Week 4 - HEENT

Question 1

cranial bones

Answer 1

frontal, parietal, occipital, temporal

Question 2

sternomastoid

Answer 2

head rotation and flexion

Question 3

trapezius

Answer 3

moves the shoulders and extends/turns the head

Question 4

thyroid gland

Answer 4

major endocrine gland responsible for cellular metabolism
- normally not palpable behind the trachea

Question 5

subjective data: health history

Answer 5

Headache: Unusually frequent, severe? Onset? Had this type before? Location? Character? Mild, moderate, severe? Course and duration? Precipitating factors? Associated factors? Other illnesses? Taking meds? What makes it worse? Treatment? Coping strategies?

Head injury: Onset? Setting? Location? Duration? Associated symptoms? Effort to treat?

Dizziness: Determine what patient means by dizziness. Onset? Associated factors?

Neck pain: Onset? Location? Associated symptoms? Precipitating factors? Related to stress, body mechanics? Coping strategies?

Lumps or swelling: Recent infection, tenderness? Duration? Change in size? History of irradiation of head, neck, upper chest? Difficulty swallowing? Do you smoke? Do you drink alcohol? (rationale: smoking and alcohol together increase the risk for cancer). Thyroid problems?

History of head or neck surgery: Ever had surgery of head or neck? Why? When? How do you feel about the results?

Question 6

objective data: physical exam

Answer 6

Normal size and shape of head = normocephalic.
Head—Inspect and palpate the skull
Size and shape
Temporal area
Temporal artery
Temporomandibular joint - open/close mouth
Facial structures - symmetry

Question 7

neck

Answer 7

inspect
- ROM
- symmetry = neck structures and trachea
- ability to shrug shoulders against resistance (CN XI)
Auscultate
- carotid artery = listen for bruit (blowing, swishing sound)
Palpate
- cervical lymph nodes –> lymph vessels detect and eliminate foreign substances from the body. Nodes are small, oval clusters of tissue that are set at intervals along the lymph vessels, like beads on a string.
Thyroid

Question 8

eye subjective data: health history

Answer 8

Vision difficulty: Any difficulty seeing or any blurring? Sudden onset or slow progression? One eye or both? Constant? Spot in front of eyes? Halos, rings around lights? Blind spots? Night blindness?
Pain: Any pain? Describe. Sudden? Quality? Pain with bright light? Foreign body? Rapid consult with opthamology or emergency dept
Strabismus, diplopia: Crossed eyes? Occurs with eye fatigue? Seeing double?
Redness, swelling: Any infections? Particular time of year? Common, usually benign condition – conjunctivitis. Unless accompanied by eye pain or change in vision.
Watering, discharge: Watering, excessive tearing? Discharge? Colour? How do you remove material?
Ocular problems: History of injury or surgery? Allergies? Glaucoma (family hx? Been tested?)
Glasses or contacts: Do you wear? How effective? Last prescription check? Any problems with contacts? How do you clean them, remove them?
Self-care behaviours: Last vision test? Tested for colour vision? Environmental factors affecting eyes?
Medications: Using eye medications? Systemic/topical?
Vision loss: How do you cope with vision loss? Maintenance of living environment?

Question 9

eye objective data: physical exam

Answer 9

normal pupil size 3-5 mm
PERRLA
- Pupils are equal, round, react to light and accommodation
inspect external ocular structures

Question 10

use of ophthalmoscope

Answer 10

+ dioptres (black) = focus on near objects
- dioptres (red) = focus on objects farther away

Question 11

normal findings of the ocular fundus

Answer 11

• optic disc
• retinal vessels
• general background
• macula

Question 12

Snellen eye chart

Answer 12

• 20 ft away
• do wear glasses if normally required
• cover one eye and read smallest line that you can
• one mistake allowed
• repeat w/ other eye

Question 13

nystagmus

Answer 13

a fine oscillating movement around the iris, may indicate weakness or disease

Question 14

extraocular muscle function/movement

Answer 14

convergence = eyes move inward toward nose

Question 15

Hirschberg’s test

Answer 15

corneal light reflex
- assessing parallel alignment of the eye axes by shining a light toward the patients’ eyes. The reflection of light should be at exactly the same spot in the two corneas. Asymmetry of the light reflex indicates deviation in alignment as a result of eye muscle weakness or paralysis.

Question 16

abnormal findings for eyes KNOW THIS

Answer 16

Ptosis = drooping upper lid
unequal pupil size
Miosis = contraction of pupil
Mydriasis = dilation of pupil
Conjunctivitis = pink eye
Glaucoma = intraocular pressure

Question 17

vertigo

Answer 17

inflammation of the semicircular canals of the inner ear that result in a spinning, whirling sensation

Question 18

ear structure

Answer 18

outer ear (auricle or pinna), tympanic membrane (translucent, pearly gray membrane), middle ear, inner ear
inner ear
- equilibrium = semicircular canals, vestibule
- hearing = cochlea

Question 19

ear subjective data: health history

Answer 19

Earaches: Location, character, other symptoms, any related trauma? What relieves it?
Infections: When? How often? How were they treated?
Discharge: Appearance, odor, related to pain?
Hearing loss: Onset, character? In which situations? Family history? Any treatment? Coping strategies?
Environmental noise: Loud noise at home or work? Coping strategies?
Vertigo: Dizziness, room spinning, loss of balance?
Self-care behaviours: How do you clean your ears? Last time hearing was checked?

Question 20

cues of possible hearing loss

Answer 20

1.Lip reading or watching your face and lips closely rather than your eyes.
2.Frowning or straining forward to hear.
3.Posturing of head to catch sounds with better ear.
4.Misunderstanding your questions or frequently asking you to repeat what you said.
5.Acting irritable or showing startle reflex when you raise your voice (recruitment).
6.Inappropriately loud voice.
7. Speech sounding garbled; possible distortion of vowel sounds.
8. Flat, monotonous tone of voice.

Question 21

ear objective data: physical exam

Answer 21

external ear - inspect and palpate
- size and shape
- skin condition
- tenderness
- external auditory canal = lesions, discharge
test hearing aculity
- conversational speech
- Whispered voice test (place one finger on the tragus and whisper words approx. 1 foot away from the other ear)

Question 22

ear objective data: physical exam cont.

Answer 22

Canal color & characteristics – pink, moist.
Cone of light - visible through otoscope, at 5:00 position in right ear and 7:00 position in left ear.
Tympanic membrane – pearly grey.
No discharge present.

*Pull pinna up and back on adults or older children (pull pinna down on infants and < 3yrs of age).

Question 23

nose, mouth, and nose

Answer 23

Nose
– warms, moistens, and filters inhaled air.
- sinuses = air-filled pockets which lighten the weight of the skull, resonate sound, provide mucus, easily inflamed.
Mouth
– the oral cavity = contains lips, palate, cheeks, tongue, teeth, gums, and salivary glands.
- Salivary glands secrete saliva which lubricates the food bolus, starts digestion, and cleans/protects the mucosa.
Throat
– pharynx is located behind the mouth and nose.
- Separated from the oropharynx by tonsils.

Question 24

nose subjective data: health history

Answer 24

Discharge: Any discharge? Continuous? Watery, purulent, mucoid, bloody?
Colds: Frequent or severe? How often?
Sinus pain: Any pain or sinusitis? How treated? Chronic postnasal drip?
Trauma: Ever have trauma to nose? Can you breathe through nose? One or both sides obstructed?
Epistaxis: How often? How much bleeding? Colour? One or both nostrils? Aggravated by scratching or picking? How treated? Difficult to stop?
Allergies: Allergic to what? How determined? What makes it worse? Can you avoid exposure? Use inhaler, spray, drops? Which ones? How often? How long have you used?
Altered smell: Any change in sense of smell?

Question 25

mouth and throat subjective data: health history

Answer 25

Sores or lesions: How long have you had? Ever had before? Single or multiple? Associated with stress, season change, food? How treated? Local medication?
Sore throat: How frequent? When did it start? Associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip, hoarseness? Worse when arising? Humidity level where you sleep? Dust or smoke at work? Usually get throat culture for sore throat? How treated? Still have tonsils and adenoids?
Bleeding gums: How long?
Toothache: Teeth sensitive to hot/cold? Lost any teeth?
Hoarseness: How long? Feel like you have to clear throat? Lump in throat? Use voice a lot at work, recreation? Associated with cold, sore throat?
Dysphagia: Difficulty swallowing? How long? Feel as though food gets stopped at certain point? Any pain?
Altered taste: Change in sense of taste?
Smoking, alcohol consumption: Smoke? Pipe, cigarettes? Smokeless tobacco? How many packs per day? How many years? When was last drink of alcohol? How much did you drink? How much do you usually drink?
Self-care behaviors: How often do you brush teeth, floss? Last dental exam? Dental appliances? Dentures? How do they fit? Sores or irritation on palate or gums? Trouble talking? Trouble chewing? How do you clean dentures?

Question 26

dysphagia

Answer 26

OROPHARYNGEAL: difficulty of transfer of food bolus from mouth to the esophagus
or
ESOPHAGEAL: difficulty passing food down the esophagus to the stomach
aspiration precautions
- high fowlers
- remain upright for 30 min following meals
- preform good oral hygiene
- thicken fluids
- take time to assist w/ feed
- lessen distractions

Question 27

nose objective data: physical exam

Answer 27

inspect and palpate
external nose
palpate sinuses:
- Frontal sinuses – in the frontal bone above and medial to the orbits
Maxillary sinuses – in the maxilla – cheekbone along the side walls of the nasal cavity

Question 28

mouth objective data: physical exam

Answer 28

inspect:
- lips
- teeth and gums
- tongue (test cranial nerve XII)
- buccal mucosa
- palate and uvula

Question 29

throat objective data: physical exam

Answer 29

inspect:
Tonsils - grading from 1+ to 4+
Use of tongue depressor
Posterior pharyngeal wall
*inspection – Ask patient to say “ah” and then use light to look in throat. May use a tongue depressor if unable to see past to the throat. Depress on the side of tongue to avoid eliciting the gag reflex.

Question 30

HEENT in head-to-toe assessment

Answer 30

HEAD
Inspect and palpate:
Skull and facial structures (size and shape, symmetry)
Temporal area (TMJ)

NECK
Inspect, auscultate, and palpate:
Neck ROM, trachea (midline)
Auscultate carotid (bruit)
Palpate cervical lymph nodes, thyroid

EYES
Inspect:
External and anterior eye structures
PERRLA

EARS
Inspect and palpate:
External ear (size and shape, skin condition, presence of lesions/discharge, tenderness)
Hearing acuity (conversational, whispered voice test)

NOSE
Inspect and palpate:
External nose, sinuses (frontal, maxillary)

MOUTH
Inspect:
Lips, teeth, gums, tongue, buccal mucosa, palate, uvula (signs of hydration)

THROAT
Inspect:
Pharynx, tonsils
CN XII (tongue extension, midline)

Question 31

focused questions for HEENT

Answer 31

Head – presence of headache
Eyes – vision difficulty or pain
Ears – earaches, hearing loss
Nose – discharge, sinus pain
Throat – pain to mouth or throat, difficulty swallowing