Exam 1 - HEENT Exam

Question 1

Head ROS

Answer 1

Head: headaches, head injury.

Question 2

Eyes ROS

Answer 2

Eyes: vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double vision, spots, specks, flashing lights, glaucoma, cataracts.

Question 3

Ears ROS

Answer 3

Ears: hearing acuity, last hearing examination, tinnitus, vertigo, earaches, infection, discharge.

Question 4

Nose (sinuses) ROS

Answer 4

Nose/Sinuses: frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble.

Question 5

Throat (mouth) ROS

Answer 5

Mouth/Throat: condition of teeth and gums, bleeding gums, last dental examination, sore tongue, frequent sore throats, hoarseness.
Neck: lumps in the neck, swollen glands, goiter, pain or stiffness in the neck.

Question 6

Head Exam PE

Answer 6

Scalp/Skull: contour, scaliness, lesions, lumps, tenderness
Hair: texture, color, distribution, quantity
Face: symmetry, color, expression, edema, involuntary movement

Question 7

External Eye Exam PE

Answer 7

Check Visual Acuity
>Use Snellen card 14 inches from nose or eye chart

External Eye
Eyebrow/lashes: flakiness, loss of hair
Eyelid: swelling, lid position, lid closure, tenderness
Lacrimal apparatus: duct, sac, tenderness, tearing

Conjunctiva/sclera color
Pull lower lids down to fully visualize conjunctiva

Cornea: opacities, surface characteristics
Use tangential lighting to assess LIGHT REFLEX

Iris: shape, color consistencies

Pupil: shape, bilateral size, reaction to light (both direct and consensual), corneal light reflection

Swinging flashlight test

EOMs (6 cardinal fields of gaze), lid lag, nystagmus, convergence, accommodation

Visual Fields: by confrontation (one eye at a time)

Question 8

How do you check visual acuity?

Answer 8

Snellen Card (14 inches from nose)

Question 9

2 types of conjunctiva

Answer 9

Palpebral (lines the inner lid)
Bulbar (globe/sclera)
Meets the cornea at the limbus

Question 10

Tarsal plates (thick tissue)

Answer 10

Keep the eyes from getting stuck together; protect and lubricates eye.

Question 11

Meibomian Glands

Answer 11

Meibomian glands are the tiny oil glands which line the margin of the eyelids (the edges which touch when the eyelids are closed).

These glands secrete oil which coats the surface of our eyes and keeps the water component of our tears from evaporating (drying out).

Question 12

Water and oil layer of the eye make up the:

Answer 12

tear film

Question 13

Six Cardinal Directions of Gaze

Answer 13

Normal conjugate movements
Nystagmus
Lid lag
Convergence

Question 14

Aqueous humor - where is it produced?

Answer 14

Anterior portion of eye cavity; fluid produced by ciliary body
Flow through pupil to anterior chamber
Out through canal of schlemm

Question 15

Aqueous humor - what is its function?

Answer 15

Controls pressure in eye

Question 16

What controls pupil size?

Answer 16

The muscles of the iris

Question 17

What controls lens thickness?

Answer 17

Muscles of the ciliary body

Question 18

What does visual fields test?

Answer 18

Visual Fields assesses peripheral vision
By confrontation

Face-to-face at eye level with patient
Patient covers right eye, you cover your left eye

Wiggle your right fingers from lateral sides to center
Patient states when your fingers can be seen

Question 19

Fundoscopic exam

Answer 19

Darken the room and have the patient look off in the distance. Switch on the ophthalmoscope light, turn the lens disc to the large round beam of white light. Turn lens disc to the 0 diopter.

Hold the ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye

Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision

Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex
Follow the red reflex and move inward toward the nasal aspect of the visual field

Question 20

Red Reflex

Answer 20

reddish-orange reflection of light from the eye’s retina that is observed when using an ophthalmoscope or retinoscope from approximately 15inches away.

Question 21

Once red reflex has been established, follow the vessels to the optic disk. What do you look for?

Answer 21

Sharpness or clarity of the disc outline
Color of the disc
Size of the central physiologic cup
Compare to the patient’s other fundus
Look for papilledema 
Swelling of the optic disc/bulging of the cup

Question 22

What do you look at in the retina?

Answer 22

Examine the Retina
Examine arteries/veins

Arteries- smaller, lighter red
Veins- larger, dark red

Check for hemorrhages, A-V nicking, cotton-wool spots

Question 23

Ear Exam PE

Answer 23

Gross hearing acuity

External ear: deformities, lumps, lesions and tragal tenderness, mastoid tenderness.

Otoscopy: pull auricle up and back; condition of external canal landmarks: umbo, color of drum.

Cone of light, valsalva (pinch nose, close mouth and exhale). Check for mobility of TM.

Question 24

External nose PE

Answer 24

External exam:  symmetry, lesions, discharge, tenderness
Nasal patency (each nostril)
Have patient occlude each nostril and breathe in

Question 25

Internal Eye Exam PE

Answer 25

Internal Eye: funduscopic exam (left eye, left hand, patient’s left eye) (right eye, right hand, patient’s right eye). Do this by dimming the room light

Red reflex: cornea, lens, aqueous/vitreous humors

Retinal structures

Optic disc: clarity, color, fovea. Cup to disc ratio = 1:2

Vessels: color, size, light reflex, artery vs. vein

Question 26

Internal Nose PE

Answer 26

Rhinoscopy: polyps, deviated septum, mucosa color, discharge
Must insert nasal speculum into nostril using a lighted scope
Paranasal sinuses: maxillary and frontal tenderness

Question 27

Overview of nose exam

Answer 27

Inspection
Anterior and inferior surface – asymmetry or deformity

Inside of nose
Mucosa – color, swelling, bleeding, exudate, ulcers, or polyps
Septum – deviation, inflammation, or perforation
Turbinates – use otoscope to view middle and inferior turbinates

Palpation of sinuses – frontal and maxillary

Question 28

Mouth and Throat PE

Answer 28

Lips: color, symmetry, moisture, lesions, pigmentation

Oral mucosa: moisture, color, lesions, odor
Use gloves, tongue blade and light source
Gums and teeth: number, color, surface characteristics

Roof of mouth, uvula

Pharynx and tonsils: landmarks, swelling, color, exudate
Is the oropharynx patent?
Parotid ducts (Stensen’s ducts)

Tongue: symmetry, color, surface characteristics

Floor of mouth, Wharton’s ducts, frenulum
Palpate oral cavity (gloved, bimanual)

Question 29

Full neck exam PE

Answer 29

Symmetry and Range of Motion with Flexion, Extension, Rotation, Lateral Bending

Lymph nodes: size, shape, mobility, tenderness, consistency

Trachea: location, symmetry

Thyroid gland: inspect anterior for symmetry, rises with swallowing.

Palpate from posterior for tenderness and enlargement with patients neck flexed and turned slightly left and right.

Question 30

Lymph nodes

Answer 30

Lymph nodes: size, shape, mobility, tenderness, consistency
List nodes: (1) preauricular; (2) postauricular; (3) occipital; (4) tonsillar; (5) submandibular; (6) submental; (7) superficial cervical; (8) posterior cervical; (9) deep cervical chain; (10) supraclavicular

Question 31

Thyroid Exam

Answer 31

Flex patient’s neck slightly forward

Place fingers of both of your hands so that your index fingers are just below the cricoid cartilage

Ask patient to swallow; feel for the thyroid isthmus rising up under your finger pads
Displace trachea to the right and palpate laterally for the right lobe of the thyroid; repeat on the left side

Note the size, shape, and consistency
Identify any nodules or tenderness

Question 32

Example ROS Doc

Answer 32

Head: Denies headaches or head injury.

Eyes: Last vision exam 6 mos ago, wears glasses to correct myopia. Positive eye dryness. Denies pain, redness, excessive tearing, double vision, spots, specks, flashing lights, glaucoma or cataracts.

Ears: Unknown last hearing exam. Hearing acuity good. Denies tinnitus, vertigo, earaches, infections or discharge.

Nose/Sinuses: Denies frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds or sinus trouble.

Mouth/Throat: Last dental exam 4 months ago. Fair condition of teeth and gums. Wears upper and lower partial plates in good repair. Intermittent hoarseness x 2 months. Denies bleeding gums, sore tongue, or frequent sore throats.

Neck: Denies swollen glands, goiter, lumps, pain or stiffness.

Question 33

Example PE doc

Answer 33

Head- AT/NC. Full head of thinning, brittle hair. Symmetrical facies, pale complexion, good expression. No involuntary movements.
Eyes- Visual acuity 20/40 OU with correction. Thinning eyebrows, eyelashes without flakiness. Puffy eyelids without tenderness, good position, full closure. Lacrimal duct without tenderness, no excess tearing, no discharge. Conjunctiva pick, moist. Injected sclera bilaterally. Corneas smooth without opacities. Irises with consistent shape and brown color. PERRLA, positive light reflection. No lid lag or nystagmus. EOMI. Visual fields intact, full confrontation. Positive red reflex, optic disc clarity color fovea, vessels.

Question 34

Example PE doc 2

Answer 34

Ears- Decreased hearing to whispered voice, L>R. No external deformities, masses, lesions tragal tenderness, mastoid tenderness. Canals without erythema, 10%, non occluding cerumen buildup. Bilateral TMs pearly grey, with positive cone of light, visible landmarks. Positive motion with valsalva.
Nose- Nose symmetric with patent nares. Septum midline. No lesions, polyps, discharge, or tenderness. Mucosa pink, moist. Frontal and maxillary sinuses without tenderness.

Question 35

Example PE doc 3

Answer 35

Mouth/Throat- Lips symmetric with consistent pale color, dry, without lesions or changes in pigmentation. Oral mucosa pale but moist, without lesions or odor. Gums pale without lesions. 30 teeth in good repair, no caries noted. Roof of mouth pale and moist, without swelling or exudates. Pharynx patent, tonsillar pillars, tonsils symmetric without swelling or exudates. Stensen’s duct visualized without signs of obstruction. Tongue symmetric, pale pink in color, without lesions or masses. Floor of mouth without lesions or masses. Frenulum intact, Wharton’s ducts visible without signs of obstruction.

Question 36

Example PE doc 4

Answer 36

Neck-symmetrical, supple with limited ROM with flexion and extension. Preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, seep cervical chain and supraclavicular nodes mobile, non tender. Trachea midline. Thyroid symmetrical without tenderness or bruits, rises upon swallowing.