L3-4: HEENT Flashcards
1
Q
HEENT: ROS
A
- Head
- headache, vertigo, syncope, head trau
- Eyes
- visual acuity changes, blurred vision, diplopia, photophobia
- Ears
- change in acuity, discharge, pain, tinnitus, recurrent ear infections
- Nose
- obstruction, discharge, epistaxis, pain
- Mouth
- toothaches, bleeding gums, sore throat, dysphagia, hoarseness, change in taste
- Neck
- pain, stiffness, swelling/masses
2
Q
Cranial Nerves
What cranial nerves are responsible for the following
- Visual Acuity
- Hearing
- EOMs
- Facial expression
- Mastication, clench
- Soft touch face
- Soft palate/uvula “Ah”
- Movement of Tongue
- Head & shoulder movement
A
- Visual Acuity (CN II)
- Hearing (CN VIII)
- EOMs (CN III, IV, VI)
- Facial expression(CN VII)
- Mastication, clench (CN V motor)
- Soft touch face (CN V sensory)
- Soft palate/uvula “Ah” (CN IX, X)
- Movement of Tongue (CN XII)
- Head & shoulder movement (CN XI)
3
Q
Hair
Alopecia Areata
Androgenic Alopecia
Seborrheic Dermatitis
A
- Alopecia Areata: autoimmune condition causing hair loss
- Androgenic Alopecia: Receding/thinning hair
-
Seborrheic Dermatitis: “Dandruff”, Greasy, Yellow scales
- Scalp, Nasolabial folds, Eyebrows, Forehead
4
Q
Psoriasis
What is it?
Clinical presentation?
A
- Autoimmune dermatologic condition
- Silvery white sharply demarcated plaques and coarse scale
5
Q
Tinea Capitis
What is it?
Clinical presentation?
What is a kerion?
A
- Fungal scalp infection
- Round scaly patches or plaques with or w/o inflammation
- Kerion: raised boggy secondarily infected fungal lesion
6
Q
Trigeminal Nerve (CN V) Sensory and Motor
How to test?
A
- Sensory - Light touch in all 3 areas bilaterally using cotton-tip applicator
- Ophthalmic
- Maxillary
- Mandibular
- Motor - palpate masseter muscle, clench teeth
7
Q
Facial Nerve
Which cranaial nerve?
How to assess?
A
- Facial Nerve (CN VII)
- Assess facial symmetry
- Raise eyebrows
- Frown
- Squeeze eyes shut
- Puff out cheeks
- Smile
8
Q
Acromegaly
What is it?
Cause?
A
- Excessive Growth Hormone production
- Large hands & feet
- Excessive facial bone growth, enlarged jaw
9
Q
Bell’s Palsy
Cause?
Clinical presentation?
A
- Idiopathic facial (7th) nerve paralysis: muscle weakness on one side of face
- Difficulty closing eye
- Flattened nasolabial fold
10
Q
Specialized Test: Assessing the Temporal Artery
What are you ascultating for?
A
- Palpate
- Auscultate for bruits
- Giant Cell (Temporal) Arteritis
- Adults >50
- New HA
- Jaw Claudication
- Elevated ESR
- Associated with condition called Polymyalgia Rheumatica (PMR)
- Giant Cell (Temporal) Arteritis
11
Q
Anatomy of the Eye
Tarsal plates
meibomian glands
bulbar conjuctiva
palpebral conjuntiva
A
- Eyelids
- Tarsal plates: firm strip of connective tissue
- Meibomian glands: sebaceous glands
- Bulbar conjunctiva
- Covers anterior eyeball
- Palpebral conjunctiva
- Covers inner eyelids
12
Q
Visual Acuity: Vital Sign of the eye
Snellen vs. Rosenbaum
What is each test measure?
A
- Snellen Chart: Test central vision @ 20 feet
- Screens for myopia (impaired far vision)
- Rosenbaum pocket chart (@ 14 inch*)
- Screens for presbyopia (impaired near vision)
13
Q
Pupils
Miosis
Mydriasis
Anisocoria
Direct pupillary light reflex
Consensual pupillary light refle
A
Miosis: excessive constriction
Mydriasis: excessive dilation
Anisocoria: pupils are unequal size
Direct pupillary light reflex: pupil constricts on same side as light
Consensual pupillary light reflex: Constriction in opposite eye
14
Q
Near Far Accommodation
What is the test?
What are you looking for?
A
- Patient focuses 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
15
Q
Extraocular Muscles (EOMs)
Nystagmus
How to test?
A
Nystagmus: uncontrolled repetitive movements of the eyes; fine rhythmic oscillation
During “H” pause @ upward & lateral gaze to detect nystagmus
Nystagmus may be seen in a variety of neurologic conditions
16
Q
Extraocular Movements: Cranial Nerves
what are the extraocuar muscles?
What are the cranial nerves assocaited with each?
A
- Extraocular Movements (CN III, IV, VI)
- LR6…SO4… AO3
- Lateral Rectus (CN VI)
- Superior Oblique (CN IV)
- All Others CN III
- Medial rectus
- Superior rectus
- Inferior rectus
- Inferior oblique
17
Q
Corneal Light Reflection
How to test?
What does it test for?
A
- Shine light into the patient’s eyes
- Corneal light reflection tests for conjugate gaze
18
Q
Ptosis
What is it?
Which cranial n.?
A
Ptosis: drooping uppe reyelid
Cranial nerve: CN III (oculomotor n.)
19
Q
Eyelid: Incomplete closure
What is it?
Which cranial n?
A
CN VII
20
Q
Chalazion vs. Hordeoleum
What are they?
Location?
A
- Chalazion
- Nontender blocked Meibomian (sebaceous) gland; points inside lid
- Hordeoleum
- 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
21
Q
Dacryocystitis
What is it?
A
- Dacryocystitis (Lacrimal Sac Inflammation)
- Infection/inflammation of the nasolacrimal sac usually secondary to blockage of the nasolacrimal duct
- Swelling between base of nose and eye
22
Q
Entropion vs. Ectropion
A
-
Entropion
- Lid inversion: INWARD turning of the lid margin
- Irritation of conjunctiva and cornea
- More common in elderly
-
Ectropion
- Lid eversion: OUTWARD turning of the lid margin exposes palpebral conjunctiva
- Excessive tearing can occur as eye may not drain effectively
- More common in elderly
23
Q
Pingueculum vs. Pterygium
A
-
Pingueculum
- Yellow, triangular growth on bulbar conjunctiva on either side of the iris
- Harmless, vision WNL
-
Pterygium
- Triangular thickening of bulbar conjunctiva that grows slowly across cornea
- May interfere with vision
24
Q
Scleral Icterus
What is it?
DDx?
A
- Scleral Icterus: Yellow discoloration of sclera, frequently association with jaundiced skin
- Elevated bilirubin
25
**Xanthelasma**
What is it?
DDx?
* **Xanthelasma:** Raised, yellow, well-circumscribed cholesterol-filled plaques around eyelids
* Commonly associated with hyperlipidemia
26
**Conjunctivitis**
What is it?
Types?
* Inflammation of the transparent covering of the eye because of bacterial or viral infection or allergic reaction. The eye appears swollen, and red with itching sensation.
* Viral, Bacterial, Allergic, Irritant Conjunctivitis
27
Thyroid related Orbitopathy
Exophthalmos
* **Exophthalmos:** Abnormal protrusion of the eyeball, lid retraction
* Seen in Grave’s Disease (Thyroid dysfunction)
* Thyroid dysfunction (hypothyroidism) may also cause loss of the lateral 1/3 eyebrows
28
**Subconjunctival Hemorrhage vs. Hyphema**
* **Subconjunctival Hemorrhage**
* Asymptomatic, self-limited
* Usually hx of cough, straining
* **Hyphema**
* Grossly visible blood in anterior chamber
* Usually secondary to trauma
* Vision threatening → refer
29
**Corneal Abrasion (With Fluorescein Stain) vs. Corneal Chemical Burn**
* _Corneal Abrasion (With Fluorescein Stain)_
* Foreign body sensation
* Photophobia, increased lacrimation, pain
* Does patient wear contacts?
* Injury?
* _Corneal Chemical Burn_
* Usually hx of liquid or gas splashed in eye
* Immediate, prolonged irrigation
30
**Cataract**
Cause
Risk factors
* Clouding (opacity) of the lens
* Causes painless progressive vision loss
* _Risk Factors:_ age, Smoking, DM, Corticosteroid Use, ETOH
31
What is the normal cup to disc ratio?
What is the normal AV ratio?
* CD Ratio: 1:2
* AV ratio: 2/3
32
**What is the Macula/fovea responsible for?**
Responsible for central vision
33
**Hypertensive Vascular Changes**
Copper wire
Silver wire
A-V nicking/crossing
* **Copper wire**
* oVessels get full and tortuous with increased light reflex with coppery luster
* **Silver wire**
* Vessel wall becomes opaque. Blood inside cannot be seen
* **A-V nicking/crossing**
* Appearance of breaks in vein when artery and vein cross
34
**Hypertensive Retinopathy**
Cotton Wool Patches
Hemorrhages
What are they?
Cause?
* **Cotton Wool Patches:** (aka. Soft exudates)
* White, gray, ovoid lesions with irregular (soft) borders
* Caused by infarcted nerve fibers
* Also seen in DM
* **Hemorrhages:**
* Caused by microaneurysms
35
**Diabetic Retinopathy**
What is it?
Neovascularization?
* Hemorrhages can be seen along with hard exudates
* Hard (well-defined borders) exudates are creamy/yellow, appear bright
* These are common with DM and HTN
* **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
36
**Glaucoma with Cupping**
What is glaucoma?
What does glaucoma do to the cup to disc ratio?
How is the anterior chamber depth related to galucoma?
* Increased pressure w/i eye results in abnormal cupping (backward depression of the disc)
* Represents optic nerve damage
* Normal Cup to Disc ratio \< 1:2.
* In Glaucoma, cup to disc ratio is \> 1:2 due to increase intraocular pressure
* May have abnormal Anterior Chamber Depth on exam (crescent shadow coming soon...)
37
**Papilledema**
What is it? Cause?
Symptoms?
* Optic disc swelling caused by increased intracranial pressure
* Sharp borders of the disc are no longer present
* Pt may have severe HA, nausea, vomiting
38
**Macular Degeneration**
* LAST STEP of eye exam is to ask pt to look directly at light
* Macula: Area of the retina that absorbs the most light
* Normal: Reflection of light from macula
* Degeneration of macula is due to build up of drusen (cellular debris)
* As degeneration occurs, the light reflection decreases
39
**Specialized Test: Checking Visual Fields**
What is it?
How to test?
* Area seen by pt when they look at a central point
* Check with fingers in each quadrant
40
**Normal Vision**
**Where is the lesion/defect for the following, cause?:**
Blind eye
Lesion at the Optic Chiasm
Lesion on Optic tract behind chiasm
* What I see on the nasal side hits the opposite (temporal) side of the retina and stays on the same side
* What I see on the temporal side hits the opposite (nasal) side of the retina and crosses at the optic chiasm
* (2) Blind eye = Defect at the optic nerve before optic chiasm (neither the nasal or temporal sight will make it to the brain)
* (3) Lesion at the Optic Chiasm
* Causes defect in both temporal fields (bitemporal hemianopsia) Ex. Pituitary tumor
* (4) Lesion on Optic tract behind chiasm (Ex. stroke, tumor) produce defects on opposite side:
* Defect at R optic tract causes L homonymous hemianopsia
* Defect at L optic tract causes R homonymous hemianopsia
41
**Specialized Test: Cover-Uncover Test**
When to perform?
How to test?
What does it test?
* When to perform:
* If abnormal corneal light reflection
* How to test:
* Occlude each eye in alternating fashion
* Observe for change in fixation of the uncovered eye.
* Observe for movement of covered eye after cover is removed.
* May reveal muscle imbalance not seen on general eye exam
42
**Strabismus**
What is it?
Esotropia
Exotropia
Hypertropia
Hypotropia
Amblyopia
* **Strabismus:** Misalignment of Eyes
* 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 (4% of children \< 6YO)
* Can result in **amblyopia** (vision loss) if not detected early and treated
* Check visual acuity if strabismus detected and refe
43
**Asymmetric Corneal Light Reflection in Patient with Strabismus**
Where is the light displaced in:
Esotropia
Exotropia
**Esotropia:** Light displaced laterally on affected eye
**Exotropia:** Lightdisplaced medially on affected eye
44
**Specialized Test: Anterior Chamber Depth**
How to test?
What does this test for?
* _Tests for:_ increased intraocular pressure
* Ex. glaucoma
* _How to test_
* Shine light from the temporal side of the patient’s eye (toward the nose)
* Look for shadow on the medial aspect of the iris
* “Crescent shadow”
45
**Specialized Test: Corneal Reflex**
Which cranial nerves?
How to test?
* CN V (sensory) and VII(motor)
* Gently touch the edge of the cornea with a rolled cotton and observe for responsive blink
Note: Don’t confuse Corneal Reflex with Corneal Light Reflection: which checks for ocular alignment
46
**Specialized Test: Eversion of the Eyelid**
How to test?
What does it test for?
* Pull down upper eyelashes and evert eyelid over cotton applicator.
* Used to rule out foreign body
47
**Gouty Tophi**
Uric acid crystal deposit after years of chronically elevated uric acid
48
**Basal Cell Carcinoma vs. Squamous Cell Carcinoma**
Clinical Presentations**?**
* **Basal Cell Carcinoma (BCC):** Raised, pearly nodule with central telangiectasia
* **Squamous Cell Carcinoma (SCC):** Crusted border, central ulceration, bleeding
49
**Assessment of Hearing**
Which cranian nerve?
Conductive Loss vs. Sensorineural Loss
* Assessment of Hearing (CN VIII)
* If hearing reduced, distinguish conductive hearing loss vs. sensorineural hearing loss.
* **Conductive Loss:** problem conducting sound waves (EAC, TM or middle ear). Abnormality usually visible
* **Sensorineural Loss:** disorder of the inner ear, cochlear nerve (CN8) impairs transmission of nerve impulse to brain. Problem is NOT visible.
50
**Types of hearing conduction**:
Air Conduction vs. Bone Conduction
What if:
AC \> BC
BC \> AC
AC \> BC
* **Air Conduction:** Sound transmitted through air (EAC, TM, middle ear) into cochlea
* **Bone Conduction:** Sound transmitted though vibrations in bone. Bypass external & middle ear
* Vibration of the skull stimulates the inner ear directly
* **AC \> BC:** Normal
* **BC \> AC:** Conductive hearing loss
* **AC \> BC:** Could also be sensorineural hearing loss
51
**Weber Test**
How to test?
What does it test for?
What is normal? abnormal?
Conductive loss vs. Sensorineural hearing loss
Causes?
* _How to test:_
* Tuning fork on top of head
* _Tests for:_
* NORMAL: Sound heard equally in both ears
* ABNORMAL: sound lateralizes
* **Conductive** loss: Sound lateralizes to **impaired (bad)** ear
* **Sensorineural hearing loss (SNH):** Sound lateralizes to **good** ear
* Bad ear cannot transmit impulses
* No signal is transduced by cochlea on affected side
* **Unilateral conductive** loss lateralizes (sound is heard best) to impaired ear
* Ex. Otitis media, perforation, cerumen, otosclerosis, etc.
* **Unilateral sensorineural** loss lateralizes to good ear
* Caused by damage to the inner ear
* Ex. Presbycusis (age related hearing loss), noise exposure, head trauma
52
**Rinne Test**
* What does it test for?
* What does it compare?
* What is normal?
* What would you expect with to see in:
* Unilateral conductive loss
* Unilateral sensorineural loss
* Compares Air and Bone Conduction
* How to test
* Place tip of vibrating tuning fork on mastoid bone
* Ask patient if they can hear it; have them tell you when sound stops
* Move tuning fork in front of ear; ask if they can still hear it.
* If they can still hear the sound, **then AC\>BC (NORMAL TEST)**
* Normal: AC\>BC
* Normally, sound is transmitted to cochlea most efficiently through air
* **Unilateral conductive loss:** Sound heard through bone longer than through air (BC \> AC)
* **Unilateral sensorineural loss:** Sound heard longer though air (AC \> BC) because AC and BC are reduced equally (normal pattern prevails)
53
Weber vs. Rinne
Normal
Conductive Hearing Loss
Sensorineural Hearing Loss
* Weber
* _Normal:_
* No lateralization (equal Bilaterally)
* _Conductive Hearing Loss:_
* Lateralizes to impaired ear
* _Sensorineural Hearing Loss:_
* Lateralizes to Good ear
* Rinne
* _Normal:_
* Air \> Bone Conduction Bilaterally
* _Conductive Hearing Loss:_
* BC \> AC in impaired ear
* AC \> BC in Good ear
* _Sensorineural Hearing Loss:_
* AC\> BC in both ears
54
**Tympanosclerosis**
* Chalky white patch- Scarring of the TM
* Seen in recurrent Otitis Media or hx of tubes or previous perforation
55
**Serous Effusion With Air Bubbles**
Cause?
Symptoms?
* Usually caused by viral URI or barotrauma
* Eustachian tube dysfunction often involved
* Sxs: Fullness or popping in ear
56
**Bullous Myringitis**
What is it?
* Painful, hemorrhagic vesicles
* Landmarks obscured
* Commonly conductive hearing loss during infection
57
**Otitis Externa**
What is it?
Symptoms?
* Infection of the external auditory canal
* Discharge and edema of the canal
* Tenderness with movement of tragus and pinna
58
**Specialized Test: Assessing the Sinuses**
Sinus percussion
Sinus palpation
Frontal Sinus Transillumination
Maxillary Sinus Transillumination
**Sinus percussion:** Tap the frontal and maxillary sinuses assessing for tenderness
**Sinus palpation:** Apply pressure to the frontal and maxillary sinuses assessing for tenderness
**Frontal Sinus Transillumination:** Place light below brow and look for glow in frontal area (Normal finding)
**Maxillary Sinus Transillumination:** Place light against cheek bone below eye and look for glow on hard palate (Normal finding)
59
**Septal Deviation vs. Septal Perforation**
Symptoms?
**Cause?**
* **Septal Deviation**
* Deviation is common and mild deviation often asymptomatic
* Deviation seldom obstructs air flow
* **Septal Perforation**
* Seen with trauma, infection, cocaine, s/p surgery
* Symptoms: crusting, epistaxis
* Small lesions may whistle
60
**Nasal Polyps**
* Soft, pale growths commonly seen in allergic rhinitis, chronic sinusitis and other conditions
* May cause nasal obstruction
* Anosmia (loss of smell)
61
**Septal Hematomas**
Cause?
**Symptoms?**
* May occur after nasal trauma
* More common in peds patients
* Symptoms: Nasal obstruction, pain & tenderness
* PE: Soft, tender swelling
* Must rule out septal hematoma in all nasal trauma
* Early diagnosis and treatment prevents abscess, deformity and other complications
62
**Epistaxis**
What is it?
Where does it most commonly occur?
* aka Nosebleed
* Highly vascular region of anteroinferior nasal septum
* 90% of all epistaxis occur in **Kiesselbach plexus/area**
63
**Rhinitis and Sinusitis**
Symptoms?
* **Allergic Rhinitis (AR):** Swollen, pale, blue, boggy turbinates, shiners, eye Sxs
* Sinusitis and URI: Erythematous turbinates
* Drainage—mucoid vs. clear vs. purulent
* **Sinusitis:** Tenderness to palpation/percussion of sinuses, abnormal transillumination
64
**Salivary glands**
What are the glands?
What are the ducts associated with the glands?
Where are they located?
* **Parotid**
* **Stensen Ducts:** Buccal mucosa lateral to molars
* **Submandibular**
* **Wharton Ducts:** Floor of mouth under tongue
65
**Examination of the Oropharynx**
Bimanual Examination
Examination of the tongue
* Bimanual Examination: Palpate oropharynx with gloved hand
* Palpate wall of mouth between internal and external fingers (“bimanual”)
* Palpate floor of mouth, tongue for masses, lesions
* Examination of the tongue: With gloves and gauze, gently grasp tip of the tongue to inspect lateral margins
* Especially important if tobacco use
66
**Carcinoma of the Lip**
Common cause?
* Squamous Cell Carcinoma common cause
* Thorough exam of lips, tongue and oral mucosa important
* Sores that don’t heal
* Newly formed lesion
* Consider Risk factors
67
**Angular Cheilitis**
What is it?
Cause?
* Irritation, fissuring of skin at corners of the mouth associated with
* Ill-fitting dentures
* Vitamin deficiency
* Excessive salivation
68
**Oral Candidiasis**
**Oral Candidiasis (Thrush)**
* White patches or plaques on the tongue or buccal mucosa
* Uncommon among healthy adults
* Thrush can Brush
69
**Leukoplakia**
What is it?
How to differentiate from thrush?
* Lesions in the mouth that present as thickened, white patches that cannot be rubbed off.
* Potentially premalignant
* Differentiated by thrush by the inability to remove white area
* Referral for biopsy
70
**Oral Carcinoma**
Main cause?
* Thorough physical exam is essential!
* Majority of oral Ca is Squamous Cell Carcinoma
71
**Torus Palantinus**
* Benign, midline mass in hard palate
72
**Gingivitis**
Symptoms?
* Causes changes to the Gums
* Redness
* Bleeding
* Edema
* Tenderness
73
**Gingival Hyperplasia**
Causes?
* Can be caused by:
* Medications
* Pregnancy
* Puberty
74
Tonsillar Hypertrophy
* persistently enlarged tonsils
75
**Hairy Tongue**
What is it?
Cause?
* Benign Condition
* Defect in desquamation of papillae
* Many causes: Candida, poor hygiene, Abx, tea, coffee, tobacco use
76
**Fissured Tongue**
* Multiple small grooves on dorsal tongue
* Benign
* Increasing incidence with advanced age
77
**Geographic Tongue**
* Dorsum of tongue reveals smooth areas void of papillae
* Benign
* “Map-like”
78
**Group A Strep**
**Exudative Tonsillitis**
Symptoms?
* ST, fever, +/- known exposure
* No cough, nasal congestion
* **Bilateral exudative tonsillitis**, cervical lymphadenopathy (LAD)
* Strep screen/culture +
79
**Mononucleosis**
Symptoms?
Cause?
* Mononucleosis (Epstein Barr Virus)
* ST, fever, fatigue
* **Bilateral exudative tonsillitis**
* Tender cervical LAD, +/- splenomegaly
* Mono screen +, strep screen negative
80
**Peritonsillar Abscess**
Symptoms?
Clinical presentation?
* **Unilateral peritonsillar swelling & shifted uvula**
* Infection spreads into peritonsillar space
* “Hot potato voice,” drooling
81
**Anatomy of the Neck**
Anterior Triangle
Posterior Triangle
* Anterior Triangle
* Boundaries: mandible, sternocleidomastoid, midline neck
* Posterior Triangle
* Boundaries: sternocleidomastoid, trapezius, clavicle
* Thyroid cartilage
* Cricoid cartilage
* Thyroid gland
* Trachea
* Carotid artery, jugular vein
82
**Lymph Nodes**
What are the lymph nodes?
What is unique about one of the categories of lymphnodes?
* Occipital
* Post-auricular
* Pre-auricular
* Tonsillar
* Submaxillary
* (submandibular)
* Submental
* Anterior cervical - superficial & deep
* Posterior cervical - superficial & deep
* Supraclavicular
* may suggest metastasis from lung or GI cancer
83
What is **_bruits_**?
signs of turbulent arterial blood flow.
84
**Goiter**
What is it?
* Enlarged thyroid (Thyromegaly)
* May be present in multiple forms of thyroid dysfunction
* Palpate thyroid while **patient swallows**
85
**Tracheal Deviation**
What is it?
Cause(s)**?**
* Trachea may shift toward one side or another
* Multiple causes
* Ex. Pneumothorax, goiter, or tumor
86
**Jugular Venous Distension**
What is it?
Cause?
* Cardiac vs. pulmonary cause
* Blood flows backward from right atrium into the jugular veins
* Stay tuned to learn more about JVD in upcoming lectures
