Unit 3 HEENT, neuro system

Question 1

Children reach 20/20 by age

Answer 1

6. If not at least 20/30 by 6, refer to ophthalmologist

Question 2

Snellen test

Answer 2

Measures central distance vision. have the patient stand 20 feet from the chart, cover one eye, and read the chart, starting with the largest letters and working down to the smallest they can clearly see, repeating for the other eye. Visual acuity is record as a fraction, 20/20, 20/40. Top number is distance the patient is from the chart. Bottom number is distance at which a person with normal vision can read the same line. 20/20 means patient can see at 20 feet what a person with normal vision can see at 20 feet. 20/40 means the patient can see at 20 feet what normal vision person can see at 40 feet.

Question 3

colorblindness

Answer 3

Ishihara chart, a color vision test used to detect red-green color blindness

Question 4

Testing vision in illiterate person

Answer 4

Tumbling E chart. Uses only E’s in various rotated forms of the E. Patient covers one eye, indicates direction of the E (up, down, left, right) by pointing or gesturing. Visual acuity is based on the smallest line of Es they can identify

Question 5

most common eye pathologies

Answer 5

cataracts, glaucoma, age-related macular degeneration (AMD), hypertensive and diabetic retinopathy, dry eye, conjunctivitis, floaters, retinal detachment

Question 6

ICP associated conditions

Answer 6

Swollen optic disc with blurred edges- papilledema, brain tumors, bleeding in the brain, hydrocephalus, infections, head injuries, abscess, pseudotumor cerebri

Question 7

eye conditions that are medical emergencies

Answer 7

herpes keratitis-acute eye pain, photophobia, tearing, blurred vision. Refer to ED.
acute angle-closure glaucoma-acute eye pain accompanied by headache, n/v, halos around lights, decreased vision. Exam reveals mid-dilated pupil that is oval-shaped, cloudy cornea, cupping of optic nerve. Refer to ED.
Orbital cellulitis-acute onset of erythematous swollen eyelid with proptosis (eyeball bulging) and eye pain on affected eye. Unable to perform full ROM with pain on eye movement. Look for hx of recent URI or sinusitis, Refer to ED.
Retinal detachment-sudden onset of shower of floaters, ‘looking thru a curtain’, sudden flashes of light, refer to ED

Question 8

degenerative changes of aging in eyes

Answer 8

presbyopia, decreased ability of eye to accommodate stiffening of lenses, usually starts at 40, near vision is affected with decreased ability to read small print at close range
cataracts
glaucoma
age-related macular degeneration
dry eye

Question 9

hyperopia and myopia

Answer 9

hyperopia is farsightedness

Myopia is nearsightedness (l M N o p)

Question 10

autoimmune disorders that cause eye problems

Answer 10

Sjogren’s Syndrome-decreased function of lacrimal and salivary glands-persistent dry eyes and dry mouth longer than 3 months, c/o gritty or sandy eyes, increase in dental caries, exam shows swollen and inflamed salivary glands
Graves disease-thyroid eye disease
lupus
MS
Uveitis-inflammation of uveal tract, middle layer of eye

Question 11

different kinds of hearing loss

Answer 11

conductive-outer and middle ear, obstruction of sound waves
Sensorineural hearing loss-inner ear, damage or aging of cochlea/vestibule, or to nerve pathways, ototoxic drugs, stroke

Question 12

descriptions of eye findings pinguecula

Answer 12

harmless, yellowish, raised growth on eyeball, chronic sun exposure

Question 13

pterygium

Answer 13

surfers eye, yellow, triangular thickening of conjunctiva extending across cornea on nasal side, chronic sun exposure

Question 14

Weber and Rinne test

Answer 14

Weber - place tuning fork midline on forehead, normal finding is no lateralization. If lateralization (hearing sound in only one ear)
abnormal finding
Rinne - place tuning fork first on mastoid process, then at front of each ear. Time each area. Normal finding is AC (air conduction ) lasts longer than BC (bone conduction) so can hear longer in front of ear than on mastoid bone

Both test CN VIII

Question 14

chalazion

Answer 14

small, painless bump on eyelid formed when meibomian (oil) gland becomes blocked

Question 15

post nasal drip

Answer 15

when mucus from nasal passages drips down back of throat. Causes are allergies, irritants, acid reflux, structural problems with nasal passages, medications, viral infections, sinus infections, hay fever. Sore throat, cough, throat clearing, bad breath, hoarseness

Question 16

allergic rhinitis

Answer 16

inflammatory changes of throat due to allergy, increases risk of sinusitis. Nose has blue-tinged or pale boggy nasal turbinates, clear mucus, posterior pharynx can show cobblestoning, has thick mucus, with colors ranging from white, clear, yellow, or green. Circles under eye

Question 17

rhinitis medicamentosa

Answer 17

prolonged use of topical nasal decongestants causes rebound effects that result in severe and chronic nasal congestion. Daily severe nasal congestion and nasal discharge

Question 18

anatomical structures of mouth and throat

Answer 18

pink to dark pink moist mucous membranes. Three salivary glands, parotid, submandibular, sublingual.
Tonsils-made of lymphoid tissue (specialized tissue with various cells for immunity, including lymphocytes, front line defense), butterfly shaped glands.
Posterior pharynx - collection of lymphoid tissue spread over the surface of back and sides of throat
tongue

Question 19

mouth and throat structures

Answer 19

Question 20

congenital abnormalities of hard and soft palate

Answer 20

cleft palate-roof of mouth doesnt fully close during fetal development, leaves an opening that extends into nasal cavity
cleft lip and palate-both lip and palate are not fused
submucous cleft palate-muscles of soft palate don’t fully fuse

Question 21

cheilosis

Answer 21

inflammation, dryness of lips, cracks, maceration at corners, fissues, scaling.

caused by vitamin deficiencies-riboflavin and iron
sun exposure
dry mouth
lip licking
infections
allergic reactions
oversalivation
poorly fitting dentures
lupus
autoimmune disease
treat underlying cause but high rate of recurrence

Question 22

criteria to dx strep throat

Answer 22

throat culture for strep A, fever, tonsillar exudate, anterior cervical lymphadenopathy, absence of cough, pain in throat that develops quickly and lasts thru the day, swallowing may be uncomfortable, headache

Question 23

manifestations of peritonsillar abscess

Answer 23

caused by infection in tissue around tonsils, sometimes strep A, other bacteria, or complication on tonsillitis, can form an abscess

Question 24

legal blindness is

Answer 24

best corrected vision of 20/200

Question 25

Cholesteatoma

Answer 25

“Cauliflower like” growth with foul smelling ear discharge. Hearing loss in affected ear. On exam, no ossicles or tympanic membrane are visible due to destruction by tumor. Hx of chronic otitis media infection. Mass isn’t cancerous, but can erode into bones of face and damage facial nerve (CN VII). Tx w abx and surgical debridement. Refer to otolaryngologist.

Question 26

Battle sign

Answer 26

Raccoon eyes (periorbital ecchymosis) and bruising behind ear (mastoid area) that appears 2-3 days after trauma. Physical exam does not show these two signs immediately after trauma. Search for clear golden serous discharge from ear or nose. Rule out basilar and/or temporal bone fx. Basilar skull fracture can cause intracranial hemorrhage. Refer to ED

Question 27

Herpes keratitis

Answer 27

Acute onset of severe eye pain, photophobia, tearing, blurred vision in one eye. Dx with fluorescein dye. A black lamp in a darkened room is used to search for fern-like lines in corneal surface. Infection permanently damaged corneal epithelium, possibly resulting in corneal blindness. Herpes simplex (herpes simplex keratitis) and herpes varicella zoster (herpes zoster ophthalmicus) or shingles can infect the eyes. Herpes zoster has eye findings accompanied by acute eruption of crusty rashes that follow ophthalmic branch (CN V) of trigeminal nerve (one side of forehead, eyelids, tip of nose.) refer to ED.

Question 28

Multiple sclerosis (optic neuritis)

Answer 28

Young adult with new or intermittent loss of vision in one eye, alone of accompanied by nystagmus or abnormal eye movements. May also be accompanied by other neuro symptoms, aphasia, paresthesia, abnormal gait, spasticity, etc. C/o daily fatigue on awakening that worsens as day goes on. Heat exacerbates and worsens symptoms. Recurrent episodes. Refer to neurologist.

Question 29

Orbital cellulitis

Answer 29

Acute onset of erythematous swollen eyelid with proptosis and eye pain of affected eye. Unable to perform full ROM of eyes with pain on eye movement. Look for hx of recent rhinosinusitis or URI

Question 30

Retinal detachment

Answer 30

Sudden onset of a shower of floaters associated with “looking thru a curtain” sensation with sudden flashes of light (photopsia). Refer to ED

Question 31

Diphtheria

Answer 31

Sore throat, fever, markedly swollen neck (bull neck), low grade fever, hoarseness, dysphagia. Posterior pharynx, tonsils, uvula, soft palate are coated with gray to yellow colored pseudo membrane that is hard to displace. Very contagious. Contact prophylaxis required. Refer to ED.

Question 32

Eyes normal findings

Answer 32

Fundi-veins are larger and darker than arteries Cones-for color, 20/20 and sharp vision Rods-detects light and shadows night vision Macula and fovea-macula responsible for central vision, fovea is in middle of macula with lots of cones, fovea determines 20/20 vision Presbyopia-age related visual change due to decreased ability to accommodate stiffening of lenses, starts around 40, near vision affected and can’t read small print at close range

Question 33

Ears

Answer 33

Ossicles (bones)-malleus, incus, stapes (smallest bone in the body) Tympanic membrane-translucent off-white to gray color with cone of light intact Tympanogram-most objective test for presence of fluid inside middle ear (is a straight line versus peaked shape)otitis media will show as straight line Pinna-large cartilage, injuries need plastic surgeon Tragus-small cartilage flap in front of ear Ceruminosis most common OTC tx is carbamide peroxide

Question 34

Nose

Answer 34

Inferior nasal turbinates are visible but medial/superior turbinates need special instruments to visualize Bluish, pale boggy nasal turbinates in allergic rhinitis Lower third of nose is cartilage, cartilage doesn’t regenerate-needs plastic surgeon

Question 35

Sinuses

Answer 35

4 air filled cavities in skull- ethmoid, maxillary, frontal, sphenoid Nearly at adult size by age 12

Question 36

Mouth

Answer 36

Membranes are pink to dark pink, and moist. Dilantin/phenytoin can cause gingival hyperplasia Swollen or red tongue is glossitis 32 teeth are normal adult amount, wisdom teeth are added on top of that Leukoplakia-white to light-gray patch appearing on tongue, floor of mouth, inside cheek. Rule out oral cancer.

Question 37

Aphthous stomatitis (canker sores)

Answer 37

Painful and shallow ulcers, Usually heal in 7-10 days, cause unknown, tx with magic mouthwash (liquid diphenhydramine, viscous lidocaine, glucocorticosteroid) Swish, hold, spit q 4 hours PRN

Question 38

Avulsed tooth

Answer 38

Soak in cool milk and see dentist for reimplementation

Question 39

Vermillion border

Answer 39

Border on edges of lips, corners are oral commissure (can have cheilosis or perleche there)

Question 40

Geographic tongue

Answer 40

Benign. Tongue surface has map-like appearance, patches may move from day to day. May c/o soreness from acid, spicy foods.

Question 41

Torus palatinus

Answer 41

Painless bony protuberance midline on hard palate (roof of mouth) may be asymmetrical but skin will be normal, doesn’t interfere with normal function

Question 42

Fishtail uvula

Answer 42

Uvula is split and resembles fish tail, may be sign of occult cleft palate but that’s rare

Question 43

Diabetic retinopathy

Answer 43

Microaneurysms caused by neovascularization Cotton wool spots, also called fluffy white-yellow patches on retina

Question 44

Cataracts

Answer 44

Opacity of the lens, either central or cortical Can appear from birth to elderly C/o glare when driving at night, halos around lights, blurred vision

Question 45

Nasal polyps

Answer 45

Painless, soft round growths inside nose May cause blockage Increased risk of aspirin sensitivity or allergy

Question 46

Hairy leukoplakia

Answer 46

Elongated papilla on sides of tongue Pathognonic for HIV Caused by Epstein Barr virus of tongue

Question 47

Leukoplakia of oral mucosa or tongue

Answer 47

Bright white plaque caused by chronic irritation, like sniff or chewing tobacco Rule out oral cancer

Question 48

Palpebral conjunctiva

Answer 48

Mucosal lining inside eyelids

Question 49

Bulbar conjunctiva

Answer 49

Mucosal lining covering eyes

Question 50

Corneal abrasion

Answer 50

C/o acute onset of severe eye pain with tearing Reports feeling foreign body sensation on eye surface Ask if wears contact lenses

Question 51

Hordeolum

Answer 51

Stye. Abscess of hair follicle and sebaceous gland May rupture and drain exudate. Infection may spread to adjoining tissue.

Question 52

Hordeolum

Answer 52

Stye. Abscess of hair follicle and sebaceous gland May rupture and drain exudate. Infection may spread to adjoining tissue. Hot compresses x 5-10 minutes BID/TID til it drains If infection spreads, dicloxacillin or erythromycin til it drains. Refer to eye doc for I&D

Question 53

Subconjunctival hemorrhage

Answer 53

Blood trapped under conjunctiva and sclera secondary to broken arterioles Caused by sneezing, coughing, heavy lifting, vomiting, local trauma, a fall or spontaneously Resolves in 1-3 weeks, like a bruise with color changes. Increased risk on HTN, aspirin, anticoagulants

Question 54

Blepharitis

Answer 54

Chronic, inflammation of eyelids-hair follicles and meibomian glands. Assoc with seborrhheic dermatitis and rosacea. Eyelid may be colonized by staph. Intermittent exacerbations. C/o itching or irritation in eyelids, gritty sensation, eye redness, crusting. Wash with baby shampoo and warm water. Scrub eyelids til It resolves. Consider topical antibiotic erythromycin eyedrops 2-3 x day. Warm compresses 2-4 x day to soften debris and relieve itching.

Question 55

Epistaxis

Answer 55

Anterior are milder and more common than posterior. Posterior can lead to severe hemorrhage. Cocaine can cause and lead to nasal septum perforation. Apply direct pressure on front of nose, can use afrin to shrink vessels/vasoconstriction, apply triple antibiotic ointment or petroleum jelly for few days. Refer posterior bleeds to ER.

Question 56

Acute otitis media

Answer 56

Infection of middle ear cavity with bacterial pathogens due to mucus trapped in middle ear secondary to Eustachian tube dysfxn. Most have a middle ear effusion. Usually strep-gram positive, haemophilus influenza, moraxella catarrhalis, both gram negative. C/o ear pain (otalgia) popping noises, muffled hearing, recent hx of cold or allergic rhinitis, may have rupture of TM (reports blood and pus seen on pillowcase on awakening with relief of ear pain) MEE’s can persist 8 weeks or longer after tx of AOM. allergy pillow covers, mattresses, HEPA allergy filters are recommended for allergic rhinitis. Many are allergic to dust mites, an indoor allergen.

Question 57

Bullous myringitis

Answer 57

AOM with blisters on a reddened and bulging TM. Conductive hearing loss. Caused by different pathogens, mycoplasma, viral, bacterial. Lateralization to affected ear (sound is perceived as louder in ear with hearing difficulty because bone condition is better than air condition in that ear) TM can rupture with purulent discharge from affected ear with relief of ear pain Amoxicillin first line of tx Tx otalgia and Eustachian tube dysfxn, as it becomes Swollen and cannot drain. Patient will c/o plugged up ear and decreased hearing in affected ear. When middle ear fluid drains, hearing will become normal

Question 58

Strep throat and rheumatic fever

Answer 58