L3-4: HEENT Flashcards
HEENT: ROS
- 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
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
- 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)
Hair
Alopecia Areata
Androgenic Alopecia
Seborrheic Dermatitis
- Alopecia Areata: autoimmune condition causing hair loss
- Androgenic Alopecia: Receding/thinning hair
-
Seborrheic Dermatitis: “Dandruff”, Greasy, Yellow scales
- Scalp, Nasolabial folds, Eyebrows, Forehead
Psoriasis
What is it?
Clinical presentation?
- Autoimmune dermatologic condition
- Silvery white sharply demarcated plaques and coarse scale
Tinea Capitis
What is it?
Clinical presentation?
What is a kerion?
- Fungal scalp infection
- Round scaly patches or plaques with or w/o inflammation
- Kerion: raised boggy secondarily infected fungal lesion
Trigeminal Nerve (CN V) Sensory and Motor
How to test?
- Sensory - Light touch in all 3 areas bilaterally using cotton-tip applicator
- Ophthalmic
- Maxillary
- Mandibular
- Motor - palpate masseter muscle, clench teeth
Facial Nerve
Which cranaial nerve?
How to assess?
- Facial Nerve (CN VII)
- Assess facial symmetry
- Raise eyebrows
- Frown
- Squeeze eyes shut
- Puff out cheeks
- Smile
Acromegaly
What is it?
Cause?
- Excessive Growth Hormone production
- Large hands & feet
- Excessive facial bone growth, enlarged jaw
Bell’s Palsy
Cause?
Clinical presentation?
- Idiopathic facial (7th) nerve paralysis: muscle weakness on one side of face
- Difficulty closing eye
- Flattened nasolabial fold
Specialized Test: Assessing the Temporal Artery
What are you ascultating for?
- 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
Anatomy of the Eye
Tarsal plates
meibomian glands
bulbar conjuctiva
palpebral conjuntiva
- Eyelids
- Tarsal plates: firm strip of connective tissue
- Meibomian glands: sebaceous glands
- Bulbar conjunctiva
- Covers anterior eyeball
- Palpebral conjunctiva
- Covers inner eyelids
Visual Acuity: Vital Sign of the eye
Snellen vs. Rosenbaum
What is each test measure?
- Snellen Chart: Test central vision @ 20 feet
- Screens for myopia (impaired far vision)
- Rosenbaum pocket chart (@ 14 inch*)
- Screens for presbyopia (impaired near vision)
Pupils
Miosis
Mydriasis
Anisocoria
Direct pupillary light reflex
Consensual pupillary light refle
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
Near Far Accommodation
What is the test?
What are you looking for?
- 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
Extraocular Muscles (EOMs)
Nystagmus
How to test?
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
Extraocular Movements: Cranial Nerves
what are the extraocuar muscles?
What are the cranial nerves assocaited with each?
- 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
Corneal Light Reflection
How to test?
What does it test for?
- Shine light into the patient’s eyes
- Corneal light reflection tests for conjugate gaze
Ptosis
What is it?
Which cranial n.?
Ptosis: drooping uppe reyelid
Cranial nerve: CN III (oculomotor n.)
Eyelid: Incomplete closure
What is it?
Which cranial n?
CN VII
Chalazion vs. Hordeoleum
What are they?
Location?
- 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
Dacryocystitis
What is it?
- 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
Entropion vs. Ectropion
-
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
Pingueculum vs. Pterygium
-
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
Scleral Icterus
What is it?
DDx?
- Scleral Icterus: Yellow discoloration of sclera, frequently association with jaundiced skin
- Elevated bilirubin
Xanthelasma
What is it?
DDx?
- Xanthelasma: Raised, yellow, well-circumscribed cholesterol-filled plaques around eyelids
- Commonly associated with hyperlipidemia
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
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
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
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
Cataract
Cause
Risk factors
- Clouding (opacity) of the lens
- Causes painless progressive vision loss
- Risk Factors: age, Smoking, DM, Corticosteroid Use, ETOH
What is the normal cup to disc ratio?
What is the normal AV ratio?
- CD Ratio: 1:2
- AV ratio: 2/3
What is the Macula/fovea responsible for?
Responsible for central vision
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
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
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
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…)
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
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
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
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
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
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
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
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”
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
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
Gouty Tophi
Uric acid crystal deposit after years of chronically elevated uric acid
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
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.
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
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
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)
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
-
Normal:
- 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
-
Normal:
Tympanosclerosis
- Chalky white patch- Scarring of the TM
- Seen in recurrent Otitis Media or hx of tubes or previous perforation
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
Bullous Myringitis
What is it?
- Painful, hemorrhagic vesicles
- Landmarks obscured
- Commonly conductive hearing loss during infection
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
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)
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
Nasal Polyps
- Soft, pale growths commonly seen in allergic rhinitis, chronic sinusitis and other conditions
- May cause nasal obstruction
- Anosmia (loss of smell)
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
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
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
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
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
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
Angular Cheilitis
What is it?
Cause?
- Irritation, fissuring of skin at corners of the mouth associated with
- Ill-fitting dentures
- Vitamin deficiency
- Excessive salivation
Oral Candidiasis
Oral Candidiasis (Thrush)
- White patches or plaques on the tongue or buccal mucosa
- Uncommon among healthy adults
- Thrush can Brush
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
Oral Carcinoma
Main cause?
- Thorough physical exam is essential!
- Majority of oral Ca is Squamous Cell Carcinoma
Torus Palantinus
- Benign, midline mass in hard palate
Gingivitis
Symptoms?
- Causes changes to the Gums
- Redness
- Bleeding
- Edema
- Tenderness
Gingival Hyperplasia
Causes?
- Can be caused by:
- Medications
- Pregnancy
- Puberty
Tonsillar Hypertrophy
- persistently enlarged tonsils
Hairy Tongue
What is it?
Cause?
- Benign Condition
- Defect in desquamation of papillae
- Many causes: Candida, poor hygiene, Abx, tea, coffee, tobacco use
Fissured Tongue
- Multiple small grooves on dorsal tongue
- Benign
- Increasing incidence with advanced age
Geographic Tongue
- Dorsum of tongue reveals smooth areas void of papillae
- Benign
- “Map-like”
Group A Strep
Exudative Tonsillitis
Symptoms?
- ST, fever, +/- known exposure
- No cough, nasal congestion
- Bilateral exudative tonsillitis, cervical lymphadenopathy (LAD)
- Strep screen/culture +
Mononucleosis
Symptoms?
Cause?
- Mononucleosis (Epstein Barr Virus)
- ST, fever, fatigue
- Bilateral exudative tonsillitis
- Tender cervical LAD, +/- splenomegaly
- Mono screen +, strep screen negative
Peritonsillar Abscess
Symptoms?
Clinical presentation?
- Unilateral peritonsillar swelling & shifted uvula
- Infection spreads into peritonsillar space
- “Hot potato voice,” drooling
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
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
What is bruits?
signs of turbulent arterial blood flow.
Goiter
What is it?
- Enlarged thyroid (Thyromegaly)
- May be present in multiple forms of thyroid dysfunction
- Palpate thyroid while patient swallows
Tracheal Deviation
What is it?
Cause(s)?
- Trachea may shift toward one side or another
- Multiple causes
- Ex. Pneumothorax, goiter, or tumor
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
