Week 3 - HEENT Flashcards
Iris
Controls the amount of light allowed to enter the eye through the pupil
Cornea
Covers the pupil and iris and is continuos with the sclera
Conjunctiva
thin, transparent membrane that covers the eye surface and inner surface of eyelids
Optic Fundus
Posterior portion of the eye seen through the ophthalmoscope includes:
- Retina
- Choroid
- Vitreous
- Retinal vessels
- Macula
- Fovea
- Optic disc
Fovea
darkened circular area around the point of central vision
Optic disc
entry point for the optic nerve
Snellen eye chart
Used for visual acuity assessment
20’ for large chart
6’ for pocket chart
Cover one eye and read smallest line possible
What is 20/30 vision?
This person is 20’ from the chart and can see at 30 feet what a normal person can see at 20’
The larger the second number the worse the vision
Myopia
nearsightedness
Hyperopia
farsightedness
Astigmatism
distortion of near and far objects
Visually blind
20/200 or less
Static finger wiggle test
- Arms length away from patient
- Close one eye, have patient cover opposite eye and have them stare at your open eye (left eye looking at right eye)
- Place hands two feet apart out of patient’s view lateral to the ears
- Wiggle fingers and bring toward you to help determine field of vision
Extraocular muscle assessment (and associated cranial nerves)
Have the patient follow your finger with their eyes through 6 cardinal directions of gaze
Extreme right
Right and upward
Down on the right
Extreme left
Left and upward
Down and left
Bridge of the nose
Look for normal conjugate movements of the eyes in each direction (note any deviation) - Nystagmus – fine rhythmic oscillation of the eyes - Lid lag when moving the eye up and down
Cranial nerves 3, 4 and 6
How to do an opthlamic exam?
Shine the beam on the pupil at 15-degree angle lateral to the patient’s line of vision
Instruct patient to look slightly up and over your shoulder at a point directly ahead on the wall
Start 15 inches away from patient and look for the red reflex (orange glow of the pupil)
- Note any opacities which may indicate cataract
Thumb on patient’s eyebrow move on the 15 degree angle toward the pupil until almost touching your thumb
What to check on a opthalmic exam?
- optic disc
- papilledema (swelling)
- venous pulsations
- fovea and surrounding macula
- opacities
What does the optic disc look like?
Yellow orange to creamy pink color with rim and central depression
Follow a blood vessel to find it
- In focus at 0 diopters
- If blurry turn the wheel the find sharp focus
Look for
* Sharpness of outline
* Color of disc
* Size of cup
* Symmetry of fundi in both eyes
How to inspect the fovea?
Have patient look directly into the light
- Look for tiny bright reflection
Nystagmus
Fine rhythmic oscillation of the eyes
Glaucoma
Retinal exam shows pallor and increasing size of the optic cup which can enlarge to more than half the diameter of the optic disc.
Gradual loss in vision in peripheral fields
Macular degeneration
Cause of poor central vision in older adults
Three ossicles of the middle ear
- Malleus
- Incus
- Stapes
Parts of the inner ear
Cochlea – for hearing
Semicircular canals - balance
Vestibule (otolith organs) - balance
Distal end of the auditory nerve
Is screening for hearing loss recommended?
Not recommended by the USPSTF
Noise reduction and avoidance are recommended for preventing/delaying hearing loss
Screening tests:
o Single item screen test
o Multi item questionnaires
o Handheld audiometers
o Watch tick test
o Whisper test
o Rub finger test
Inspecting the nasal cavity and mucosa
- Inspect the nares with an otoscope with largest speculum
- Tilt head back and inspect each nostril avoiding contact with nasal septum (handle to the side)
- Look at inferior and middle turbinates, nasal septum, narrow nasal passage between them
- Some asymmetry is normal
- Look for color, swelling, bleeding or exudate (clear, mucopurulent, purulent)
* Viral rhinitis – red and swollen mucosa
* Allergic rhinitis – pale, bluish, red
Sinus assessment
Palpate frontal and maxillary sinuses for tenderness
- Local tenderness with symptoms like facial pain, pressure, fullness, purulent discharge, nasal obstruction, smell disorder for more than 7 days suggests acute bacterial rhinosinusitis involving frontal or maxillary sinuses
Vertigo
Sensation of true rotational movement off the patient or surroundings. Point to a problem with the labyrinths of the inner ear, peripheral lesions of CN VIII or lesions in its central pathways or nuclei in the brain
Tinnitus
o Perceived sound that has no external stimulus – ringing, rushing, roaring noise in one or both ears.
o May accompany hearing loss,
Rhinorrhea
- Drainage from the nose that is often associated with nasal congestion, sense of stuffiness or obstruction. Often accompanied by watery eyes, itchy nose, sore throat
Otitis externa
Infection of the external portion of the ear – pain when pulling the auricle up
Otitis media
infection of the middle ear, may cause tympanic membrane swelling and/or purulent fluid in the middle ear.
Anatomy of the oral cavity
o Labial frenulum
o 32 teeth
o Tongue with papillae
o Hard palate
o Soft palate
o Uvula
o Posterior pharynx
o Posterior pillar
o Anterior pillar
o Buccal mucosa (lines the cheeks)
Oral cavity assessment
- Inspect the lips (color, moisture, lumps, ulcers, cracking, or scaliness).
o Inspect the oral mucosa (discoloration, ulcers, white patches, nodules). - Palpate the oral mucosa (if indicated for any lesions, thickening).
- Inspect the gingiva (erythema, discoloration, ulceration, swelling).
- Inspect the gum margins and interdental papillae (swelling, ulceration).
- Inspect the teeth (missing, discolored, misshapen, or abnormally positioned).
- Inspect the roof (hard palate) and floor of the mouth (erythema, discoloration, nodules, ulcerations, or deformities).
- Test the hypoglossal nerve, or CN XII (symmetry of tongue protrusion).
- Inspect the tongue (color, texture, lesions).
- Palpate the tongue (if indicated for any lesions, thickening).
- Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx (color, symmetry, exudate, swelling, ulceration, or tonsillar enlargement).
- Test the vagus nerve, or CN X (symmetry of uvula).
Inspection of the pharynx
o Say ahh with tongue in - rise of the soft palate – test of the CNS X (vagus nerve), check for uvula deviation (will point to opposite side and away from the lesion)
o Inspect soft palate, anterior and posterior pillars, uvula, tonsils
Screening for oral carcinoma
Inspection and palpation remain standard for detection of oral cancers
How are the tonsils graded?
Tonsils are graded on a scale from 0 to 4.
0 - you’ve had them removed
1 - they’re barely visible,
2 - they’re normal
3 - they’re large and just about touching that thing that hangs down at the back of your throat called the uvula
4 - they’re ginormous
Survey of respiration
- Respiratory distress?
- Tachypnea
- Cyanosis/pallor
- Diaphoresis
- Clubbing
- Audible sounds of breathing (wheezing, stridor)
- Use of accessory muscles
Inspection of anterior and posterior chest
- Focus on areas of bruising, tenderness, respiratory expansion, fremitus (vocal resonance)
- Note any crepitus
- Abnormalities or masses
- Test chest expansion
- look for asymmetry/barrel chest
Percussion sounds for chest
- Flat
- Dull
- Resonant
- Hyper resonant
- Tympanitic
Why do you percuss the chest?
Helps establish whether underlying tissues are air-filled, fluid-filled or consolidated
Vesicular lung sounds
soft and low pitched
Bronchovesicular lung sounds
inspiratory and expiratory sounds are equal in lengths, may be separated by silent interval
Bronchial lung sounds
louder, harsher, higher in pitch with short silence between inhalation and exhalation
Tracheal lung sounds
large harsh sounds heard over the trachea in the neck
Fine crackles
softer, higher pitched more frequent than coarse crackles. Heard mid to later inspiration, short duration, and higher frequency than coarse.
Coarse crackles
appear in early inspiration and throughout expiration, popping sound, longer duration, and lower frequency than fine crackles. Result of boluses of gases passing through the airways as the open and close intermittently
Wheezes
continuous musical sounds that occur during rapid airflow when bronchial airways are narrowed almost to the point of closure. Inspiratory, expiratory of biphasic
Rhonchi
lower pitch than wheezes (same mechanism as wheeze), may disappear with coughing. -Snoring
Pattern for percussion and auscultation - posterior chest
Ladder pattern
Start upper right, then left alternating down the ladder for 5 levels then auscultate upper and then lower lateral levels
Pattern for percussion and auscultation of anterior chest
Ladder pattern
start on upper right, ladder down 4 levels then lateral top (right and left) and lateral bottom (left and right)
Four methods of chest assessment
- Inspect the chest (deformities, muscle retraction, lag).
- Palpate the chest (tenderness, bruising, sinus tracts, respiratory expansion, fremitus).
- Percuss the chest (flat, dull, resonant, hyperresonant or tympanitic).
- Auscultate the chest (breath sounds, adventitious, transmitted voice sounds).
Rib markers
1 - sternal angle/angle of Lois is the 2nd rib
2 - back/neck bony prominence - C7 then T1
3 - inferior tip of the scapula is the 7th rib
Visceral pleura
covers the outer surface of the lungs
Parietal pleura
lines the pleural cavity along the inner rib case and upper surface of the diaphram
Cough
Reflex response to stimuli that irritate receptors in the larynx, trachea or large bronchi
(mucus, pus, blood, allergens, dust, foreign bodies, hot/cold air)
May be cardiovascular or GI in origin
- Acute – less than 3 weeks
- Subacute 3-8 weeks
- Chronic – 8+ weeks
Hemoptysis
Spitting up blood
Chest pain
Lungs and pericardium have no pain receptors - pain often comes from pleural receptors or intercostal muscles
GERD and anxiety may also cause chest pain
Chest pain
Lungs and pericardium have no pain receptors - pain often comes from pleural receptors or intercostal muscles
GERD and anxiety may also cause chest pain
Stridor
continuous high frequency high pitched musical sound produced during airflow through narrowing in the upper respiratory tract, immediate intervention needed. Best heard over the neck
Mediastinal crunch
series of precordial crackles synchronous with heartbeat, not respiration. Best hear in left lateral position. Occurs due to air entry into the mediastinum causing mediastinal emphysema a Produces severe chest pain.
Pleural rub
discontinuous, low frequency grating sound that arises from inflammation and roughening of the visceral pleura as it slides against the parietal pleura. Occurs during inspiration and expiration, best heard at the axilla and lung bases.
Asthma
Episodic wheezing and dyspnea but cough may occur along, often with hx of allergies. Cough at times with thick mucoid sputum especially near the end of an attack.
Pneumonia
- Breath sounds bronchial or bronchovesicular
- Spoken EE sounds like AY
- Spoken words louder
- Whispered words louder and clearer
- Increased tactile fremitus
COPD
- Breath sounds are decreased, muffled or distant to absent
- Transmitted voice sounds and fremitus are decreased
Atelectasis
- Dullness with percussion
- Lateral displacement of the trachea
- Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests inspissated secretions
Screening for thyroid cancer
Examine the thyroid gland to identify nodules
- Nodules greater than or equal to 2 cm, and fixed to adjacent tissues are concerning for malignancy
- US to determine if biopsy is indicated
Thyroid assessment
Inspection
- Alone, neck back
- With swallowing
Palpation
- Posterior approach
- Index fingers below cricoid cartilage
Anterior approach
- Palpate between cricoid cartilage and suprasternal notch
- Retract SCM muscle slightly with one hand, use the other to palpate the thyroid
Note shape/size/consistency
- Soft in graves disease - hyperthyroidism
- Firm in Hashimoto thyroiditis (body attacks thyroid - hypothyroidism)
o If enlarged, listen for a bruit
o Found in graves disesase and toxi multinodular goiter
Cervical lymph node assessment
o Preauricular
o Postauricular
o Tonsillar
o Occipital – base of skill behind ear
o Submandibular
o Submental
o Anterior superficial cervical—palpate for these nodes anterior and superficial to the SCM muscle.
o Posterior cervical—palpate along the anterior edge of the trapezius by flexing the patient’s neck slightly forward toward the side being examined (Fig. 11-10).
o Deep cervical chain—deep in the SCM muscle and often inaccessible to examination. Hook your thumb and fingers around either side of the SCM muscle to find them.
o Supraclavicular—palpate deep in the angle formed by the clavicle and the SCM muscle
Head and neck examination
o Examine the hair (quantity, distribution, texture, any pattern of loss).
o Examine the scalp (scaliness, lumps, nevi, lesions).
o Examine the skull (size, contour, deformities, depressions, lumps, tenderness).
o Inspect the skin in the head and face (expression, contours, asymmetry, involuntary movements, edema, masses).
o Palpate the cervical lymph nodes (size, shape, delimitation, mobility, consistency, tenderness).
o Examine the trachea (deviation, breath sounds over it).
o Examine thyroid gland (size, shape, and consistency).
