HEENT Flashcards
Corneal Ulcers (Contact Lens Users)
presents:
Dx tests:
Cause:
presents:
Soft contact lens user, severe eye pain, foreign body sensation, tearing, and photophobia.
Dx tests:
Look for a whitish lesion on the cornea by using a penlight and/or performing a slit lamp exam and fluorescein dye test.
Cause:
The most common cause is infection due to Pseudomonas, Staphylococcus, or Streptococcus, which can permanently impair vision because of scarring or perforation.
It is considered an ophthalmologic emergency. Refer to ED.
Herpes Keratitis
presents:
Dx tests:
differents kinds:
Tx?
presents:
Acute onset of severe eye pain, photophobia, tearing, and blurred vision in one eye.
Dx tests:
-Diagnosed by using fluorescein dye. A black lamp in a darkened room is used to search for FERNLIKE lines in the corneal surface.
differents kinds:
herpes simplex virus in eye = herpes simplex keratitis.
herpes zoster ophthalmicus = shingles of the trigeminal nerve (cranial nerve [CN] V) ophthalmic branch
Herpes zoster ophthalmicus has eye findings accompanied by an acute eruption of crusty rashes that follow the ophthalmic branch (CN V1) of the trigeminal nerve (one side of forehead, eyelids, and tip of nose). Refer to ED.
oral or topical antiviral.
Acute Angle-Closure Glaucoma
acute presents:
chronic presents:
examination reveals:
acute presents:
acute onset of severe eye pain accompanied by headache, nausea/vomiting, halos around lights, lacrimation, and decreased vision.
chronic presents:
If the rise in intraocular pressure (IOP) is slower, patient may be asymptomatic. With chronic angle-closure glaucoma, the patient may be asymptomatic or report a dull ache and blurred vision.
examination reveals:
Examination reveals a mid-dilated pupil(s) that is OVAL shaped. The cornea appears cloudy. Funduscopic examination reveals cupping of the optic nerve. This is an ophthalmologic emergency.
Refer to ED.
Multiple Sclerosis (Optic Neuritis)
presents:
referral to:
Young Caucasian woman in her 20s to 30s reports loss of visual acuity over hours to days.
-Color vision is affected
-central scotoma (blind spot central vision) is common.
-May be accompanied by other neurologic symptoms (e.g., aphasia, paresthesia, abnormal gait, spasticity).
-Complains of daily fatigue on awakening that worsens as the day goes on.
-Higher-than-normal temperature will worsen symptoms (Uhthoff phenomenon).
-Has recurrent episodes.
-Refer to neurologist.
Orbital Cellulitis
presents:
unable to:
look for HX of:
-Acute onset of erythematous swollen eyelid with proptosis (bulging of the eyeball) and pain in affected eye.
-Unable to perform full range of motion (ROM) of the eyes (abnormal extraocular movement [EOM] exam) with pain on eye movement.
-Look for history of recent rhinosinusitis or upper respiratory infection (URI).
-Caused by acute bacterial infection of the orbital contents (fat and ocular muscles). More common in young children than adults. Serious complication. Refer to ED.
Retinal Detachment
presents:
-Sudden onset of floaters (or increase in floaters)
-associated with “looking through the curtain” sensation
-sudden flashes of light (photopsia).
-Central vision may be intact or lost if macula is detached.
-Refer to ED.
Auricular Hematoma
presents
tx
may result in
Direct blunt trauma to the ear that can cause bleeding in the auricular cartilage.
-The hematoma should be drained as soon as possible.
-If the hematoma is not drained, it can result in cauliflower ear.
-It is more common in wrestlers, boxers, and mixed martial arts fighters.
Acoustic Neuroma AKA ______
presents
more common in
refer to
(Vestibular Schwannoma)
“ear tumor on johnny deps ex-WANNOMA”
Patient in their 50s to 60s presents with
-unilateral hearing loss (sensorineural) and
-tinnitus,
-which has been present for about 3 to 4 years.
Complains of
-unsteadiness while walking
-episodes of veering or tilting that can fluctuate in severity.
-More common in Asians.
-Caused by tumor of the acoustic nerve (CN VIII).
-If facial nerve (CN VII) involved, may have facial paresis and paresthesias.
-Refer to neurologist.
Cholesteatoma
presents as
1.
2.
exam results
may have Hx of
tx includes
refer to
-Patient complains of hearing loss and intermittent ear discharge (otorrhea) from one ear that is purulent and foul smelling.
-1. perforation of the tympanic membrane (TM) on the superior quadrant and a cauliflower-like or pearly-white mass (Figure 1).
-2. Another presentation is an intact TM with missing landmarks with the white mass visible behind the TM.
Tympanogram will be abnormal (straight line).
History of chronic or recurrent otitis media infection.
The mass is not cancerous, but it can erode into the bones of the face and damage the facial nerve (CN VII).
Treated with antibiotics and surgical excision and repair.
Refer to otolaryngologist.
Battle Sign (Basilar Skull Fracture)
what bone?
Hx of?
presents with
1.
2.
3.
refer to
Parietal bone (side of skull) is most fractured.
Linear fracture most common, followed by depressed and basilar skull fractures.
Causes in adults include falls, assaults, car collisions, and penetrating missiles.
-“Raccoon eyes” (periorbital ecchymosis)
- bruising behind the ear (mastoid area)
-appear about 1 to 3 days after trauma.
-hemotympanum (blue to purple color of the TM), which is caused by blood inside the middle ear.
Physical exam (after trauma) does not show these two clinical signs immediately.
-**Search for a clear, golden serous discharge from the ear or nose, which is also found in up to 20% of temporal bone fractures.
**The findings of the Battle sign, raccoon eyes, hemotympanum, and otorrhea/rhinorrhea are highly suggestive of a serious head injury. Additional clinical findings are determined by brain hemorrhage, brain injury, and/or CN injury.
Refer to ED.
Clear, Golden Fluid Discharge From the Nose/Ear (Otorrhea/Rhinorrhea of Cerebrospinal Fluid)
Indicative of a basilar and/or temporal skull bone fracture.
If accompanied by the Battle sign, raccoon eyes, and hemotympanum, it is usually associated with a serious head injury.
Refer to ED.
Avulsed Tooth
Considered a dental emergency.
The sooner the avulsed tooth is reimplanted, the better the outcome.
If a young child, determine if it is primary tooth (baby tooth); if yes, do not reimplant.
If permanent tooth, avoid touching root, and handle only the crown:
-Rinse tooth in normal saline; irrigate socket with normal saline
-reimplant tooth.
Afterward, have patient bite down on gauze and refer to dentist as soon as possible.
-Store tooth in cool milk or saline, or store inside cheek (buccal sulcus) if unable to reimplant.
Peritonsillar Abscess
presents
exam findings
refer to
Severe sore throat
-difficulty swallowing,
-odynophagia (pain on swallowing)
-trismus (jaw muscle spasm making it difficult to open mouth)
-a “hot potato” voice.
-Unilateral swelling of the peritonsillar area and soft palate.
-Affected area is markedly swollen and appears as a bulging red mass with the
-***uvula displaced away from the mass.
-Accompanied by malaise, fever, and chills. Refer to ED.
Diphtheria
presents
exam findings
refer to
hint: weird guy on tic-toc
-Sore throat, fever, and markedly swollen neck (“bull neck”).
-Low-grade fever, hoarseness, and dysphagia.
The posterior pharynx, tonsils, uvula, and soft palate are coated with a gray to yellow pseudomembrane that is hard to displace.
-Very contagious. Contact prophylaxis required. Refer to ED.
“Weird look guy on tic-toc with a thick neck “DIP baby DIP”- has terrible oral hygiene. “
Virchow’s Node AKA _______
presents:
suggestive of
refer to
(Troisier’s Sign/Node)
An enlarged and hard left-sided supraclavicular node(s) that is associated with malignancy, especially in adults age 40 years or older.
Highly suggestive of cancers of the stomach, colon, pancreas, gallbladder, kidneys, ovaries, testicles, prostate, or lymphoid tissue.
-The left supraclavicular lymph node drains via the thoracic duct, abdomen, and thorax.
-Workup includes a thorough history, physical exam, laboratory testing, and imaging.
-Refer to surgeon for a biopsy.
“my shoulder is a bIRCH OW! for my bird…keep your TROiSiERS on! im getting a biopsy”
Normal Findings: Eyes
Fundi:
Cones:
Rods:
macula and fovea:
Presbyopia:
Blepharitis:
-Fundi: The veins are larger than arteries; veins are darker (in color) than arteries.
Cones: For color perception, sharpest vision (20/20 vision).
Rods: For low-light vision (night vision), peripheral vision.
Macula (and fovea): Responsible for our central vision, sharpest vision (20/20 vision), and color vision. The center of the macula is called the fovea. It contains large numbers of cones. Diseases of the macula cause a loss of central vision.
Presbyopia: Age-related visual change due to a decreased ability of the eye to accommodate and focus due to stiffening of the lenses; usually starts at the age of 40 years; near vision is affected with decreased ability to read small print at close range.
Blepharitis: Inflammation of the edges of the eyelids where the eyelashes grow. The tiny oil glands at the base of the eyelashes become clogged. The eyelids (upper and/or lower) are red, irritated, and itchy. Small scales like dandruff may be present. Blepharitis tends to recur. May be associated with dandruff, seborrheic dermatitis, or rosacea.
Tympanogram:
abnormal results look like:
may indicate:
This is the most objective measure to test for presence of fluid inside middle ear
-a straight line (normal is a peaked shape).
-Acute otitis media (AOM) and serous otitis media will show a straight line on testing
Kiesselbach’s plexus:
Located on the anterior inferior aspect of the nose (lower one-third). An anterior nosebleed is the result if the area is traumatized.
“kissing someone- lick the inside of their nose to be funny”
If the gums are red and swollen, the patient may have gingivitis (gums may bleed when brushing teeth) or be taking
phenytoin (Dilantin) for seizures (gingival hyperplasia).
“DILlin was shaking the ANT IN the can- im sure its giving it seizure’s. accedentally hit himself in the face and now his gums are bleeding”
Leukoplakia:
-White-to-light-gray patch that appears on tongue, floor of mouth, or inside cheek.
-Rule out oral cancer. Chewing or smoking tobacco, alcohol abuse, and human papillomavirus (HPV) are risk factors for oral cancer.
Aphthous stomatitis AKA ______
Treat symptoms with
(canker sores):
Painful shallow ulcers on soft tissue (inside) of the mouth that usually heal within 7 to 10 days
Cause is unknown.
Treat symptoms with “magic mouthwash” (combination of liquid diphenhydramine, viscous lidocaine, and glucocorticosteroid).
Swish, hold, and spit every 4 hours as needed.
Other options includes Orabase cream/ointment (OTC).
“ive got an AP exam for stoma this afternoon!- I cnat have a canker sore!”
Avulsed tooth:
Store in cool milk (no ice), saline, or inside mouth by the cheek (adults). Considered a dental emergency.
Vermilion border:
Vermilion border is at the edges of the lips. The corners of the lips are called the oral commissures (cheilosis, perleche)
“VERMen live at the border”
Mumps (Parotitis)
presents:
-School-aged child to adult with acute onset of fever, headache, fatigue, myalgia, and anorexia.
-Within 48 hours, the salivary/parotid gland(s) becomes swollen and tender. It can be unilateral (25%) or bilateral.
-The cheek appears puffy, and the angle of the jaw on the involved side appears swollen.
-The swelling and tenderness usually subside in about 1 week.
-Complications are rare and include orchitis (of one testicle), meningitis, encephalitis, deafness, and others.
-Mumps is a nationally notifiable disease; report all cases to local or state health department.
“looks like this kid swallowed a PAROT. not theres a big lUMP in this throat”
Tonsils:
when they secrete thick white exudate =_________
yellow-to-green exudate = _______.
A peritonsillar abscess AKA_____ is a serious deep-neck infection, and it is a rare complication of ________.
mononucleosis
strep throat
“quinsy”
complication of: tonsillitis
peritonsillar abcess- Refer to ED or call 911.
The anterior cervical lymph nodes can become enlarged with__________
posterior cervical lymphadenopathy can be caused by________
viral or bacterial infections (strep throat).
Mononucleosis
- Palpebral conjunctiva:
- Bulbar conjunctiva:
- Buccal mucosa:
- Soft palate:
- Hard palate:
- Hyperopia:
- Myopia:
- Amblyopia:
- Miosis:
- Ptosis:
- Mucosal lining inside eyelids
(“be a pal- he’s crying”) - Mucosal lining covering the eyes (“bulb around the eyes”)
- Mucosal lining inside the mouth
- Area where uvula, tonsils, and anterior of throat are located
- “Roof” of the mouth
- “Farsightedness”; distance vision is intact, but near vision is blurry. (“hyper-opia” super sight)
- “Nearsightedness”; near vision intact, but distance vision is blurry. (“my-opia” i can only see MY paper in front of me)
- Also called “lazy eye.” Usually starts in infancy. The affected eye has reduced vision. Refer to ophthalmologist. (“LYOPy eye)
- Excessive constriction of the pupil of the eye (when im trying to see Mi-osis, I have to constrict my eye so so small)
- Drooping of the upper eyelid
(“PT!- im not having a stoke! my eye is only drooping a little)
Geographic Tongue
benign
Tongue surface has a maplike appearance; patches may move from day to day.
Patient may complain of soreness with acidic foods, spicy foods.
Torus Palatinus
-Painless bony protuberance midline on the hard palate (roof of the mouth); may be asymmetric; skin should be normal.
-Does not interfere with normal function.
benign
“Torus- WALRUS”
Fishtall or Split Uvula
benign
Uvula is split into two sections and resembles a fishtail.
May be a sign of an occult cleft palate (rare).
Physiologic Gaze-evoked Nystagmus
On prolonged, extreme lateral gaze, a few beats of nystagmus that resolve when the eye moves back toward midline in healthy patients is normal.
Can also be caused by brain lesions.
Papilledema
Optic disc swollen with blurred edges due to increased intracranial pressure (ICP) secondary to bleeding, brain tumor, abscess, pseudotumor cerebri
Disc Cupping
Optic nerve cupping is associated with glaucoma.
It is caused by increased IOP, and it is measured by using the “cup-to-disc” ratio.
The “cup” of the optic disc is the center, and the surrounding area is the “disc.”
**The normal cup to disc ratio = about 1/3 or 0.3
As glaucoma progresses, the cup-to-disc ratio becomes abnormal (increased).
**~0.6 or greater is suspicious
Hypertensive Retinopathy
-Copper and silver wire arterioles (caused by arteriosclerosis); see Figure 1.
-Arteriovenous nicking is caused by compression of a vein by an arteriole as it passes over it; it appears as if it is “nicked” or it is missing a small area.
-Retinal hemorrhages
Diabetic Retinopathy
-Microaneurysms (small bulges in retinal blood vessels that often leak fluid) caused by
-neovascularization (new fragile arteries in the retina that rupture and bleed)
-Cotton-wool spots (fluffy yellow-white patches on the retina); see Figure 2.
Cataracts
typical first symptom
-Opacity of the lens of the eye, which can be central (nuclear cataract) or on the sides (cortical cataract)
-Up to 20% of older adults (age 65–74 years) are affected; however, cataracts can appear at any age from infants (congenital cataracts) through adults to the elderly.
-Symptoms include difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision.
-bilateral
Koplik’s Spots
Clusters of small red papules with white centers inside the cheeks (buccal mucosa) by the lower molars (Figure 1)
-Pathognomonic for measles (rubeola)
Hairy Leukoplakia
Elongated papilla on the lateral aspects of the tongue that is pathognomonic for HIV infection (Figure 2)
-Caused by Epstein–Barr virus (EBV) infection of tongue
Chalazion
-A chronic inflammation of the meibomian gland (specialized sweat gland) of the eyelids. It may resolve spontaneously in 2 to 8 weeks.
Classic Case
-Patient complains of a gradual onset of a small superficial nodule on the upper eyelid that feels like a bead and is discrete and movable (Figure 1).
-Painless. Can slowly enlarge over time. If chalazion is large, it can press on the cornea and cause blurred vision.
-Treatment is incision and drainage, surgical removal, or intrachalazion corticosteroid injections by ophthalmologist.
Pterygium
-A yellow triangular (wedge-shaped) thickening of the conjunctiva that extends across the cornea on the nasal side (Figure 1).
-Results from chronic sun exposure. Sometimes called surfer’s eye. Can be red or inflamed at times. Patient may complain of foreign body sensation on the eye.
tx:
-If inflamed, refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations. Use artificial tears as needed for irritation.
-Recommend use of good-quality sunglasses (100% against UVA and UVB).
-Remove surgically if the growth encroaches on cornea and affects vision
Entropion and Ectropion
Entropion
The eyelid (usually the lower eyelid) is turned inward (Figure 1A). The eyelashes continuously rub against the cornea, causing irritation, watery eyes, redness, pain, and/or foreign body sensation. More common in the elderly.
Ectropion
The eyelid is turned outward or sags away from the eye (Figure 1B). It causes irritation and eye dryness. More common in the elderly.
Vertigo
Dix–Hallpike maneuver:
Epley maneuver:
Clinical Pearls
-Be careful with geriatric patients, since antivertigo medications (meclizine) are antihistamines and may cause dizziness and sedation (increased risk of falls).
-It is important to distinguish if a patient with vertigo has peripheral vertigo (vestibular apparatus disorder) versus central vertigo, which can be serious to life-threatening (cerebellar stroke, brainstem bleeding)
-A person with vertigo will describe the sensation of the room spinning or of rotational movement. May be associated with nystagmus.
-It is important to assess if the person has vertigo or other types of dizziness such as near syncope, hypoglycemia, orthostatic hypotension, cerebrovascular disease, and arrhythmias. Table 1 lists the differential diagnoses of vertigo.
–Dix–Hallpike maneuver: Gold-standard clinical test for benign paroxysmal positional vertigo disease (BPPV). A positive finding is rotary nystagmus with latency of limited duration.
–Epley maneuver: This maneuver can be done in the clinic or at home by the patient. See Figure 2 for instructions on how to perform the maneuver.
