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Flashcards in HEENT Deck (127):
1

temporal arteries

palpate & auscultate

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2

Snellen Chart

CNII

  • chart tests central vision
  • 20 feet from chart
  • Glasses (except reading) should be worn
  • Test one eye at a time, repeat
  • Have patient cover eye with card. Don’t press eye, can lose vision for a period.
  • Read the smallest line of print reading more than half of letters
  • Record OD (right eye), OS (left eye). OU (both eyes) 20/20, 20/30, and corrected to designate use of glasses
  • If miss one character can say, “20/30 -1” – or office standard

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3

Rosenbaum Chart

(CN II). 

  • Use Rosenbaum chart to assist with screening of presbyopic patients, age 45+ or those wearing bifocals
  • Hold the card 14 inches from patient’s eyes or at a reasonable distance for the patient
  • Test each eye separately with and without glasses
  • Presbyobic patients may read through the bifocal
  • Record the line with the smallest letters/figures
  • Pediatric near allen test – for kids. Can use other symbols than letters as well!

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4

Cover/Uncover Test

tests for strabismus

  • Observation of binocular eye movement
  • Fix gaze on far object
  • Cover one eye and observe
  • Alternate eye
  • Check covered eye for refixation movement
  • Alternating esotropia-covering fixating eye, the opposite eye moves outward
  • Alternating exotropia-outturned eye refixates inward when opposite eye is covered

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5

Inspect eyelids for...

symmetry, ptosis, edema, erythema

 

6

Entropian: describe & examination technique

 common in elderly

 

  • Inward turning of the lid margin
  • Lower lashes may not be apparent as these are engulfed in the margin causing irritation to the conjunctiva and lower cornea
  • Examination technique-squeeze eyes together and open

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7

Inspect sclera and conjunctiva for ...

  • color
  • discharge
  • pterygium
  • corneal arcus/
  • foreign body
  • hemorrhage.

Note and inspect both the bulbar and palpebral conjunctiva

bulbar conjunctive: covers most of anterior eyeball

palpebral conjunctiva: lines the eyelids

8

pterygium

  • Elevated, external thickening of the bulbar conjunctiva
  • Extends into corneal surface
  • May obstruct vision: wedge shaped area

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9

Ectropion

  • The lower lid margin is turned outward and exposes the palpebral conjunctiva
  • When the punctum of the lower lid turns outward, the eye drains improperly
  • Common geriatric finding

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10

Headache: Primary vs Secondary

  • Primary (90%):  Migraine, tension, cluster, chronic
  • Secondary: structural, systemic, infectious

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11

Common Primary Headache Types

Cluster, Tension, Migraine

Cluster: tends to be unilateral, retroorbital

Tension: tends to be bilateral, temporal

Migraine: Tends to be unilateral, assoc w/ other symptoms, e.g., aura, photophobia, NA, cravings for food, euphoria, dizziness

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12

Headache + nausea/vomiting, consider...

migraine,

tumor, subarachnoid hemorrhage, ... (increased ICP)

13

Valsalva aggravates headache, consider...

acute sinusitis, mass lesion/ICP

14

Coughing, sneezing  aggravates headache, consider...

increased ICP

15

Headache Warning SIgns

  • Progressively frequent or severe over 3-month
  • Sudden onset like “thunderclap” or “worse headache of my life” (SA hemorrhage, esp >50 w/following Sx)
  • New onset > 50 years
  • Aggravated or relieved by position change
  • Precipitated by Valsalva maneuver
  • Recent trauma
  • Associated papilledema, neck stiffness or neurologic deficits

Not necessarily together but signal need for further imaging

Could be increased ICP, bleed, progressive concussion, malignancy, etc. = don’t wait

16

7 bones of skull

 

  • 2 Frontal
  • 2 Parietal
  • 2 Temporal
  • 1 Occipital

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17

Skull: anatomy of newborn

  • Bones connected by Sutures
  • Posterior fontanel closes by 2 months
  • Anterior fontanel closes by 24 months

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18

Facial anatomy: fused & movable bones

Fused bones

  • Frontal
  • Zygomatic
  • Nasal
  • Ethmoid
  • Lacrimal
  • Sphenoid
  • Maxillary

Movable Bones

  • Mandible

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19

Facial landmarks

  • Palpebral fissures
  • Nasolabial folds

Look for symmetry

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20

Facial innervation

Trigeminal (CNV): Muscles of mouth & jaw

Facial (CN VII): Muscles of eyebrows, forehead, cheeks, lips

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21

Trigeminal nerve: areas of innervation (sensory)

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22

Enlarged skull may indicate...

hydrocephalus or paget’s dz of bone

23

Vertigo vs dizziness

Vertigo is rotational, not just losing balance

24

Causes of vertigo

Peripheral: in labyrinths of inner ear, peripheral lesions of CNVIII, indicates vestibular disease. BPPV, labyrinthitis, menieres

Central: CNVIII pathways or nuclei in brain. Ataxia, diplopia, dysarthria, vertigo. Central neurologic causes in cerebellum or brainstem (CVD, posterior fossa tumor)

Migraine

25

Symptoms of Menieres

vertigo, tinnitus and hearing loss 

26

Ototoxic drugs

aminoglycosides, asa, nsaids, furosemide, some chemo

27

Children and PMH: high risk for hearing loss

  • Prenatal infections
  • Birth weight <1500 gm
  • Hypoxia
  • Craniofacial anomalies
  • High bilirubin
  • Recurrent ear infections
  • Speech or language delay
  • Facial or ear injury
  • Foreign body in ear (children & geriatric- cognitive imp)

28

Personal/social history & risk for hearing loss

  • Exposure to environmental or industrial noise
  • Use of recreational headphones
  • Use of ear protective equipment                                                                                                           
  • Daycare or preschool
  • Allergies
  • Exposure to second-hand smoke
  • Piercings

29

Insufflation of ear

Most otoscopes have a small air vent connection that allows the doctor to puff air in to the canal. Observing how much the eardrum moves with air pressure assesses its mobility, which varies depending on the pressure within the middle ear. 

 

30

Anatomy of ear

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31

Otoscope technique: young children vs  older children & adults

young children: pull pinna back and down

Older: Pull auricle upward, backward, slightly away from head

32

Tympanic Membrane

Visualize tympanic membranes, noting the landmarks, light reflex, & pars tensa (landmarks include: umbo, malleus, short process) 

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33

Whispered Voice test

  1. Stand 2 feet behind patient
  2. Occlude non-test ear with finger
  3. Exhale
  4. Whisper 3 numbers/letters (something that makes no sense so they can’t “guess”)
  5. Patient repeats
  6. Test each ear

Sense of unilateral vs bilateral and what test to move on to

34

Weber test

  • Test for lateralization
  • Tuning Fork 256 Hz or 512 – at either extreme, not fine detail
  • Set into vibration, hold only base
  • Place base on top of head or midforehead.
  • If nothing heard, try again. Could not have worked - Could also be bilateral hearing loss.
  • Unilateral sensory: will hear in good ear

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35

Rinne Test

  • Air Conduction (AC) vs Bone Conduction (BC)
  • Place base on mastoid bone
  • When patient can no longer hear sound, place fork close to ear
  • [Description: Rinne] “U” should face forward
  • AC>BC normal
    • Conductive loss: BC = AC or BC> AC (external, middle ear)
    • Sensorineural loss: AC > BC (inner, cochlear nerve, centrl connx to brain)

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36

Otitis Externa vs Otitis Media

OE: tug test +,  may be hard to look in ear, painful

OM: pain when press on mastoid process, erythema, may see bubbles, fluid

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37

TM: perforation, myringotomy tubes

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38

US Preventive Task Force: Risk Groups for Hearing Loss

  • Screening for adults 50 years of age and older

Risk groups

  • Congenital or family hearing loss
  • Syphilis
  • Rubella
  • Meningitis
  • Exposure to hazardous noise level
    • Work
    • Soldiers

39

Sensorineural Hearing Loss

inner ear, cochlear nerve, central connections to brain

trouble understanding speech – complain others are mumbling
noisy environments make it worse

40

Conductive Hearing Loss

external or middle ear

noisy environments may help

41

nasal anatomy

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42

The Sinuses

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43

Transillumination

Dark room. Strong narrow light source.

Frontal: light snugly deep under each brow, close to nose. Shield light w/hand. Look for dim red glow through air filled frontal sinus to forehead.

Maxillary: pt tilts head back w/mouth opened wide. Shine light downward from just below inner aspect of each eye. Look through open mouth at hard palate. Reddish glow = normal air filled sinus.

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44

Stensen's Ducts

parotid duct – opens onto buccal mucosa near upper second molar. Frequently marked by its own small papilla. Usually not visible unless blocked. 

45

Number of teeth

  • 20 primary
    • First teeth 6-8 months
    • Start to lose 6 years
  • 32 Secondary

46

Oral Thrush vs Leukoplakia

Oral thrush is easily removed. Leukoplakia is hard to remove - suggests immunocompromised

47

Smooth tongue

Vitamin deficiency

48

Fissured Tongue

FVD, elderly

49

Muscle groups of neck

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50

Major vessels of neck

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51

Head & Neck Lymph nodes

  • Preauricular
  • Posterior auricular
  • Occipital
  • Submental
  • Submandibular
  • Tonsilar
  • Superficial cervical
  • Deep cervical
  • Posterior cervical
  • Supraclavicular

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52

Traits of problem lymph nodes

FIRM, FIXED, TENDER, UNILATERAL

53

physiologic enlarged thyroid

Pregnancy

54

Scotoma

Centralized scotoma or blind spot obliterated central vision, such as with macular degeneration. It can also be caused by a CVA or Traumatic Brain Injury (TBI) causing optic nerve damage.

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55

Routine Health Maintenance for Eyes


—Routine eye screening/examinations
—Ventilation/spray nozzles
—Safety goggles
—Sports goggles
—Age appropriate toys/monitoring
—Counseling: Fire/Smoking/Fireworks/optical radiation/tanning booths/sun exposure
 

56

Equipment for Eye Exam


—Opthalmoscope/panoptic
—Cotton tip applicator
—Cotton wisp
—Exam gloves
—Snellen Eye Chart/Pedi-Allen Near Chart
—Rosenbaum Pocket Vision Screener 
 


—Office:
—Direct opthalmoscope
—Slit lamp (for corneal abrasion, foreign body...)
—Color vision testing
—Florescein (corneal abrasion)
—Tonometry
 

57

Slit lamp

may use for corneal abrasion, foreign body

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58

Flourescein Stain

blotting paper contains orange dye (flourescein stain).

Contact lenses must be removed.

provider touches surface of the eye with the flourescein stained paper and then ask the patient to blink, which spreads the dye over the corneal surface.

The patient’s own lacrimal fluid will lubricate the eye.

Next, the provider shines a cobalt blue light (can use slit lamp) on the patient’s eye to detect any corneal abrasion, which appears greenish under the light.

Document the size, location and shape of the corneal injury, and of course which eye.

The flourescein paper may sting a little bit and briefly discolor the sclera, but this does not require irrigation due to the test; tears will wash the dye out. 

Flourescein gtts are available, but most likely you will use the flourescein paper. 

 

 

 

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59

Corneal Abrasion

S/S: pain, gritty substance, hurts when blink, etc., photophobia, decreased visual acuity

PE: tearing,

Fluorescein stain to detect

Tx: irrigate, topical antibiotics, possibly topical nsaids, possibly patching. Usually resolves 24-48h

60

Direct vs indirect ophthalmoscopy

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61

Fundus (eye)

area where blood vessels can be directly observed

62

macula

located on the retina (creamy yellow spot surrounding the fovea and does not have sharp margins). Light narrows to a point on the macula, which is the center of vision. 

63

Fovea

a 2.5mm diameter that appears slightly dark in center of macula and is responsible for central vision.

high concentration of cones but no rods, and this is where our vision is most sharp and is the location of most color vision.

While the normal field of vision for each eye is about 135 degrees vertically and about 160 degrees horizontally, foveal field of vision represents a small conical area of only about 1 degree. BUTonly the fovea is able to perceive and send clear, sharply focused visual images to the brain. 

64

"Blind Spot" the eye

Point of the optic nerve is the “blind spot.” (fundoscopy)

65

myopia

impaired far vision. Near sighted. 

66

Hyperopia

impaired near vision. Far sighted.

67

Presbyopia

decreased accommodation – lens is harder w/age, less compliant

68

Low Vision

visual acuity from 20/70 – 20/200

69

Legal blindness

better eye is 20/200 or less w/correction. Does not mean no vision. 

70

adolescents & vision changes

Adolescents can get worse vision during growth spurt (Or better!)

71

Pediatric Amblyobia: definition


—2 lines of visual acuity difference or a visual acuity of 20/30 or lower determined by a Snellen chart

—Loss of visual acuity and binocular vision that is often irreversible after age 5
 

72

Pediatric Amblyobia​: recommendations

may go unnoticed w/o screening
—

  • —Using Wright figures (preliterate visual acuity chart), Snellen letters, HOTV chart
  • USPSTF and AAP recommend all preschool children (3-5 years) be screened for visual impairment (acuity and strabismus) as part of routine preventative care
  • —Refer to ophthalmologist
  •  

73

Strabismus

 

  • Impairment of eye muscles manifesting as turning of eyes/crossed eyes
  • —May be evident when patient is tired, during intense close work or reading
  • —Babies have pseudostrabismus - a false strabismus as eyes appears crossed from extra skin covering the inner corners of eyes or wide bridge of nose
     

74

Strabismus: Types


—Esotropia-inward turning
—Exotropia-outward turning
—Hypertropia-upward turning
—Hypotropia-downward turning
 

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75

Strabismus: Classification


—Frequency-constant or intermittent
—Unilateral
—Alternating-sometimes right eye turns, sometimes left eye turns
 

76


—Newborn vision
 

see black and white; focuses on face; sluggish pupil response; can’t distinguish R, G, Y; acuity 20/400

77


—1 month vision
 

fixes on objects; well developed pupil response 20/300

78


—2 months vision
 

coordinates eye movements; distinguishes R-G, not Y-G; 20/150

79

3 months: vision


improved coordination and focus, convergence, colors-R, G, Y
 

80

6 months vision


some accommodation; 20/50
 

81


—12 months vision
 

acuity is 20/50

82


—2 years vision
 

acuity is 20/30 with good color

83


—3 years vision
 

20/20

84


—5 years vision
 

acuity is 20/30, with accommodation

85


—6 years vision
 

acuity is 20/20

86

Eye Structures

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87

Anatomy of episclera and sclera

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88

Eye anatomy cross section

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89

Hordeolum

A Stye

An inflamed hordeolum will often calm and scar into a hard chalazion.

A hordeolum is an acute purulent inflammation of the eyelid. It may be sterile or may show both inflammatory cells and bacteria, most commonly Staphylococcus aureus. An internal hordeolum represents inflammation of a meibomian gland just under the conjunctival side of the eyelid. An external hordeolum (stye) arises from an eyelash follicle or a lid-margin tear gland.

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90

Chalazion

  • may first present with eyelid swelling and erythema and then evolve into a painless, rubbery, nodular lesion.
  • commonly in patients with eyelid margin blepharitis and in those with rosacea.
  • Tx: Antibiotics are not indicated since chalazion is a granulomatous condition. Small chalazia often resolve without intervention. For larger lesions, frequent hot compresses may allow them to drain although typically most clear spontaneously in weeks to months. Symptomatic patients with recalcitrant lesions can be referred to an ophthalmologist for incision and curettage or direct glucocorticoid injection.

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91

Xanthelasma

  •  cholesterol-filled, soft, yellow plaques that usually appear on the medial aspects of the eyelids bilaterally
  • most often occur in middle-aged and older adults-think hyperlipidemia
  • a classic feature of primary biliary cirrhosis, which is a condition often associated with marked hypercholesterolemia. 

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92

Molluscum contagiosum 

caused by a poxvirus and spread by direct contact or by fomites. It is usually seen as one or multiple small, pale, shiny nodules with central umbilication.

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93

Squamous cell carcinoma

much less common but faster growing than basal cell carcinoma

can arise de novo or from preexisting actinic keratosis and is more likely to metastasize.

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94

Actinic keratosis

a premalignant condition. It predisposes to squamous cell carcinoma. Biopsy, followed by surgical excision or cryotherapy, is recommended

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95

Epicanthal fold

  • Prominent epicanthal fold may suggest Down’s syndrome
  • Normal variant with very young children and  some races
  • Draw an imaginary line between the two medial canthi and observe for Mongolian slant

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96

Palpebral or Mongolian Slant

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97

Lacrimal Glands & Sjogren's Syndrome

 Sjogrens Syndrome: inflammation of exocrine glands (--> dry eyes/mouth/etc)

Schirmers test: put a piece of filter paper under the lower eyelid and measure how many tears are produced and absorbed.  >8mm, normal tear production, <8mm,  abnormally low tear production (need to be seen by an ophthalmologist to be evaluated for corneal ulcerations d/t lack of tears) 

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98

Exophthalmos

 

  • —Wide eyed stare
  • —Protrusion of eyes
  • —May have associated edema to eyelids and conjunctival injection
  • —Often secondary to Graves’ hyperthyroidism, tumor, or inflammation of the orbit
     

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99

Visual fields by confrontation

  • —Provider is positioned 12 inches from patient, face to face
  • —Provider’s hands are 2 feet apart
  • —Patient gazes at your nose
  • —Patient should point to your fingers as they are seen
  • —Begin outside the visual range, wiggling 2 fingers in each outer quadrant of the visual field (temporal, superior, inferior)
  • —F/up with holding 1 to 2 fingers, ask “how many fingers do you see?”
  • —Normal test is viewing both sets of fingers simultaneously

If defect noted:

  • assess boundaries
  • Test one eye at a time moving from defective area to good area
  • Repeat at several levels to define the border

 

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100

PERRLA

Pupils equal, round, reactive to light, accommodation

Reaction: direct & consensual

101

Corneal light reflex

  • Hold penlight at arms length in front of child
  • Gain child's attention blink/tap light
  • When child fixated on light
    • Examiner lines up light with her eyes
    • Note position of Corneal Light Reflex on each eye
    • Should fall on nasal portion of each cornea

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102

EOMs

 

  • —Have patient follow your finger or pencil as you sweep through the 6 cardinal gazes
  • —Wide “H” beginning with patient’s extreme right, right upward, right downward, no pause, extreme middle left, left upward, left downward
  • —Check nystagmus by pausing during upward and lateral gazes
  • —Elders may need further distance
  • —Checking CN III, IV, VI
  • —Babies-twist body in 6 fields and observe eyes should follow

SO4, LR6, the rest are 3

103

Opthalmoscopic Exam: process

 

  • —Darkened room
  • —Patient focuses on distant spot
  • —No glasses
  • —Start with diopter at 0 or 10 (if patient wears glasses); hold finger on disc
  • —Use medium circle of light
  • —Hold the opthalmoscope using proper technique
  • —Patient focuses on distant point
  • —Begin at a 15 degree angle, 15 inches from face and shine light into pupil 
  • —Locate the red reflex, light illuminates the retina 
  • —Move closer to focus on the retina (fundus)
  • —Look for vessels (about 3-5cm from patient)
  • —Once you find a blood vessel(s), try to adjust focus (diopters)
  • —Locate the optic disc; if you have trouble seeing it, follow the blood vessels centrally, these become larger as you approach the disc
  • —Check the optic disc margins, these should be sharp except for the nasal portion which may normally be blurred
     

104

Opthalmoscopic Exam: for nearsighted/farsighted patients


—Start at zero or higher if needed
—For nearsighted patients, start with disc in the red-rotate counterclockwise (minus)
—For farsighted patients, start with disc in the black-rotate clockwise (positive)
 

105

Opthalmoscopic Exam: what to assess

 

  • —Assess the color of the disc-yellow orange
  • —Assess the physiologic cup:disc ratio (appears yellow white and cup is ~1/3 the size of the disc)
  • —Examine the arteries at the disc and all 4 directions (2 arteries: 3 veins); check for + venous pulsations
  • —Assess for any lesions, hemorrhages, abnormalities
  • —Check the arteries: vein ratio and appearance
  • —Lastly, move more temporally and view the macula (darker spot in the center of retina); check fovea at center
     

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106

AV Crossing & changes

Normal arterial wall is transparent, so vein crossing beneath artery can usually be seen. When the arterial walls lose their transparency, changes appear in the AV crossing

3 types of changes: AV concealment/nicking when vein appears to stop abruptly on either side of artery; Tapering when vein appears to taper on either side of artery; Banking when vein is twisted on idstal side of arter and forms a dark, wide knuckle

107

Papilledema

 

  • —Swelling of the optic disc and bulging of the physiologic cup
  • —Characterized by loss of definition of the optic disc margin
  • —Due to increased intracranial pressure (ICP) and pressure on the optic nerve
  • —Found in meningitis, subarachnoid hemorrhage, trauma, lesions, tumor
     

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108

Glaucoma

  • physiologic cup widens occupying most of the disc ratio; so if you see a widening of the cup, this is the most common cause.
  • open angle glaucoma is most common
  • Acute closed angle 5 % of cases: ocular emergency
  • Congenital glaucoma: autosomal recessive
  • Physical findings:  marked elevated intraocular pressure, unreactive pupil, increased cupping of optic disc
  • Slit lamp exam

Treatment topical pressure lowering agents, oral carbonic anhydrase inhibitors, laser surgery 

109

Macular Degeneration

 

  • —Causes central vision loss
  • —Characterized by undigested cellular debris, known as Drusen deposits in the macula
  • —Drusen may be central or scattered
  • —Initially, patient is asymptomatic
  • —As Drusen grow in accumulation, vision becomes blurred centrally and may be lost
     

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110

Drusen deposits

  • Yellow-white flecks scattered around the macular region are little mounds beneath the retinal pigment epithelium. They are tombstones of dead retinal pigment epithelial cells. Most common cause is age-related macular degeneration

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111

Amsler Grid 

Central Vision Impairment

Look at grid from 14 in away. Shouldn't see wavy distorted lines. If you do, may be macular degeneration

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112

Cotton Wool Patches

Soft exudates-Whitish or grey irregular patches with soft borders like cotton.

They result from infarcted nerve fibers. Debris is associated with hypertensive retinopathy and SLE.

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113

Hard Exudates

These yellow flecks are called hard exudates. They are the lipid residues of serous leakage from damaged capillaries. The most common cause is diabetes. Other causes are retinal vein occlusion, angiomas (Von Hippel-Lindau Disease), other vascular dysplasias, and radiation-induced retinal vasculopathy.

“macular star”

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114

Location of cataracts

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115

Immature vs mature cataract

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116

Retinal Detachment

Separation of the retina and underlying choroidal circulation leading to ischemia and permanent blindness.

c/o flashing lighfs/floaters

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117

Inspect internal nose

Must use light source

Largest ear speculum. Tilt pt’s head back and insert speculum gently into vestibule of each nostril, avoiding contact w/sensitive nasal septum.

Direct speculum posteriorly then upward in small steps, try to see inferior and middle turbinates, nasal septum, narrow nasal passage between. 

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118

cheilosis 

scaling, fissures at corner of mouth

119

Wharton’s ducts

 

At base of tongue, ducts of the submandibular gland pass forward and medially. Open on papillae that lie on each sind of lingual frenulum.

120

sudden unilateral painless vision loss

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, cetntral retinal artery occlusion

121

Sudden unilateral painful vision loss

usually in cornea or anterior chamber: corneal ulcer, uveitis, traumatic hyphema, acute glaucoma. Optic neuritis from MS. Immediate referral. 

122

sudden bilateral painless vision loss

medications that change refraction e.g., cholinergics, anticholinergics, steroids

123

sudden bilateral painful vision loss

chemical, radiation exposures

124

gradual bilateral vision loss

Cataracts, macular degeneration

125

slow central vision loss

nuclear cataract, macular degeneration

126

peripheral vision loss

open-angle glaucoma

127

one-sided vision loss

hemianopsia and quadrantic defets