Lecture Three (HEENT)- Exam 1 Flashcards
What do you inspect with: Skull, hair, scalp and face?
- Skull: abnormalities, trauma
- Hair: quality, distribution, texture, and patterns of hair loss (balding, chemo, alopecia)
- Scalp: Scaliness, lumps, nevi, lesions, nits and part in multiple places, various locations
- Face: symmetry, expression, invol mvt, edema, masses, abnormal facies, facial hair and eyebrows
What do we check in neck?
- Symmetry
- Masses
- Trachea midline
- Visible LN
What do we do for the TMJ in examination?
- Inspect: swelling, redness
- Palpate: place tips of index fingers just in front of the tragus and ask pt to open and close mouth. Fingers should drop into joint spaces.
- Asses: tenderness, ROM, snapping/clicking/smoothness of mvt
What are all the different LN we need to know?
Where is the submental, submandiblar, tonsillar, preauricular and posterior auricular LNs?
- Submental: in the midline a few centimeters behind the tip of the mandible
- Submandiblar: midway between the angle and the tip of mandible
- Tonsilar: at the angle of the mandible
- Preauricular: in front of ear
- Posterior auricular: superficial to the mastoid process
Where is the occipital, anterior superficial cervical, posterior cervical, deep cervical chain, and supraclavicular LNs?
- Occipitals: at the base of the skull posteriorly
- ASC: superficial to the SCM muscle
- Post cervical: along the anterior edge of the trapezius
- Deep cervical chain: deep to the scm muscle and often inaccessible to examination
- Supraclavicular: deep in the angle formed by the clavicle and the SCM muscle
What do you document about LNs?
- Size
- Shape
- Mobility
- Consistency
- tenderness
- Skin changes: erthema, induration (larger than norm+dense), drainage, breakdown
What are shotty nodes?
Small, mobile, discrete, nontender nodes, noted in normal people. Can be normal
For LNs: what does tender mean?
Suggests inflammation
For LNs: hard or fixed LN means what?
Malignancy
What do you do for the trachea?
Palpate for tracheal deviation: palpate on each side of the tracea and SCM, compare
What do you do for the thyroid?
Ask the patient to swallow:
* Observe upward mvt of thyroid gland
* Note contour and symmetry
Palpate the gland:
* Confirm with swallow test
* Posterior: places hands to either side from behind
* Notes: size, shape, consistency->soft, firm, hard, nodules, symmetry
What do we use to test visual acuity?
Hand-held chart rosenbaum
How do you use Hand-held chart rosenbaum?
- Well lit room
- have pt hold 14 inches away
- Should wear glasses/contacts if prescribed
- Cover one eye, switch, both eyes together
- Read smallest print
- Must identify more than half the letters to get line correct
What are the three eye descriptors?
- OD (right eye)
- OS (left eye)
- OU (both eyes)
How do you do the visual field: confrontation
- Stand about arm’s length away in front of patient
- Have pt cover on eye
- Close your opposite eye (same anatomical eye) to mimic field of vision
- Place your hands about 2 ft. apart, aprox lateral to the patient’s ear
- Ask if patient can see your fingers!!!!!!
- Wiggle fingers and move in an arc (as if over a ball) towards the front
- Close your opposite eye as switching sides
- DO NOT GO TOO FAST
- note where they can see your fingers
What is protrusion, esotropia, exotropia, hypertropia, hypotropia?
- Protrusion: proptosis
- Esotropia: inward deviation
- Exotropia: outward deviation
- Hypertropia: upward deviation
- Hypotropia: downward deviation
What do we inspect for the eyelides?
What is this?
Ectropion
What is this?
Entropion
What is this?
Exanthelasma: cholesterol issue
What is this?
Hordeolum
What is this?
Chalazion usually points inside rather than lid margin
Not the same as a hordeolum
What is this?
Blepharitis
Head and shoulder shampoo
What happens when the conjuctiva is white?
anemia
What do you do for the conjunctiva and sclera in examination?
What do you do for the cornea, lens, iris for the examination?
What do you inspect and measure with pupils?
- Inspect: size, shape and symmetry
- Measure the pupils with card or reference (side of pen light)
What is miosis and mydriasis?
- Miosis: constriction
- Mydriasis: dilation
How do you text the light reaction of the pupils
Test light reation both direct and consensual
* Dim light
* Ask pt to look in distance
* Shine light into each pupil in turn
* Direct reaction: pupillary constriction in the same eye
* Consensual reaction: pupillary constriction in the opposite eye
How you check accommodation and convergence?
- Hold finger or pencil about 10cm from patient’s eye
- Ask patient to look alternately at it and into distance directly behind it
- Watch for pupillary constriction with near effort and convergence of the eyes
- Accommodation is the patient’s ability to focus on both far and away
What is PERRLA?
Pupils are equal, round and reactive to light and accommodation
How do you test extraocular movements?
Use the letter H
What do you look for and note for extraocular movements?
Looks for conjugate mvts of the eyes in each direction
Note:
* Deviation from normal (strabismus)
* Dysconjugate gaze
* Nystagmus: a few ticks can be normal on extreme lateral gaze; bring finger back into within field of binocular vision and look again
* Lid lag: if suspected, check up and down in midline position
How many cardinal directions are there?
6
What is this?
Convergence: bring to nose and see if eyes come together
How do you do the convergence test?
How do you eversion the lid?
- Use a small stick (tongue depressor of cotton swab) to push down as you raise the edge of the lide, thus everting the eyelid
- Do not press on the eyeball itself
- Then secure the upper laskes against the eyebrow with thumb as you inspect
What are the different adjustments on the ophthalmoscope?
Apeture wheel: light and shape
Focus wheel: diopter
How do you use a standard ophthalmoscope?
How do you use panoptic?
What do you note for a ophthalmoscopic exam?
- Sharpness or clarity of the disc outline
- Color of the disc: yellowish-orange to creamy pink. White or pigmented crescents may ring disc, normal finding
- Size of central physiologic cup. Yellowish-white: Horizontal diameter is usually less than half the horizontal diameter of the disc
How do an ophthalmoscopic exam
What does the papilledema signals? What does it look like?
Increased intracranial pressure
What is AV nicking? Seen in who?
- The vein appears to stop abruptly on either side of the artery: arterial walls lose their transparency
- Seen in patients with hypertensive retinopathy
Superficial retinal hemorrhages:
* Seen in who?
* What does it look like?
- Severe HTN
- Papilledema
- Occlusions of the retinal artery
What is soft exudate: cotton wool spots? What is the txt?
- HTN
- DM
- HIV
- Other viruses
- Txt: Figure out why they have it
What is drusen?
- Normal aging
- age related macular degeneration
What is this?
Cotton wool spots
What is this?
drusen
What is this?
Retinoblastoma
What is retinoblastoma? What type of reflex?
- Congenital malignant tumor occuring in first two years of life
- White “cat’s eye” reflex
- Chalky-white areas of calcification
What are the key components of the ear examination?
For ear canals and TM, waht do you inspect?
- Inspect the ear canal (cerumen, discharge, foreign bodies, redness of the skin or swelling)
- Inspect the TM and amlleus (color, contour, perforations, mobility
If hearing loss or difficulty is present, determine sensorineural or conductive via what?
Tuning fork tests
* Test lateralization if unilateral hearing loss or difficulty (weber’s) is present
* Compare air conduction vs bone conduction (Rinne)
How do you inspect the ear? and Palpation?
What are otoscope exam techniques?
With the otoscope, what do you inspect? (ear)
Discharge, foreign bodies, redness of the skin, swelling and cerumen
For the otoscope exam: what do you need to inspect of the TM
- Note color and contour
- Cone of light
- Look for red bulging TM
- Fluid behind TM: serous effusion
For the otoscope exam: what do you identify?
The handle of the malleus and short process of the malleus
What does short process and prominent handle suggest?
retracted membrane
- For the otoscope exam, what do you scan and observe?
- What do you check for?
Scan and observe:
* Pars flaccida superiorly
* Margins of the pars tens
Check for perforation
What is the whisper test?
What are tuning fork tests for? What may it help determine?
- For patients that fail the whisper test
- May help determine if the hearing loss is conductive or sensorineural in origin
What is the weber test?
Failed weber test suggests what?
Otosclerosis, otitis media, perforation of the eardrum, cerumen
What is the rinne test?
For the rinne test: what is normal, conductive and sensorineural hearing loss?
For the nose and paranasal sinus exam: what do you inspect, and test for?
- Inspect the ant. and inferior surfaces of the nose (asymmetry, deformities, tenderness)
- Test for nasal obstruction of each nostril (if indicated)
- Inspect the nasal muscosa, nasal spetum, inferior and middle turbinate, and corresponding meatuses with a light source or otoscope with large speculum (deviation, marked asymmetry, polyps, ulcers)
For the nose, paranasal sinus exam, what do you palpate?
- Palpate the frontal sinuses (tenderness, pressure, fullness)
- Palpate the maxillary sinuses (tenderness, presure, and fullness)
How do you palpate sinuses?
- Press up on the frontal sinus from under the bony brows
- Press on the maxillary sinuses
For the external nose, what do you insepct?
inspect the ant. and inf. surfaces of the nose: asymmetry, deformities and lesions
For the external nose: what do you check for?
Patency (if indicated)
* occlude one nostril at a time
* Ask to breathe in
For the interior nose, what should you do? With thumb and otoscope
Inspection of nose with otoscope: what do you inspect of the nasal mucosa?
- Swelling
- Bleeding
- Exudate: note character (clear, muscopurulent, purulent)
Inspection of nose with otoscope: what do we inspect with the septum?
- Deviation
- Inflammation
- Perforation
- Polyps
- Ulcers
How many teeth do we have?
32
What are the key components of an mouth exam?
What do we inspect of the lips?
What do we inspect of the oral mucosa?
- Discolaration
- Ulcers
- White patches
- nodules
What should you palpate and scrape with the oral mucosa?
- Palpate any concerning lesions
- Scrape white patches to determine candidiasis from leukoplakia
What is this?
Aphthous ulcer (canker sore): from stress or virus
What are you looking for with inspection of the hard palate and floor of mouth?
What should you do when examining the tongue?
What is this?
Carcinoma of the tongue
What is the examation of the pharynx?
What should you note about the tonsils
What is a fissured tongue, candidasia, black hairy tongue, smooth tongue, oral hairy leukoplakia
