HEENT (part 1) Flashcards
How should you describe a normal head assessment?
Normocephalic, atraumatic
During your general visual inspection of the face, skull, hair, and scalp what are looking for?
Trauma, symmetry, skin lesions, scales, hair distribution
During your palpation of the face, skull, hair, and scalp what are you looking for?
Lumps, bumps, tenderness, lesions
Describe regions based on underlying bone
What CN is involved with visual acuity?
CN II
What CN is involved with hearing?
CN VIII
What CNs are involved with extraocular muscles?
CN III, IV, VI
What CN is involved with facial expression?
CN VII
What CN is involved wiith mastication?
CN V (motor)
What CN is involved with soft touch of the face?
CN V (sensory)
What CNs are involved with soft palate/uvula “Ah”?
CN IX, X
What CN is involved with movement of the tongue?
CN XII
What CN is involved with head and shoulder movement?
CN XI
During your visual inspection of the hair what are looking for?
-Quantity, distribution, texture
-Hair loss
(Alopecia Areata- Autoimmune condition causing hair loss
Androgenic Alopecia- Receding/thinning hair)
-Lice, nits
-Seborrheic Dermatitis- “Dandruff”
If during your head inspection you see silvery white sharply demarcated plaques and coarse scale, what disease might you suspect?
Psoriasis
If during your head inspection you see round scaly patches or plaques and a kerion, what disease might you suspect?
Tinea Capitis
If during your visual inspection of the face you notice elongated head, bony prominence of the forehead, and enlarged nose, ears, jaw, and lips, what disease might you suspect?
Acromegaly
If during your visual inspection of the face you notice edema around the eyes that does not pit with pressure, dry skin, and coarse/dry/thinned eyebrows, what disease might you suspect?
Myxedema (hypothyroidism)
If during your visual inspection of the face you notice the face is pale, and edematous with slit-like eyes, what disease might you suspect?
Nephrotic syndrome (kidney disorder that causes your body to excrete too much protein in your urine)
If during your visual inspection of the face you notice round “moon” shape, red cheeks, and excessive facial hair, what disease might you suspect?
Cushing’s Syndrome (increased adrenal hormone production)
If during your visual inspection of the face you notice edema anterior to the ear lobes and above the angles of the jaw, what disease might you suspect?
Parotid gland enlargement
If during your visual inspection of the face you notice a “mask-like” expression, decreased blinking, forward flexed neck, oily skin, and drooling, what disease might you suspect?
Parkinson’s disease
When you palpate the TMJ, what are you checking for?
Listen and feel for clicks, range of motion, clench teeth
How do you test CN V sensory function?
Light touch in all 3 areas bilaterally using cotton-tip applicator
How do you test CN V motor function?
Palpate masseter muscle, clench teeth
How do you test CN VII function?
Check for facial symmetry Raise your eyebrows Frown Squeeze eyes shut Puff out cheeks Smile (WITH TEETH)
If during your visual inspection of the face you notice the patient has difficulty closing one eye and has a flattened nasolabial fold, what disease might you suspect?
Bell’s Palsy -Idiopathic facial (7th) nerve paralysis causing muscle weakness on one side of face
When you auscultate the temporal artery, what are you listening for?
Bruits
If you notice bruits when auscultating the temporal artery, what may the patient have?
Giant cell (Temporal) Arteritis
What does EOMI mean?
Extraocular movements intact
How do you test the extraocular movements?
Move your finger through a large and asking the patient to follow with just their eyes.
- You need to watch for parallel movements
- Pause at upward and lateral gaze to look for any nystagmus
- At the end of the H, patient will follow finger in towards their nose to test for convergence
Ptosis is commonly seen with a problem in which cranial nerve?
CN III
How do you conduct a corneal light reflection test and what does it test for?
Shine light into the patient’s eyes to test for strabismus/conjugate gaze (ocular alignment)
-light should reflect off the pupils in the same spot (negative)
What type of conjunctivitis typically has yellow drainage from the eye?
Bacterial conjunctivitis
What chart should you use to screen for myopia and at what distance?
Snellen Chart at 20 ft
Myopia (impaired far vision)
What chart should you use to screen for presbyopia and at what distance?
Rosenbaum Chart at 14 in
Presbyopia (impaired near vision)
How do you conduct a visual acuity exam?
Have the patient cover one eye and read the smallest line possible
Have the patient cover the other eye and read the line backwards
What is the correlation between the numerator and denominator on a visual acuity score?
The larger the denominator, the worse the vision
What could an absent red light reflex indicate?
Cataracts or retinoblastoma
What is the last part of the ophthalmoscpic exam? How do you do it? And what are you looking for?
View Macula/fovea
Responsible for central vision
Pt looks directly into the light (temporal)
Young, healthy pts you may see bright reflection from macula
Degeneration of macula is due to build up of drusen (cellular debris): as degeneration occurs, the light reflection decreases
What is miosis?
Excessive constriction
What is mydriasis?
Excessive dilation
What is anisocoria?
Pupils are unequal in size
How do you conduct a pupil exam?
Ask the patient to look straight ahead as you shine a bright light obliquely into each pupil
What is a direct pupillary light reflex?
Pupils constrict on the same side as the light
What is a consensual pupillary light reflex?
Pupil constricts on the opposite eye
How do you conduct a near/far accommodation exam?
Ask the patient to focus on an object approximately 10cm away then focus on an object >6 feet away
Watch for pupillary constriction with near effort, and dilatation with distance.
• Narrows (constricts) with Near • Dilates with Distance
How should you describe normal extra-ocular muscles?
EOMI
Extra-ocular movements intact
If a patient has glaucoma, what kinds of things may appear in their ophthalmoscope exam?
Increased pressure within eye results in abnormal cupping
Indicates optic nerve damage Normal cup to disc ratio < 1:2
Glaucoma cup to disc ratio > 1:2
May have abnormal Anterior Chamber Depth: crescent shadow
What is nystagmus?
Fine rhythmic oscillation of the eyes associated with neurologic conditions
What are the ocular muscles and their associated cranial nerves?
LR6…SO4… AO3
Lateral Rectus CN VI
Superior Oblique CN IV
All Others CN III
How do you conduct a corneal light reflection test?
Shine light into the patient’s eyes to test for conjugate gaze
When you visually examine the eyelids, what types of things should you be looking for?
Edema Lesions Width of palpebral fissures Condition and direction of the eyelashes Ability to close eyes: Ptosis (droopy eyelid) is a CN III problem, incomplete closure is a CN VII problem
What is a chalazion?
*Nontender blocked Meibomian (sebaceous) gland; points inside lid
What is a hordeolum (stye)?
*Tender, red infection at the inner or outer margin of eyelid; usually from Staphylococcus aureus
When located on inner lid margin usually from obstructed Meibomian gland
When located on outer lid margin usually from obstructed eyelash follicle or tear gland
What is dacryocystitis?
Infection/inflammation of the nasolacrimal sac usually secondary to blockage of the nasolacrimal duct
Swelling between base of nose and eye
What is entropion vs ectropion?
Entriopion = Lid inversion: INWARD turning of the lid margin
Irritation of conjunctiva and cornea
Ectropion = lid eversion: OUTWARD turning of lid
How do you conduct a Cover-Uncover exam?
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 removed.
What is a pingueculum?
Yellow, triangular growth on the bulbar conjunctiva on either side of the iris
Harmless
*Vision WNL (within normal limits)
What is a pterygium?
Triangular thickening of bulbar conjunctiva that grows slowly across cornea.
*May interfere with vision
What is scleral icterus?
Yellow discoloration of sclera Elevated bilirubin
Frequently associated with jaundiced skin
What is xanthelasma?
Raised, yellow, well-circumscribed cholesterol-filled plaques around eyelids
-Commonly associated with hyperlipidemia
What are the different types of conjunctivitis?
Viral, bacterial, allergic, or irritant conjunctivitis
bacterial more goopy
What is exophthalmos?
Abnormal protrusion of the eyeball, lid retraction
Seen in Grave’s Disease
Another finding in thyroid dysfunction is loss of the lateral 1/3 eyebrows
What is episcleritis?
Localized ocular inflammation of the episcleral vessels.
Central Nodule with radiation of vessels
Usually self-limiting, benign
May be associated with autoimmune conditions
What is subconjunctival hemorrhage?
Burst blood vessel in the conjunctiva
Hx of cough, sneeze, straining, +/- blood thinner use
Asymptomatic, self-limited
If recurrent, consider bleeding disorder
What is hyphema?
Grossly visible blood in anterior chamber
Usually secondary to trauma
Vision threatening- Refer!
What are symptoms associated with a corneal abrasion?
Foreign body sensation
Photophobia, increased lacrimation, pain
What is a corneal chemical burn?
Usually hx of liquid or gas splashed in eye
Immediate, prolonged irrigation
What is an eye puncture?
Puncture wound with hemorrhage and asymmetric, non reactive dilated pupil
What are cataracts?
Clouding (opacity) of the lens
Causes painless progressive vision loss
Risk Factors: Age, Smoking, DM, Corticosteroid Use, ETOH
How do you conduct an ophthalmoscopic exam?
Darken room
May use small or large beam of light, just do not use maximum light
Ask patient to keep both eyes open
Turn disc to 0 diopters (keep finger on dial in order to adjust focus as needed)
Ask pt to look at a fixed point on the wall
When examining the pts R eye, use your R hand to hold ophthalmoscope to your R eye (and vice versa)
Approach pts eye 15° lateral to their line of vision.
Look through pupil for the “red reflex”
Brace yourself with hand on pts shoulder or brow
Move closer to pt’s eye almost touching pt’s eyelashes
Follow blood vessels centrally to find optic disc
What could an absent red light reflex indicate?
Cataracts or retinoblastoma
What should you see when looking at the optic disc during an ophthalmoscope exam? What are normal cup:disc and AV ratios?
Always compare findings bilaterally
Note the sharpness and clarity of disc outline
Note disc color (yellow-orange), size of central cup
Cup is normally 1/2 diameter of disc
“Cup:disc ratio is < 1:2”
-“AV ratio 2:3”
Why might a clinician use a PanOptic instrument instead of an ophthalmoscope?
Larger view than the traditional ophthalmoscope
Increases distance between examiner and clinician
Clinician may use his/her same eye to examine both of the patient’s eyes
How do copper wire hypertensive vascular changes appear?
Vessels get full and tortuous with increased light reflex with coppery luster
How do silver wire hypertensive vascular changes appear?
Vessel wall becomes opaque. Blood inside cannot be seen
How do A-V nicking/crossing hypertensive vascular changes appear?
Appearance of breaks in vein when artery and vein cross
If a patient has hypertensive retinopathy, what kinds of things may appear in their ophthalmoscope exam?
Cotton wool patches
Hemorrhages
What are cotton whool patches?
Soft exudates
White, gray, ovoid lesions with irregular (soft)
borders
Caused by infarcted nerve fibers
If a patient has diabetic retinopathy, what kinds of things may appear in their ophthalmoscope exam?
Hemorrhages
Hard exudates (well-defined borders)
Exudates are creamy/yellow,
appear bright, neovascularization
What is neovascularization?
Development of new blood vessels arising from the disc and extending to the margins
Caused by abnormal permeability and vascular occlusion
More numerous and tortuous
If a patient has glaucoma, what kinds of things may appear in their ophthalmoscope exam? (cup:disc ratio)
Increased pressure within eye
Optic nerve damage
Glaucoma cup to disc ratio > 1:2
Anterior Chamber Depth: crescent shadow
If a patient has a detached retina, how would that affect their vision?
Curtain like shadow over vision
Flashes, floaters
Risk of vision loss
What is pilledema?
Optic disc swelling that is caused by increased intracranial pressure
No sharp borders of the disc
Pt may have severe HA, nausea, vomiting
How is a visual field test conducted?
Sit at same level as pt
Pt closes one eye and looks at provider’s nose
Examiner closes opposite eye
Examiner places hand to periphery of
visual field
“While looking at my nose, how many fingers am I holding up?”
Check all 4 quadrants and each eye individually
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
What I see on the ____ side hits the opposite (temporal) side of the retina and stays on the same side
Nasal
What I see on the ____ side hits the opposite (nasal) side of the retina and crosses at the optic chiasm
Temporal
What kind of visual field defect would cause a blind eye?
Defect at the optic nerve before optic chiasm (neither the nasal or temporal sight will make it to the brain)
What kind of visual field defect would cause bitemporal hemianopsia?
AKA: Tunnel vision
Lesion at the Optic Chiasm
What kind of visual field defect would cause left homonymous hemianopsia?
Lesion on Optic tract behind Chiasm produce defects on opposite side:
• Defect at R optic tract causes L homonymous hemianopsia
• Defect at L optic tract causes R homonymous hemianopsia
When should you preform a Cover-uncover test?
If you see abnormal corneal light reflection
What is strabisum?
“Lazy eye”
Deviation of the eyes from their normally conjugate position Congenital or acquired
Esotropia, Exotropia, Hypertropia, Hypotropia
One of the most common eye problems encountered in children
Can result in amblyopia (vision loss) if not detected early and treated
Check visual acuity if strabismus detected and refer
If a patient has an asymmetric corneal light reflection where the light is displaced laterally on affected eye, what kind of strabisum do they have?
Esotropia
If a patient has an asymmetric corneal light reflection where the light is displaced medially on affected eye, what kind of strabisum do they have?
Exotropia
If a patient has an asymmetric corneal light reflection where the light is displaced superiorly on affected eye, what kind of strabisum do they have?
Hypotropia
If a patient has an asymmetric corneal light reflection where the light is displaced inferiorly on affected eye, what kind of strabisum do they have?
Hypertropia
How do you conduct an anterior chamber depth test and what does it test for?
Tests for increased intraocular pressure: glaucoma
Shine light from the temporal side of the pts eye (toward the nose)
Look for shadow on the medial aspect of the iris
“Crescent shadow”
How do you conduct a corneal reflex test and what does it test for?
CN V (sensory) and VII (motor) Gently touch the edge of the cornea with a rolled cotton and observe for responsive blink
What is alopecia areata
autoimmune condition causing hair loss
What is androgenic alopecia
receding/thinning hair
