Respiratory and HEENT exam Flashcards
Head and Face inspection
Shape of head and face
- Congenital abnormalities
Hair pattern and texture
-Thyroid dysfunction
Head motion (tremors and tics) - Neurologic disorders
Expression of the face
- Psychological disorders
Movements of the forehead, eyes, and mouth
- Neurologic disorders
Edema, puffiness or localized swelling
- Heart failure, infection
Prominent features
- Congenital abnormalities
Hirsutism
- Endocrine disorders
Fetal Alcohol Syndrome
small head low nasal bridge epicanthal folds small eye openings flat midface short nose thing upper lip smooth philtrum underdeveloped jaw
fragile X
long face
hurler syndrome
very hairy
Treacher Collins Syndrome
big front of face
Acromegaly
Elongated head
Coarsened facial features
Bony overgrowth of forehead, nose and lower jaw
Cushing’s disease
round / moon facies
ear inspection and palpation
Inspection Auricle for redness, lesions Canal Discharge, foreign bodies, redness, swelling Tympanic membrane Color and contour
Palpation
Auricle for masses or tenderness
Preauricular Pit
Developmental defect in the branchial arches
Keloid
Overgrowth of collagen in scar tissue
Keloids grow beyond the borders of the original injury
Cauliflower Ear
Usually caused by repeated blows to the external ear among boxers and wrestlers
Hematoma separates the cartilage from the perichondrium
Scar tissue fills the gap between the two layers
Otoscopic Examination
Insert largest speculum that the ear will accommodate
Pull the ear up and back
Inspect the canal and the tympanic membrane
Otitis Externa
Infection of auditory canal Prolonged swimming Humidity Sweating Ear plugs/hearing aids Aggressive ear cleaning Foreign body/impacted cerumen Derm conditions: eczema, psoriasis (nail pitting)
Otitis Externa symptoms
Otalgia (external +/- internal) Itching Discharge Hearing loss of sense of fullness Radiation to mastoid, jaw or internal Most common in children, immune compromised (medication, chronic infection, chemotherapy, diabetes)
Acute Otitis Externa
Focused HEENT: Detail on ear exam Mastoids Neck palpation Lymph nodes
DDX:
OM with perforation
Mastoiditis
Canal carcinoma
otitis externa responsible parties and treatment
The bacteria responsible for an acute infection is most often Pseudomonas or Staphylococcus Aureus.
Chronic infections (>3m) are fungal or allergic in origin
Oral antibiotics are usually not effective. Ear drops must be used and the canal must be opened and if possible cleaned.
A solution of 1 part white vingear (5% acetic acid) mixed with 3 parts water is often helpful in preventing this disorder. (frequent swimmer)
Clean and remove FB if needed
Keep dry: 3-10 days (adult? ear plugs? Severity?)
Oral analgesics, can consider topical lidocaine
Do not mess with it
Topical antibiotics/steroid 5-10 days
Ok with perforation: fluoroquinolones only
Otitis Media
This is a bacterial infection of the middle ear. This infection is one of the most common reason for pediatric physician visits.
Left untreated, 50% of all cases of otitis media will clear without antibiotics, but 1 in 400 will progress to acute coalescent mastoiditis, a life threatening ear infection; and rarely meningitis, a life threatening brain infection, can occur.
otitis media symptoms/ infections
URI symptoms, fever, anorexia, vomiting, diarrhea young>>adult Otalgia, hearing loss, “popping” Winter and daycare Many viral Frequent co-infection with - Strep Pneumoniae - H. Influenzae - Moraxella Catarrhalis
otitis media exam
Bilateral ear exam
tenderness, canal, TM, mobility
Nose and Oral exam often involved
Cervical LN
Lungsotitis media treatment
Pain control: oral, topical Decongestants? Antibiotics: severity, >48 hrs, >102°F, under 24 months old; Amoxicillin 80 mg/kg/day given bid Augmentin dose for amoxicillin component Cephalosporins for PCN allergic Ceftriaxone 50 mg/kg IM x1 5-10 days: age and severity (younger=longer)
Follow Up!
Hemotympanum
A collection of blood in the middle ear that is visible through the tympanic membrane
Usually caused by head trauma
Tympanic Membrane Retraction
A portion of the tympanic membrane is weakened and retracts into the middle ear as a result of the relative negative pressure
Auditory acuity can be compromised because the tympanic membrane is draped over the ossicles and impedes their vibration
Rhinitis
Inflammation of the inner lining of the nose is characterized by an itchy/runny nose, sneezing, and nasal congestion.
Allergic rhinitis is usually caused by an antigen or group of antigens, i.e. animals, dust, fabrics
Seasonal allergic rhinitis (also called hay fever) is usually caused by pollen in the air, and sensitive patients have symptoms during peak times of the year
Epistaxis
Anterior epistaxis is the most common type, accounting for about 90 % of nosebleeds. Bleeding is usually visible on inspection and typically occurs in the area Kesselbach’s plexus.Etiologies include arid climates, inhaled irritants, hypertension, coagulopathies and inhaled drug use, primarily cocaine.
In general, posterior epistaxis occurs in older patients, who have fragile vessels because of hypertension, atherosclerosis, coagulopathies, or weakened tissue. Bleeding is profuse because of the larger vessels in that location (usually, the sphenopalatine artery) and usually requires hospitalization and surgical treatment.
Deviated Septum
A condition whereby the nasal septum is deviated laterally, can either be congenital or secondary to trauma.
Septal Perforation
Etiologies include any condition where the blood supply to the septum is chronically compromised
Commonly caused by inhalation (Snorting) of vasoconstrictive substances, i.e. cocaine
Sinusitis
Anything that causes swelling in the sinuses or keeps the cilia from moving mucus can cause sinusitis. This can occur because of changes in temperature or air pressure such as swimming or diving.
Sinus infections can occur after an upper respiratory infection. The virus infects the mucus membranes of the sinuses, causing them to swell and narrow. The mucus membranes increase secretions, but the secretions are trapped in the swollen sinuses. This stagnant mucus in the sinuses becomes secondarily infected with bacteria.
Oral Cavity
Always use a tongue blade and a light source
Inspect: Teeth Gums Buccal mucosa All surfaces of tongue Hard palate Posterior oropharynx - Uvula - Tonsils or absence thereof
Basal Cell Carcinoma
Most common skin cancer Slow growing Often found on sun exposed areas Fair skinned individuals Over exposure to radiation; solar, x-rays , etc.
Squamous Cell Carcinoma
Risk factors are very similar to basal cell
More aggressive and metastasizes early
Usually appears as a scaly, crusting patch
Herpes simplex
HSV-1 accounts for majority of cases
Asymptomatic shedding occurs that is still contagious. Most contagious when symptomatic.
Either physical or emotional distress causes a recurrence of the infection frequently at the original site of infection
Peutz-Jeghers Syndrome
An autosomal dominant disease
Melanin deposition of mucous membranes
Multiple intestinal polyps
15-fold increase in cancers of the gastrointestinal tract
tooth attrition vs erosion
grinding vs acid from bulemia, e.g.
Thrush
An oral infection caused by an overgrowth of Candida albicans seen commonly in:
- Infants
- Immunosuppressed patients
- Patients on antibiotic therapy
- Patients on chemotherapy
Patients usually complain of irritation of the mouth and altered taste
Geographic Tongue
Appearance is caused by loss of papillae May be linked to Vitamin B deficiency No treatment is necessary Not contagious More prominent with fever, upper respiratory infection Can be mildly tender
Fissured Tongue
Probably a genetic condition
Usually asymptomatic and noticed on routine examination
May be Vitamin A deficiency. Rare in USA except in inflammatory bowel diseases causing poor absorption.
Hairy Leukoplakia
Usually an early sign of HIV infection
Associated with pipe smoking and chewing tobacco or snuff
May resemble thrush
Usually painless
Rarely undergoes malignant transformation
Oral Carcinoma
Generally aggressive cancers
Main risk factors are chronic alcohol use and smoking
Frequently detection is delayed because of inadequate examinations
Tonsillar Carcinoma
Usually squamous cell
There is likely a link to HPV infection
Often present late in the course of the disease since there are few early symptoms
Torus Palatinus
A hard bony growth in the center of the roof of the mouth (hard palate). It is
Not a tumor but rather a benign bony growth called an exostosis.
Commonly occurs in females over the age of 30 and rarely needs treatment.
Occasionally it is removed for the proper fitting of dentures
Tonsillitis
This is a common condition which is usually caused by gram positive bacteria. If the organism is Streptococcus pyrogenes , there is a risk of developing rheumatic fever.
Often multiple different bacteria exists in the tonsillar crypts, which can be difficult to culture.
Treatment with antibiotics to prevent rheumatic fever or tonsillar abscess formation is usually advisable.
Respiratory-General Appearance
Colors: - Cyanotic (Hypoxemia) - Pink (emphysema, CO2 toxicity) - Pallor (anemia) Respiratory rate Respiratory effort Using accessory muscles of respiration Cough Wheeze Nicotine staining of fingers
Respiratory inspection
Tracheal position
- May be displaced by neck mass, pneumothorax or lung mass
Deformities of the thorax
- Funnel Chest (pectus excavatum)
- – Depression in lower portion of sternum
- – Compression of heart & great vessels may cause murmurs
Barrel chest
- AP diameter is increased with age & in chronic obstructive pulmonary disease (COPD)
Pigeon chest (Pectus carinatum)
Sternum is displaced anteriorly, increasing AP diameter
Adjacent costal cartilages are depressed
Funnel chest (Pectus excavatum)
Depression of lower portion of the sternum
In severe cases, the heart or great vessels may be compressed
Barrel Chest
Seen in chronic asthmatics or patients with COPD
Caused by chronic air trapping in the alveoli
Lateral/ AP chest measurement is less than 2:1
Respiratory palpation
Tenderness may indicate a rib fracture
Decreased motion with respiration may indicate bronchial obstruction or pleural effusion
Subcutaneous emphysema is seen with pneumothorax
Tactile fremitus is helpful in diagnosing consolidation
Respiratory auscultation
Provides the majority of information in the pulmonary examination
Knowledge of the underlying anatomy is essential to making an accurate diagnosis
You are listening to moving air and anything that alters the architecture of the pulmonary tree will alter the flow of air.
Bates chart pages 328-331 describe changes in pathology well.
Pneumonia
Auscultation
- Decreased breath sounds over affected area
- Sounds over affected area are bronchial rather than vesicular
- Primarily rales but may have wheezing or rhonchi
Percussion
Dullness
Special Tests
Bronchophony-Increased
Tactile fremitus-Increased
COPD physical exam
Auscultation
Decreased breath sounds throughout lung fields
Primarily wheezing but may have rhonci
Percussion
Hyperresonance
(Special Tests)
Tactile fremitus-Decreased
Congestive Heart Failure PE
Auscultation
- Decreased breath sounds most prominent in dependent portions of the lung
- Rales (crackles)
Percussion
- May be unchanged or decreased (dull) over dependent portions of the lungs
Special Tests
- Bronchophony-Usually unchanged
- Tactile fremitus-Usually unchanged
Pneumothorax PE
Auscultation
- Breath sounds decreased or absent on affected side
Percussion
- Marked hyperresonance
Special Tests
- Bronchophony-Decreased
- Tactile fremitus-Decreased
Pleural Effusion
Auscultation
- Decreased or absent on affected side
Percussion
- Dullness on affected side
Special Tests
- Bronchophony-Unchanged
- Tactile fremitus-Decreased
