

what does the trigmeninal nerve do

A
  • sensory
    • opthalmic, maxillary, mandibular
    • lightly touch in all 3 areas bilaterally with Qtip
  • motor
    • palpate masseter muscle, clench teeth
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38
Q

how to test CN7

A
  • check for facial symmetry
  • wrinkle forehead “raise your eyebrows”
  • squeeze eyes shut
  • puff out cheeks
    • smile- “show your teeth”
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39
Q

acromegaly

A
  • excessive growth hormone production
  • large hands and feet
  • excessive facial bone growth and enlarged jaw
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40
Q

bells palsy

A
  • idiopathic facial nerve paralysis causing muscle weakness on one side of face
  • difficulty closing one eye
  • flattened nasolabial fold
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41
Q

how to assess the temporal artery

A

palpate and ausculate for bruits

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42
Q

giant cell (tempora)l arteririts

A
  • adults >50
  • new HA
  • jaw claudication
  • elevated ESR
  • associated condition PMR
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43
Q

tarsal plates of eyelids

A

firm strip of CT

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44
Q

meibomian glands of eyelids

A

sebaceous glands

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45
Q

bulbar conjunctiva of eyelids

A

covers anterior eyeball

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46
Q

palpebral conjunctiva

A

covers inner eyelids

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47
Q

visual acquity tests

A

snellen chart

rosenbaum pocket chart

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48
Q

what does 20/200 mean

A

pt sees at 20 ft what someone with normal vision sees at 200 ft

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49
Q

snellen chart screens for

A

myopia

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50
Q

distance that snellen chart tests

A

20 feet

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51
Q

myopia

A

impaired far vision

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52
Q

rosenbaum pocket chart screens for

A

presbyopia

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53
Q

presbyopia

A

impaired near vision

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54
Q

distance that rosenbaum tests at

A

14 inches; bedside screen

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55
Q

for x/y vision, the larger the denominator

A

the worse the vision

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56
Q

when examinating the lacrimal apparatus look for

A

excess tearing/ dryness

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57
Q

when examining the bulbar conjunctiva and sclera, look for

A

infection, inflammation, icterus

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58
Q

when examining the palpebral conjunctiva look for

A

pallor

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59
Q

when examining the pupils look for

A
  • equality and pupillary reaction (direct and consensual)
  • convergence
  • near-far accomodation
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60
Q

when examining the eyes, you assess

A
  • lacrimal apparatus
  • bulbar conjunctiva and sclera
  • palpebral conjunctiva
  • cornea and lens
  • pupils
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61
Q

PPERRL

A

Pupils Equal Round Reactive to Light

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62
Q

pupil inspection

A

size, shape, equality

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63
Q

miosis

A

excessive pupillary constriction

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64
Q

mydriasis

A

excessive pupillary dilation

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65
Q

ansicoria

A

pupils are unequal size

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66
Q

direct pupillary light reflex

A

pupil constricts on same side as light when you shine bright light in obliquely

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67
Q

consensual pupillary light reflex

A

pupil constricts in opposite eye of the one one you shine a bright light into obliquely

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68
Q

EOMI

A

extraocular muscles

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69
Q

EOMI testing

A
  • tests 6 cardinal directions of gaze
  • move fingers through a large H to test EOMs
  • ask pt to keep head in meidline and just move eyes
  • make sure H is big enough for full ROM
  • watch for conjugate (parallel) movements
  • pause at upward and lateral gaze to detect nystagmus
    • after H pattern, pt follows finger to assess convergence with near vision
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70
Q

nystagums

A

fine rhythmic oscillation of the eyes

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71
Q

Near far accomodation testing

A
  • pt focuses on object 10 cm away then an object greater than 6 feet away
  • watch for pupillary constriction with near and dilation with distance
  • Narrows with Near
  • Dilates with Distance
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72
Q

corneal light reflection

A

shine light into pt’s eyes and note corneal light reflection

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73
Q

corneal light reflection tests for

A

conjugate gaze

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74
Q

extraocular movements

A

lateral rectus- CN6

superior oblique- CN4

all others- CN3

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75
Q

eyelid examination

A

look for

  • edema
  • lesions
  • width of palpebral fissures
  • condition and direction of the eyelashes
  • adequacy with which the eyes closes
    • ptosis
    • incomplete closure
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76
Q

Ptosis seen with problem with CN

A

3

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77
Q

incomplete eye closure seen with problem with CN

A

7

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78
Q

chalazion

A

nontender

meibomian (sebaceous) gland obstruction/ inflammation

points inside lid

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79
Q

hordeolum

A

aka stye

tender, red infection near hair follicles of eyelashes

like pimple or boil poining on eyelid margin

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80
Q

which one hurts, chalazion or hordeolum?

A

hordeolum- it’s horrible

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81
Q

dacryocystitis

A

lacrial sac inflammation/ infection

usually secondary to blockage of nasolacrimal duct

sweling b/w base of nose and eye

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82
Q

orbital contact dermatitis

A

ex pt would be 50 yo male went camping and now returned with itchy rash on face

now developed swelling and itching around eyes, right eye more than left

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83
Q

periorbital/ preseptal cellulitis

A

example would be 32 yo with low grade fever, swelling, redness, pain and inability to open L eye

also has increased nasal congestion, facial pressure, and headache x 2 weeks prior to symptoms

no hx or trauma

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84
Q

entropion

A

eyelid inversion

more common in elderly

inward turning of the lid margin

irrititation of the conjunctiva and cornea

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85
Q

ectropion

A

eyelid eversion

margin of lower lid turns outwards

exposes palpebral conjunctiva

more common in elderly

excessive tearing can occur as puncta may not drain effectively

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86
Q

pingueculum

A

yellow trianglular nodule on the bulbar conjucntiva on either side of the iris

harmless

vision WNL

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87
Q

pterygium

A

medial sclera triangular thickening of bulbar conjunctiva that extends from inner canthus to cornea

may interfere with vision

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88
Q

scleral icterus

A

yellow discoloration of sclera

elevated bilirubin

jaundiced skin

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89
Q

xanthelasma

A

sharply demarcated yellow deposits of fat under the skin around eyelids

associated with hyperlipidemia

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90
Q

viral conjunctivitis

A

not usually goopy

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91
Q

bacterial conjunctivitis

A

usually goopy

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92
Q

types of conjunctivitis

A

viral, bacterial, allergic, irritant

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93
Q

exophthalmos

A

abnormal protrusion of the eyeball

seen in graves disease (thyroid dysfunction)

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94
Q

what causes loss to the lateral 1/3 of eyebrows

A

thyroid dysfunction

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95
Q

episcleritis

A

central nodule with radiation of vessels

most often associated with systemic disease

occasionally associated with autoimmune conditions

usually self limiting and benign

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96
Q

uveitis

A

aka iritis

red, painful, photophobia, no discharge

causes:

  • infectious- herpes and CMV
  • autoimmune/ systemic immune- sarcoidosis, juvenile idiopathic arthritis, IBD (Crohns, UC)
  • idiopathic
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97
Q

subconjunctival hemorrhage

A

hx of cough, straining, coumadin use (if coumadin use may be more serious and need to review labs)

asymptomatic

self limiting

if recurrent, consider bleeding disorder

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98
Q

hyphema

A

grossly visible blood in anterior chamber

usually secondary to trauma

vision threatening- refer

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99
Q

corneal abrasian

A

can be visualized with fluorescein stain

pt example- 22 yo with R eye foreign body sensation since mowing the lawn

increased photophobia, lacrimation, pain

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100
Q

corneal chemical burn

A

usually pt provids hx of liquid or gas splashed in eye

immediate and prolonged irrigation

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101
Q

cataract

A

clouding, opacity of the lens

causes painless progressive vision loss

risk factors- age, smoking, DM, corticosteroids, ETOH

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102
Q

opthalmoscope aperture- small

A

easier view through non-dilated pupil

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103
Q

opthalmoscope aperture- large

A

view through dilated pupil

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104
Q

opthalmoscope aperture- grid

A

make measurements

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105
Q

opthalmoscope aperture- slit

A

determine elevation or concavity in retina

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106
Q

opthalmoscope aperture- cobalt filter

A

for fluorescein staining to visualize corneal lesions

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107
Q

how to do opthalmoscopic exam

A

darken room

may use small or large round beam of light on scope

do not use maximum light

ask pt to try to keep both eyes open

turn disc to 0 diopters, keep index finger on dial in order to adjust focus as needed

ask pt to look over shoulder at fixed point on wall that is at eye level

R hand, R eye, Pt R eye

L hand, L eye, Pt L eye

approach pt’s eye about 15 degrees lateral to pt’s line of vision

look for red reflex first- absent red reflex= opacity of lens (cataracts, detached retina, retinoblastoma, artificial eye)

brace yourself with hand on pt’s shoulder or brow

move closer to pt’s eye almost touching their eyelashes

follow blood vessels centrall to find optic disc (nasal side of fundus)

adjust diopter dial to adjust focus

always compare findings bilaterally

note disc margins, color, size of central cup (cup: disc ration is < 1:2)

inspect vessels

inspect for hemorrhage exudate, and edema of optic disc (papilledema)

view macula, fovea

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108
Q

veins of the eyes are ____ and _____ than arteries

A

larger and darker

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109
Q

eye artery to vein ratio is

A

2:3

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110
Q

how do you view the macula/ fovea

A

pt looks directly into the the light (temporal)

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111
Q

what is the macula/ fovea responsible for

A

central vision

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112
Q

pan optic

A

larger

increases distance b/w pt and clinician

clinician my use the same eye to examine both of the pt’s eyes

most clinicial settings do not have

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113
Q

hyptertensive vascular changes- copper wire

A

vessels get full and tortuous with increased light reflex

coppery luster

114
Q

hyptertensive vascular changes- silver wire

A

vessel wall becomes too opaque and blood cannot be seen

115
Q

hyptertensive vascular changes- AV nicking

A

artery-vein nicking

appearance of breaks in vein when artery and vein cross

116
Q

hypertensive retinopathy- cotton wool patches

A

aka soft exudates

white, gray, ovoid lesions with irregular (soft) borders

caused by infarcted nerve fibers

also seen in DM

117
Q

hyptertensive retinopathy- hemorrhages

A

caused by microaneurysms

118
Q

diabetic retinopathy

A

hemorrhages can be seen along with hard exudates

hard (well defined borders) exudates are cream/ yellow and appear bright common with DM and HTN

neovasculation

119
Q

neovascularization

A

development of new blood vessels arising from the disc and extending to the margins

caused by abnormal permeability and vascular occlusion

more numerous and torturous

120
Q

glaucoma with cupping

A

increased pressure within eye resulting in abnormal cupping (backward depression of disc)

represents optic nerve damage

normal up to disc ratio is < 1:2, but in glaucoma the ratio is > 1:2 because of intraocular pressure

may have an abnormal anterior chamber depth on exam

121
Q

detached retina

A

curtain like shadow over vision

flashes, floaters, risk of vision loss

122
Q

papilledema

A

optic disc swelling caused by increased intracranial pressure

pt may have severe HA, nausea, vomiting

123
Q

macular degeneration

A

observed in the last step of eye exam, normal would have reflection of light

with degeneration there is decreased reflection

degeneration is due to build up of dusen (cellular debris)

124
Q

Specialized vision tests

A

visual field

cover-uncover

anterior chamber

corneal reflex

lid eversion

125
Q

How to check visual fields

A

provide sit at same level of pt to ensure similar visual fields

pt closes one eye and looks at providers nose

examiner closes opposite eye to mimic pts visual fiedl

examiner places handto periphery of visual field, checks each eye individually and tests all 4 quadrants

“while looking at my nose, how many fingers am I holding up?”

next provider moves wiggling fingers slowly from periphery (in each quadrant) centrally

“while looking at my nose, please say now when you can see my wiggling fingers”

check all 4 quadrants and each eye individually

then perform the wiggling finger technique, moving fingers peripherally to centrally in each quadrant and pt says “now” when they see the fingers

126
Q

normally what i see on the nasal side

A

hits the opposite (temporal) side of the retina and stays on the same side

127
Q

normally what i see on the temporal side

A

hits the opposite (nasal) side of the retina and crosses at the optic chiasm

128
Q

visual field defects- horizontal defect

A

occlusion of a branch of the cenral retinal artery may cause a horzontal (altitudinal) defect. Shown is the lower field defect associated with occlusion of the superior branch of this artery.

129
Q

visual field defects- blind eye

A

defect at the optic nerve before the optic chiasm (neither the nasal or temporal sight will make it to the brain)

130
Q

visual field defects- lesion at the optic chiasm

A

causes defect in both temporal fields (bitemporal hemianopsia)

ex Pituitary tumor

131
Q

visual field defects- lesion on optic tract behind chiasm

A

produces defects on opposite side

defets on R optic tract causes L homonymous hemianopsia

defect on L optic tract causes R homonymous hemianopsia

ex: stroke, tumor

132
Q

cover- uncover test will test for

A

muscle imbalance not otherwise seen in general eye exam

you occlude each eye in alternating fashion and observe for change in fixation of the uncovered eye. Also assess for movement of the covered eye after cover is moved

133
Q

when do you do the cover-uncover test

A

when you see an abnormeal corneal light reflection

134
Q

striabismus

A

misalignment of the eyes

deviation of the eyes from their normally conjugate position

can be congenital or acquired

one of the most common eye problems in children (4% of children under 6)

check visual acquity if strabismus is detected and refer

135
Q

esotropia

A

eye turns in medially

a type of strabismus

light will be displaced laterally on affected eye

136
Q

exotropia

A

eye turns out laterally

a type of strabismus

light will be displaced medially on affected eye

137
Q

hypertrophia

A

eye turns up

a type of strabismus

138
Q

hypotropia

A

eye turns down

a type of strabismus

139
Q

anterior chamber depth tests for

A

increased intraocular pressure

ex glaucoma

140
Q

how to do anterior chamber depth test

A

shine light from temporal side of patient’s eye (towards nose)

look for shadow on the medial aspect of the iris

“crescent shadow”

141
Q

corneal light reflection tests for

A

ocular alignment

142
Q

corneal reflex tests

A

CN5 sensory and CN7 motor

143
Q

how to do corneal reflex test

A

gently touch the edge of the cornea with a rolled cooton and observe for response blink

144
Q

what is this?

A

alopecia areata

145
Q

what is this?

A

seborrheic dermatitis

146
Q

what is this?

147
Q

what is this?

A

tinea capitis

148
Q

what is this?

A

acromegaly

149
Q

what is this?

A

bells palsy

150
Q

what are the arrows

A

green- pupil

gray- medial canthus

blue- limbus- where the bulbar conjunctiva merges with cornea

orange- lateral canthus

151
Q

what are the arrows

A

green- lacrimal gland

black- lacrimal sac with puncta

blue- nasolacrimal duct

152
Q

what is this?

A

chalazion- nontender

153
Q

what is this?

A

hordeolum- painful

154
Q

what is this?

A

dacrycocytis

aka lacrimal sac inflammation

155
Q

what is this?

A

orbital contact dermatitis

156
Q

what is this?

A

periorbital/ preseptal cellulitis

157
Q

what is this?

158
Q

what is this?

159
Q

what is this?

A

pingueculum

160
Q

what is this?

161
Q

what is this?

A

scleral icterus

162
Q

what is this?

A

xanthelasma

163
Q

what is this?

A

viral conjunctivitis

164
Q

what is this?

A

bacterial conjunctivitis

165
Q

what is this?

A

exophthalmos

166
Q

what is this?

A

episcleritis

167
Q

what is this?

A

uveitis aka iritis

painful

168
Q

what is this?

A

subconjunctival hemorrhage

169
Q

what is this?

170
Q

what is this?

A

corneal abrasion with fluorescein stain

171
Q

what is this?

A

corneal chemical burn

172
Q

what is this?

A

eye puncture

173
Q

what is this?

174
Q

what is this?

A

hemorrhages- hypertensive retinopathy

175
Q

what is this?

A

hypetertensive retinopathy

176
Q

what is this?

A

creamy exudates in diabetic retinopathy

177
Q

what is this?

A

a normal fundus

178
Q

what is this?

A

fundus with neovascularization from diabetic retinopathy

179
Q

the one on the left is a normal fundus, what is the one on the right

A

fundus with cupping from glaucoma

abnormal optic nerve

180
Q

what is this?

A

detached retina

181
Q

what is this?

A

papilledema

182
Q

what is this?

A

macular degeneration

183
Q

what is this?

A

blind right eye- right optic nerve lesion

184
Q

what is this?

A

bitemporal hemianopsia- optic chiasm lesion

185
Q

what is this?

A

left homonymous hemianopsia

right optic tract lesion

186
Q

what is this?

A

crescent shadow from abnormal intraocular pressure

187
Q

we inspect the ear for

A

deformities, lesions

188
Q

we palpate the ear

A

the pinna, the tragus, and the mastoid for tenderness

example- otitis externa causes pain when there is movement of the helix and tragus

189
Q

the length of the external auditory canal is

A

24 mm ending in the tympanic membrane

190
Q

gouty tophi

A

deposit of uric acid crystals that occurs aftery years of chronically elevated uric acid

191
Q

what is this?

A

gouty tophi

192
Q

basal cell carcinoma

A

raised nodule with central telangiectasia

193
Q

squamous cell carcinoma

A

crusted border with central ulceration and bleeding

194
Q

what is this?

A

basal cell carcinoma

195
Q

what is this?

A

squamous cell carcinoma

196
Q

how do you do a gross hearing test

A

rub fingers together by each ear

if hearing is reduced you need to distinguish between conductive hearing loss and sensorineural hearing loss

197
Q

conductive loss

A

problme conducting sound waves (EAC, TM or middle ear)

abnormality is usually visible

198
Q

sensorineural hearing loss

A

disorder of the inner ear

cochlear nerve impairs transmission of nerve impulse to the brain

problem is not visible

199
Q

specialized tuning fork test- weber

tests for

A

lateralization

200
Q

specialized tuning fork test- rinne

tests for

A

compares air conduction to bone conduction

201
Q

air conduction

A

sound transmitted through the air (EAC –> TM –> middle ear) into cochlea

202
Q

bone conduction

A

sound transmitted through vibrations in bone

bypass external and middle ear

vibration of the SKULL stimulates the inner ear directly

203
Q

normally which is greater, air or bone conduction?

204
Q

with conductive hearing loss which is greater, air or bone conduction

205
Q

with sensorineural hearing loss, which is greater, air or bone conduction

206
Q

how to do a weber test

A
  • place the vibrating tuning fork on top of the pt’s head and ask where they hear the sound, L, R, or both
    • normally they should hear sound in both ears equally
    • unilateral conductive loss- the sound lateralizes (is heard best) to the impaired (bad) ear
      • ex: otitis media, perforation, cerumen, otoscerlosis
    • unilateral sensorineural loss- the sounds lateralizes (is heard best) to the good ear because the bad ear cannot trasmit the impulse.
      • there is no signal transduced by the cochlea on the affected side
      • caused by damage to the inner ear
        • ex: presbycusis (age related hearing loss), noise exposure, head trauma
207
Q

weber test sound lateralizes to impaired ear

A

conductive hearing loss

208
Q

weber test sound lateralizes to good ear

A

sensorineural loss

209
Q

damage to inner ear causes

A

sensorineural loss

210
Q

how to do a rinne test

A

place tip of vibrating tuning fork on mastoid bone

ask pt if they can hear it, have them tell you when the sound stops

move tuning fork in front of ear, ask if they can still hear it

if they CAN then AC > BC, therefore a normal test

211
Q

in a rinne test, normal is

212
Q

in a rinne test, with BC > AC, you would have

A

unilateral conductive loss

the sound hear through bone is longer than through air

in the impaired ear BC > AC but in the good ear AC> BC

213
Q

in a rinne test with AC > BC, you would have

A

a normal result OR unilateral sensorineural loss

unilateral sensoriuneural loss the sound is heard longer through air because AC and BC are reduced equally and the normal pattern prevails

AC > BC in both ears

214
Q

where is the loss? if it lateralizes (sound is heard best) to the damaged ear it is

A

conductive loss

215
Q

where is the loss? if it lateralizes (sound is heard best) to the good ear it is

A

sensorineural loss

216
Q

how to do an otoscope exam of the ear

A

brace yourself with 1 or 2 fingers against patients head

pull auricle (pinna) upward and back and insert otoscope slightly down and forward

in infants pull auricle down and back

inspect EAC for cerumen, lesions, foreign body, d/c

inspect tympanic membrane for redness, retraction, bulging, perforations, scarring

217
Q

the middle ear anatomy

A

air filled, there is a cone of light (light reflection) located in the anterior inferior quadrant of the tympanic membrane

bony landmarks- malleus and umbo (visible)

218
Q

pneumatic otoscopy is used to test

A

tympanic membrane (TM) mobility

see if there is serous OM or TM perforations

219
Q

how to do pneumatic otoscopy

A

speculum large enough for a snug fit

gently squeeze bulb to send a puff of air against the TM- normally the TM would move inwards, if no movement then thre is effusion

220
Q

tympanosclerosis

A

chalky white patch of scarring on the TM

caused by recurrent otitis media or hx of tubes or previous perforation

221
Q

what is this

A

TM perforation

222
Q

what is this?

A

tympanosclerosis

223
Q

what is this?

A

bulging erythematous TM consistent with acute otitis media

224
Q

what is this?

A

foreign bodies in the ear

225
Q

what is this?

A

serous effusion with air bubbles

usually caused by viral URI or barotrauma

eustachian tube dysfunction often involved

symptoms include- fullness in ear, popping in ear

226
Q

what is this?

A

myringotomy tube

usually remains in ear for 6-12 months

usually falls out on own

used for: repeat bouts of OM, persistent effusion, hearing loss

227
Q

what is this?

A

bullous myringitis

painful hemorrhagic vesicles

+/- hearing loss during infection

228
Q

what is this?

A

otitis externa

infection of the EAC

notice the drainage and edema of the canal

tenderness and movement of the tragus and pinna

229
Q

what do the turbinates do

A

clean, humidify and warm air

230
Q

what is the meatus

A

groove below each turbinate

231
Q

what does the inferior meatus drain

A

nasolacrimal duct

232
Q

what does the middle meatus drain

A

the paranasal sinuses

233
Q

we inspect and palpate the external nose/ nasal bridge

A

to evaluate for asymmetry, deformities, tenderness

234
Q

how do you test for nasal patency

A

ask pt to occlude one nostril and sniff

235
Q

how to do a nasal speculum exam

A

gently insert speculum into nose

avoid touching septum and turbinates

use light source

inspect internal nasal septum, mucosa, turbniates

look for septal deviation or perforation, inflammation, polyps, d/c

236
Q

to transilluminate frontal sinus, place the light

A

below the brow and look for glow (normal)

237
Q

to transilluminate the maxillary sinus place the light

A

agains the cheek bone below the eye and look for glow on the hard palate (normal)

238
Q

what is this

A

septal deviation

symptoms- nasal obstruction, headache, change in smell

see spurs and crests

239
Q

what is this?

A

septal perforation

seen with trauma, infection, cocaine, s/p surgery

symptoms- crusting, epistaxis

small lesions may whistle

240
Q

what is this?

A

nasal polyps

soft, translucent growths

can cause nasal obstruction

anosmia

241
Q

what is this?

A

foreign body

242
Q

what is this?

A

septal hematomas

seen following trauma

more common in peds pts

symptoms- increased nasal obstruction, pain, tenderness

PE: soft, tender, swelling

must rule out septal hematomal in all nasal trauma and document

243
Q

what is this?

A

epsitaxis

highly vascular region of the anteroinferior nasal septum

90% of all epistaxis occur in the kiesselbachs plexus/ area

244
Q

why do you get these?

A

rhinitis and sinusitis

245
Q

why would you have swollen, pale, blue, boggy turbinates

A

allergic rhinitis (AR)

also would have shiners and eye Sxs

246
Q

why would you have erythematous turbinates

A

sinusitis and URI

also drainage- mucoid vs. clear vs. purulent

247
Q

why would have you tendernous to palpation of sinuses

248
Q

anatomy of the mouth and pharynx

A

lips, tongue, buccal mucosa, 32 adult teeth, gingiva, tonsils, anterior/posterior pillars, hard & soft palate, uvula, whartons duct (drains submandibular gland), stensons duct (drains parotid gland)

249
Q

how to examine oropharynx

A

inspect lips, teeth, gingivae, buccal mucosa, floor of mouth, hard & soft palates, tongue, tonsils, pillars, and posterior orpharynx for color, symmetry, lesions

inspect palate and uvula

CN 9 and 10- ask pt to say “Ah”, gag reflex, consider wetting tongue blade if pt has a sensitive gag reflex

palpation- bimanually

250
Q

examine salivary glands

A

palpate for masses

parotid- stensons duct- buccal mucosa lateral to molars

submandibular- whartons ducts- floor of mouth under tongue

251
Q

ask pt to stick out tongue and move it side to side; assesses function of CN__

252
Q

bimanual exam of oropharynx

A

palapate oropharynx with gloved hand

palpate wall of mouth between internal and external fingers (what bimanual means)

feel floor of mouth, tongue for masses, induration

253
Q

how to extend lateral margins of tongue

A

wearing gloves, use gause to grasp the tip of tongue

254
Q

what is this?

A

squamous cell carcinoma

when doing an oral exam, look for sores that dont heal and newly formed lesions

consider risk factors

255
Q

what is this?

A

angular cheilitis

irritation, fissuring of the skin at the corners of the mouth associated with ill fitting dentures, vitamin deficiency, and excessive salivation

256
Q

what is this?

A

oral candidas (thrush)

white patches or plaques on the tongue or bucacl mucosa

uncommon among healthy adults

can brush away

257
Q

what is this?

A

leukolplakia

potentially premalignant

differentiated by thrush by inability to remove white area

referral for biopsy recommended

258
Q

what is this?

A

oral carcinoma

through physical exam is necessary

majority of oral cancer is SCC

259
Q

what is this?

A

torus palatinus

benign, midline mass of the palate

260
Q

what is this

A

gingivitis

causes changes to the gums

  • redness
  • bleeding
  • edema
  • tenderness
261
Q

what is this?

A

gingival hyperplasia

can be caused by medication such as dilantin (phytoin), cyclosporine, Ca channel blockers

can also be caused by poor dental hygiene and pregnany

262
Q

what is this?

A

tonsillar hypertrophy

numerous tonsilar crypts

263
Q

what is this?

A

hairy tongue

benign condition

defect in desquamation of papillae

many causes- Abx, tea, coffee, tobacco use

264
Q

what is this?

A

fissured tongue

multiple small grooves on the dorsum of tongue

benighn

increasing incidence with advanced age

265
Q

what is this?

A

geographic tongue

dorsum of tongue shows smooth areas void of papillae

benign

266
Q

what is this?

A

bilateral exudative tonsilitis

could be caused by Group A strep OR mononucleosis (Epstein Barr virus)- determine diagnosis by strep screen/ culture and mono screen

267
Q

strep A

A

ex pt: worsening sore throat x 2 days, fever of 102, n/v, 3 friends with similar Sxs, no cough, nasal congestion, fatigue

bilateral exudative tonsilitis and cervical LAD

diagnosed determined by pos strep screen/ culture

268
Q

mononucleosis

A

ex pt- sore throat x 5 days, fever 101, fatigue, tender anterior and posterior cervical LAD

bilateral exudative tonsilitis

slight splenomegaly

diagnosed by negative strep screen, positive mono screen

269
Q

what is this?

A

peritonsillar abscess

unilateral peritonsillar swelling and shifted uvula

infections spreads into the peritonsillar space

drooling

hot potato voice

very sore

270
Q

anatomy of neck

271
Q

how to examine the neck

A

inspect while observing the patient swallowing

look for symmetry, masses, scars, nodes, tracheal position, thyroid

evaluate ROM- flexion, extension, rotation, lateral bending

evaluate motor function of CN 11 and strength

272
Q

how to evaluate motor fxn of CN11 and strength

A

lateral rotation of neck against resistance

shoulder shrugging against resistance

273
Q

examination of the trachea

A

inspect for deviation from midline- deviation may suggest mediastinal mass/ pneumothorax

palpate and assess mobility

274
Q

label these lymph nodes

275
Q

how to examine lymph nodes

A

use pads of your index and middle fingers

neck should be relaxed

can examine one side or both sides at once

note size, shape, consistency, mobility or tenderness of nodes

shotty (small, mobile, nontender) nodes are common in children

supraclavicular LN may suggest metastasis from lung or GI cancer

276
Q

how to do a carotid artery exam

A

auscultate each carotid, listening for “bruits” (signs of turbid arterial blood flow… whooshing)

palpate the carotid arteries using gentle pressure and only one side at a time

277
Q

examine the thyroid

A

inspect for enlargement, asymmetry from the front

from the posterior or anterior, place fingers below cricoid cartilage on each side of the neck

palpate the isthmus and each lobe

ask pt to swallow, feel for gland rising beneath fingers, note size, shape, and consistency

note any masses, nodules, or tenderness

278
Q

goiter

A

an enlarged thyroid aka thyromegaly

can be present in multiple forms of thyroid dysfunction

remember to palpate the thyroid while pt swallows

279
Q

what do you do if they have an enlarged thyroid?

A

auscultate

listen over the lateral lobes to detect a bruit

bruits may be present in hyperthyroidism or toxic multinodal goiter

280
Q

tracheal deviation

A

trachea shifts to one side or other because of goiter pnueumothorax, or tumor

281
Q

what is this?

A

JVD- jugular venous distension

caused by cardiac and pulmonary dx

blood flows backwards from right atrium into the jugular veins

Physical Diagnosis (4 decks)

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