HEENT (Physical Diagnosis) Flashcards
What are you palpating for when examining a patient’s skin?
Temperature
Texture
Turgor
Describe the procedure for orthostatic vitals
Obtain BP and pulse in the supine, (sitting), and standing positions
Patient should be supine for five min before the first vitals
Retake vitals after standing for three min and compare
What is considered an abnormal result when doing orthostatic vitals?
≥20mmHg drop in SBP or ≥10mmHg drop in DBP
Increase of HR of ≥20 bpm
How do you test CN VII function?
Facial muscles
Squeeze eyes shut
Wrinkle forehead
Smile w/ teeth
Puff out cheeks
How do you test CN V sensory function?
Have patient close eyes
Ask them to say “Now” each time they feel you touch their face
Use cotton tipped swab to touch forehead, checks, and chin bilaterally
How do you test CN V motor function?
Palpate masseter muscle and ask patient to clench teeth
How do you test CN II function?
Visual acuity test using Snellen or hand-held Rosenbaum chart
Visual fields testing
How do you test CN VIII function?
Hearing test
Have patient close eyes, ask them if they can hear you bilaterally when you rub your fingers together next to each ear
Testing EOMs evaluates what cranial nerves?
CN III
CN IV
CN VI
How do you test CN IX and X?
Open mouth and say “Ah”
How do you test CN XII?
Stick out your tongue and wiggle it side to side
How do you test CN XI?
Head rotation and shoulder shrug against resistance
Autoimmune condition causing hair loss
Alopecia Areata
Receding or thinning hair
Androgenic alopecia
Greasy, yellowish scales
Most common in scalp, nasolabial folds, eyebrows, and forehead
Seborrheic Dermatitis
Autoimmune condition characterized by silvery white, sharply demarcated plaques and coarse scale, +/- associated hair loss
Psoriasis
Fungal infection of the scalp with scaly patches or plaques w/ or w/o inflammation
Tinea Capitis
Raised, boggy, secondarily infected fungal lesion of the hair
Kerion
Seen with Tinea Capitis
Increased growth hormone after puberty —> Enlargement of bone and soft tissue in face —> elongated head with bony prominence of the forehead, nose, and lower jaw
Acromegaly facie
Facial edema pronounced around eyes that does not pit with pressure —> dully, puffy looking face
Myxedema facie
Associated with severe hypothyroidism
I say moon facie, you say…
Cushing’s Syndrome
I say parotid gland swelling, you say…
Mumps
I say mask-like facie, you say…
Parkinson’s Disease
What are the three sensory branches of CN V?
Ophthalmic
Maxillary
Mandibular
Idiopathic paralysis of CN VII causing weakness on one side of face
Bell’s Palsy
Difficulty closing eye and flattened nasolabial fold
Bell’s Palsy
What condition might prompt you to palpate the temporal artery and Auscultate it for bruits?
Giant Cell Arteritis
Adult >50 with …
New onset HA
JAW CLAUDICATION
Elevated ESR
Giant Cell Arteritis
Giant Cell Arteritis is commonly associated with what condition?
Polymyalgia rheumatica (PMR)
What are the different components of the lacrimal apparatus?
Lacrimal gland
Lacrimal sac
Puncta
Nasolacrimal duct
Sebaceous glands located on the inner surface of the eyelid
Meibomian glands
The snellen chart is used for testing visual acuity at what distance?
20 ft
Screens for myopia
The Rosenbaum chart is used for testing visual acuity at what distance?
14 inches
Screens for presbyopia
What does it mean when we say a patient has 20/200 vision?
Patient sees clearly at 20 feet what a person with normal vision would see at 200 feet
The larger the denominator, the worse the patient’s vision
Excessive constriction of the pupils
Miosis
Excessive dilation of the pupils
Mydriasis
Pupils that are of unequal size?
Anisocoria
What are you evaluating when you pause at the upward and lateral gaze upon testing EOMs?
Nystagmus (fine rhythmic oscillation of the eyes)
When checking near-far accommodation, the pupils ______ for near vision and ______ for far vision
Narrows (constricts) for Near
Dilates for Distance
Shining light into the patient’s eyes and noting the corneal light reflection rests for…
Conjugate gaze
Ptosis indicates a problem with which cranial nerve?
CN III
Drooping of eyelid seen with CN III problem
Ptosis
Nontender meibomian gland obstruction and inflammation on the inner surface of eyelid
Chalazion
Tender, red infection near hair follicle of eyelashes on eyelid margin
Hordeolum
Infection/inflammation of the nasolacrimal sac, usually secondary to blockage of the nasolacrimal duct
—> swelling between base of nose and eye
Dacryocystitis
32 yo presents with low grade fever, swelling, redness, pain, and inability to open eye
Complains of increasing nasal congestion, facial pressure, and HA x2 weeks prior to these Sx without any treatment
No hx of trauma
What’s your Dx?
Periorbital/presentation cellulitis
Lid inversion —> irritation of the conjunctiva and cornea
Entropion
Lid eversion that exposes palpebral conjunctiva —> excessive tearing
Ectropion
Yellow, triangular nodule on the bulbar conjunctiva on either side of the iris
Pingueculum
Harmless, vision WNL
Triangular thickening of the medial bulbar conjunctiva that extends from inner canthus to the cornea
Pterygium
May interfere with vision
Yellow discoloration of the sclera associated with elevated bilirubin and jaundiced skin
Sclera icterus
Sharply demarcated yellow deposits of fat underneath the skin around the eyelids
Xanthelasma
Associated with hyperlipidemia
Conjunctivitis with clear discharge is more likely ______ while purulent discharge is more likely ______
Clear = viral
Pus = bacterial
Abnormal protrusion of the eyeball, characteristically seen in Grave’s Disease
Exophthalmos
Other than bulgy eyes, how will the face of a patient with hyperthyroidism look?
Loss of the lateral 1/3 of eyebrows
Central nodule with radiation of blood vessels on the sclera
Episcleritis
Red, painful inflammation of sclera, with photophobia and discharge
Uveitis (iritis)
Infectious causes of uveitis
Herpes
CMV
Systemic immune mediated causes of uveitis
Sarcoidosis
Juvenile Idiopathic Arthritis
IBD
Inflammatory cells in anterior chamber of the eye
Hypopyon
Blood on the sclera, associated with Hx of cough, sneeze, straining, or Coumadin use
Subconjunctival hemorrhage
Grossly visible blood in anterior chamber of the eye, usually secondary to trauma
Hyphema
Photophobia, increased lacrimation, and pain following foreign body sensation in the eye
Corneal abrasion
How do you diagnose a corneal abrasion?
Fluorescein stain —> cobalt filter on ophthalmoscope
Clouding (opacity) of the lens causing painless, progressive vision loss
Cataract
Absence of red reflex during ophthalmoscopic exam could indicate…
Cataract
Detached retina
Retinoblastoma
Artificial eye
Vascular changes visible on fundoscopic exam indicative of hypertension
Copper wire
Silver wire
A-V nicking
Cotton wool patches (soft exudates) caused by infarcted nerve fibers
Hypertensive retinopathy
Hemorrhages and hard exudates, with well-defined borders, that are creamy/yellow and appear bright on fundoscopic exam
Diabetic retinopathy
Neovascularization visible on fundoscopic exam is indicative of …
diabetic retinopathy
Cup to disc ratio > 1:2 on fundoscopic exam
Increased intraocular pressure (glaucoma)
Crescent shadow due to abnormal anterior chamber depth
Glaucoma
Curtain-like shadow over vision associated with flashes and floaters
Detached Retina
Optic disc swelling due to increased intracranial pressure
Papilledema
Area of the retina that absorbs the most light
Macula
Macular degeneration is due to …
Build up of drusen (cellular debris)
As degeneration occurs, the light reflection from the macula decreases
A lesion of the right optic nerve would result in what type of visual field defect?
Unilateral blindness in the right eye
A lesion at the optic chiasm would result in what type of visual field defect?
Bitemporal hemianopsia (tunnel vision)
A lesion of the optic tract posterior to the optic chiasm would result in what type of visual field defect?
Homonymous hemianopsia - loss of half of each field (same side lost in both eyes)
Defect at the R optic tract —> L homonymous hemianopsia
Defect at the L optic tract —> R homonymous hemianopsia
If you see an abnormal corneal light reflection, what test should you perform next?
Cover Uncover Test
May reveal muscle imbalance
Misalignment of the eyes from their normally conjugate position
Strabismus
What are the four types of strabismus?
Esotropia (one eye deviated inward)
Exotropia (one eye deviated outward)
Hypotropia (one eye deviated downward)
Hypertrophia (one eye deviated upward)
Light displaced medically on affected eye during corneal light reflection test
Exotropia
Light displaced laterally on affected eye during corneal light reflection test
Esotropia
The corneal reflex test evaluates the sensory function of ______ and the motor function of _______
CN V sensory
CN VII motor
Pain with movement of the helix and tragus of the ear
Otitis externa
Deposit of uric acid crystals that occur after years of chronically elevated uric acid
Gouty tophi
Raised nodule with central telangiectasia
Basal cell carcinoma
Skin lesion with crusted border, central ulceration, and bleeding
Squamous cell carcinoma
Bone conduction > Air conduction usually indicates…
Conductive hearing loss
Air conduction > Bone conduction
Normal
OR
Sensorineural hearing loss
During the Weber test, sound lateralizes to _____ ear in conductive hearing loss and to _____ ear in sensorineural hearing loss
To bad ear for conductive
To good ear in SNHL
Weber test —> unilateral lateralization to impaired ear
Conductive loss
Ex: Otitis media, perforation, cerumen, otosclerosis
Weber test —> unilateral lateralization to good ear
Sensorineural loss
Ex: Presbycusis, noise exposure, head trauma
Normal results for the Rinne Test
Air conduction > bone conduction
Bony prominence visible in the center of the tympanic membrane
Umbo
Where will you see the cone of light on examination of the tympanic membrane?
Anterior and inferior quadrant of the TM
Procedure used to assess TM mobility in cases of suspected serous OM or TM perforations
Pneumatic otoscopy
Chalky white patch on the TM seen in recurrent otitis media or patients with hx of tubes or previous perforation
Tympanosclerosis
Patient complains of fullness or popping in ear
Otoscopy shows serous effusion with air bubbles
Viral URI or barotrauma —> Eustachian tube dysfunction
Myringotomy tubes usually remain in ear for _______
6-12 months
Frequently fall out on their own
Painful, hemorrhagic vesicles on TM, +/- hearing loss
Bulbous myringitis
How do you transilluminate the frontal sinuses?
Place light below brow and look for glow in frontal area
How do you transilluminate the maxillary sinuses?
Place light against cheek bone below eye and look for glow on hard palate
Symptoms of septal deviation
Nasal obstruction, headache, change in smell
May see spurs and crests on exam
In peds patients with nasal trauma, you must rule out….
Septal hematoma
Sx: Increased nasal obstruction, pain, and tenderness
90% of all epistaxis occurs in…
Kiesselbach’s plexus - highly vascular region of the anteroinferior nasal septum
Swollen, pale, blue, boggy turbinates, +/- shiners/eye symptoms
Allergic rhinitis
Ducts that drain the submandibular glands on the floor of the oral cavity
Wharton’s ducts
Ducts that drain the parotid gland in the buffalo mucosa lateral to the molars
Stensen’s ducts
Irritation, fissuring of the skin at the corners of the mouth associated with ill fitting dentures, vitamin deficiency, or excessive salivation
Angular cheilitis
White patches or plaques on the tongue or buccal mucosa that can be brushed away
Oral candidiasis (thrush)
White patches on the tongue or buccal mucosa that cannot be removed by brushing aside
Leukoplakia
Potentially premalignant —> must biopsy
Majority of oral cancer is …
Squamous cell carcinoma
Benign midline mass in hard palate
Torus palantinus
Drugs that can cause gingival hyperplasia
Dilantin (phenytoin)
Cyclosporine
CCBs
Benign defect in desquamation of tongue papillae associated with abx, tea, coffee, and tobacco use
Hairy tongue
Benign, map-like areas of smoothness devoid of papillae on surface of tongue
Geographic tongue
Worsening sore throat x 2 days Fever 102 N/V No cough, nasal congestion, or fatigue Bilateral exudative tonsilitis Cervical LAD
Group A strep tonsilitis
Sore throat x 5 days Fever 101 Fatigue Tender anterior and posterior cervical LAD BL exudative tonsilitis Slight splenomegaly
Mononucleosis (EBV)
Unilateral peritonsilar swelling
Shifted uvula
Hot potato voice
Drooling
Peritonsillar abscess
Deviation of trachea from midline may suggest…
Mediastinal mass
Pneumothorax
_______ LAD may suggest metastasis from lung or GI cancer
Supraclavicular
Carotid bruits are indicative of…
Turbulent arterial blood flow, usually secondary to CAD
What do you need to ask patient to do during examination of the thyroid?
Swallow
