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NR509 - Advanced Assessment > Week 3 - HEENT > Flashcards

Week 3 - HEENT Flashcards

1
Q

Iris

A

Controls the amount of light allowed to enter the eye through the pupil

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2
Q

Cornea

A

Covers the pupil and iris and is continuos with the sclera

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3
Q

Conjunctiva

A

thin, transparent membrane that covers the eye surface and inner surface of eyelids

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4
Q

Optic Fundus

A

Posterior portion of the eye seen through the ophthalmoscope includes:
- Retina
- Choroid
- Vitreous
- Retinal vessels
- Macula
- Fovea
- Optic disc

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5
Q

Fovea

A

darkened circular area around the point of central vision

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6
Q

Optic disc

A

entry point for the optic nerve

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7
Q

Snellen eye chart

A

Used for visual acuity assessment

20’ for large chart
6’ for pocket chart

Cover one eye and read smallest line possible

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8
Q

What is 20/30 vision?

A

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

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9
Q

Myopia

A

nearsightedness

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10
Q

Hyperopia

A

farsightedness

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11
Q

Astigmatism

A

distortion of near and far objects

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12
Q

Visually blind

A

20/200 or less

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13
Q

Static finger wiggle test

A
  • 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
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14
Q

Extraocular muscle assessment (and associated cranial nerves)

A

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

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15
Q

How to do an opthlamic exam?

A

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

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16
Q

What to check on a opthalmic exam?

A
  1. optic disc
  2. papilledema (swelling)
  3. venous pulsations
  4. fovea and surrounding macula
  5. opacities
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17
Q

What does the optic disc look like?

A

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

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18
Q

How to inspect the fovea?

A

Have patient look directly into the light
- Look for tiny bright reflection

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19
Q

Nystagmus

A

Fine rhythmic oscillation of the eyes

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20
Q

Glaucoma

A

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

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21
Q

Macular degeneration

A

Cause of poor central vision in older adults

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22
Q

Three ossicles of the middle ear

A
  • Malleus
  • Incus
  • Stapes
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23
Q

Parts of the inner ear

A

Cochlea – for hearing

Semicircular canals - balance

Vestibule (otolith organs) - balance

Distal end of the auditory nerve

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24
Q

Is screening for hearing loss recommended?

A

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

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25
Q

Inspecting the nasal cavity and mucosa

A
  1. Inspect the nares with an otoscope with largest speculum
  2. Tilt head back and inspect each nostril avoiding contact with nasal septum (handle to the side)
  3. 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
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26
Q

Sinus assessment

A

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

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27
Q

Vertigo

A

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

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28
Q

Tinnitus

A

o Perceived sound that has no external stimulus – ringing, rushing, roaring noise in one or both ears.
o May accompany hearing loss,

29
Q

Rhinorrhea

A
  • 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
30
Q

Otitis externa

A

Infection of the external portion of the ear – pain when pulling the auricle up

31
Q

Otitis media

A

infection of the middle ear, may cause tympanic membrane swelling and/or purulent fluid in the middle ear.

32
Q

Anatomy of the oral cavity

A

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)

33
Q

Oral cavity assessment

A
  • 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).
34
Q

Inspection of the pharynx

A

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

35
Q

Screening for oral carcinoma

A

Inspection and palpation remain standard for detection of oral cancers

36
Q

How are the tonsils graded?

A

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

37
Q

Survey of respiration

A
  • Respiratory distress?
  • Tachypnea
  • Cyanosis/pallor
  • Diaphoresis
  • Clubbing
  • Audible sounds of breathing (wheezing, stridor)
  • Use of accessory muscles
38
Q

Inspection of anterior and posterior chest

A
  • 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
39
Q

Percussion sounds for chest

A
  • Flat
  • Dull
  • Resonant
  • Hyper resonant
  • Tympanitic
40
Q

Why do you percuss the chest?

A

Helps establish whether underlying tissues are air-filled, fluid-filled or consolidated

41
Q

Vesicular lung sounds

A

soft and low pitched

42
Q

Bronchovesicular lung sounds

A

inspiratory and expiratory sounds are equal in lengths, may be separated by silent interval

43
Q

Bronchial lung sounds

A

louder, harsher, higher in pitch with short silence between inhalation and exhalation

44
Q

Tracheal lung sounds

A

large harsh sounds heard over the trachea in the neck

45
Q

Fine crackles

A

softer, higher pitched more frequent than coarse crackles. Heard mid to later inspiration, short duration, and higher frequency than coarse.

46
Q

Coarse crackles

A

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

47
Q

Wheezes

A

continuous musical sounds that occur during rapid airflow when bronchial airways are narrowed almost to the point of closure. Inspiratory, expiratory of biphasic

48
Q

Rhonchi

A

lower pitch than wheezes (same mechanism as wheeze), may disappear with coughing. -Snoring

49
Q

Pattern for percussion and auscultation - posterior chest

A

Ladder pattern
Start upper right, then left alternating down the ladder for 5 levels then auscultate upper and then lower lateral levels

50
Q

Pattern for percussion and auscultation of anterior chest

A

Ladder pattern
start on upper right, ladder down 4 levels then lateral top (right and left) and lateral bottom (left and right)

51
Q

Four methods of chest assessment

A
  • 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).
52
Q

Rib markers

A

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

53
Q

Visceral pleura

A

covers the outer surface of the lungs

54
Q

Parietal pleura

A

lines the pleural cavity along the inner rib case and upper surface of the diaphram

55
Q

Cough

A

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

56
Q

Hemoptysis

A

Spitting up blood

57
Q

Chest pain

A

Lungs and pericardium have no pain receptors - pain often comes from pleural receptors or intercostal muscles

GERD and anxiety may also cause chest pain

57
Q

Chest pain

A

Lungs and pericardium have no pain receptors - pain often comes from pleural receptors or intercostal muscles

GERD and anxiety may also cause chest pain

58
Q

Stridor

A

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

59
Q

Mediastinal crunch

A

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.

60
Q

Pleural rub

A

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.

61
Q

Asthma

A

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.

62
Q

Pneumonia

A
  • Breath sounds bronchial or bronchovesicular
  • Spoken EE sounds like AY
  • Spoken words louder
  • Whispered words louder and clearer
  • Increased tactile fremitus
63
Q

COPD

A
  • Breath sounds are decreased, muffled or distant to absent
  • Transmitted voice sounds and fremitus are decreased
64
Q

Atelectasis

A
  • Dullness with percussion
  • Lateral displacement of the trachea
  • Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests inspissated secretions
65
Q

Screening for thyroid cancer

A

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

66
Q

Thyroid assessment

A

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
67
Q

Cervical lymph node assessment

A

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

68
Q

Head and neck examination

A

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).

NR509 - Advanced Assessment (9 decks)

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