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Flashcards in Week 5: HEENT Deck (58)
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What are normal findings when assessing the head of a newborn/infant?

Soft ridges and concavities (sutures and fontanelles)


Abnormal findings in a head assessment of a newborn/infant (6)

  1. Cephalohematoma: initially soft swelling that develops a raised bony margin within a few days, resolves within several weeks
  2. Hydrocephalus: anterior fontanelle bulging, eyes deviated downward revealing upper sclerae and creating setting sun sign
  3. Craniosynostosis: premature closure of one or more of the sutures
  4. Increased intracranial pressure: bulging, tense fontanelle
  5. Congenital hypothyroidism: enlarged posterior fontanelle
  6. Dehydration: depressed anterior fontanelle


What would be included in the evaluation of an infant with abnormal facies? 

Consider what would be needed to be considered as part of history, exam and what measurements would need to be taken

  • History: family history, perinatal history, pregnancy history (any exposure, any trauma during delivery)
  • Abnormalities on exam: growth, development, other dysmorphic somatic features
  • Measurements: head circumference, height, weight


What are the 3 mechanisms of facial dysmorphogenesis?

  1. Deformations from intrauterine constraint
  2. Disruptions from amniotic bands of fetal tissue
  3. Malformations from intrinsic abnormality in face/head or brain


What are some considerations when assessing abnormal facial structure in a newborn/infant? (2)

  1. Similarity to a parent may be reassuring but may also indicate familial disorder
  2. Determine whether the facial features fit a recognizable syndrome, compare with references and pictures of syndromes and tables/databases of combinations of features


In considering the examination of the thyroid what do you suspect the cause of diffuse enlargement would be? A single nodule? Multiple nodules? 

  1. Diffuse enlargement: Graves, Hashimoto thyroiditis, endemic goiter
  2. Single nodule: cyst, benign tumor or one nodule within a multinodular gland; malignancy possible
  3. Multiple nodules: metabolic process


How do you use an ophthalmoscope? 


  1. Darken the room
  2. Turn the focusing wheel to the 0 diopter
  3. Hold the ophthalmoscope in your R hand and use your R eye to examine the R eye (same for left)
  4. Keep it firmly braced against the medial aspect of your bony orbit with the handle tilted laterally at 20 degrees slant from the vertical
  5. Place yourself 15 inches away from the patient and at an angle 15 degrees lateral to the patient's line of vision


What are diopter settings for?

  • Turn counterclockwise (minus diopters) if patient nearsighted; clockwise (plus diopters) if patient farsighted
  • To view anterior aspect: +10 to +20
  • To view posterior aspect: 0


How would the FNP assess pupillary response? (3)

  • Dim light, then shine bright light obliquely into each pupil
  • Direction reaction: pupillary constriction in same eye
  • Consensual reaction: pupillary constriction in the opposite eye


How would the FNP assess visual fields by confrontation?

Confrontation: static finger wiggle test

  1. Position arm's length away from patient
  2. Close one eye and have pt close the opposite eye
  3. Place hands 2 ft apart out of the patient's view, lateral to the patient's ears
  4. Wiggle fingers and slowly bring your moving fingers forward into the patient's center of view
  5. Patient should tell you when they can see your finger movement
  6. Test each quadrant and each eye individually
  7. Record any deficits


How does the FNP assess extraocular movements? Convergence?

  • Extraocular movements: 6 EOMs test (in an H)- patient follows finger to the right, right and upward, down to the right, extreme left, left and upward then down to the left
  • Convergence: follow finger or pencil as you move it in toward the bridge of the nose


What are the various visual field deficits and their etiologies? (8)

  1. Central vision loss: nuclear cataract, macular degeneration
  2. Peripheral loss: advanced open-angle glaucoma
  3. Horizontal defect: occlusion of a branch of the central retinal artery may cause a horizontal defect; ischemia of the optic nerve
  4. Blind right eye: lesion of the optic nerve
  5. Fixed defect: scotomas, suggest lesions in the retina or visual pathways
  6. Bitemporal hemianopsia: lesion at the optic chiasm may involve only fibers crossing over to the opposite side; visual loss involves the temporal half of each field
  7. L homonymous hemianopsia: lesion of the optic tract; involves L half of each field
  8. Homonymous left superior quadrantic defect: partial lesion of the optic radiation in the temporal lobe


What are the etiologies of moving specks and flashing lights with floaters?

  • Moving specks or strands: vitreous floaters
  • Flashing lights with new vitreous floaters: retinal detachment


What are the types of double vision? What cranial nerve abnormalities do they indicate? (2)

  1. Horizontal: images side by side CN III or VI
  2. Vertical: images on top of each other CN III or IV

Note: Diplopia that persists with one eye closed suggests a problem with cornea or lens


What would you expect the normal fundoscopic exam to look like?

  • Process: Tiny disc vessels give normal color to the disc
  • Appearance
    • Color yellowish orange to creamy pink
    • Disc vessels tiny
    • Disc margins sharp
    • Physiologic cup centrally located, may be absent


What do you expect the fundoscopic exam of a patient with hypertension or diabetes to look like?

  • hypertension: cotton wool patches, copper wiring, AV crossing
  • diabetes: cotton wool patches, late stage is neovascularization


What would you expect in a fundoscopic exam in a patient with papilledema? (6)

What are some possible causes?

  • Process: elevated ICP causes intra-axonal edema along the optic nerve, leading to engorgement and swelling of the optic disc
  • Appearance
    • Color pink, hyperemic
    • Often with loss of venous pulsations
    • Disc vessels more visible, more numerous, curve over the borders of the disc
    • Disc swollen with margins blurred
    • Physiologic cup not visible
  • Causes: intracranial mass, lesion, hemorrhage, meningitis


What would you expect on fundoscopic exam of a patient with glaucoma?

  • Process
    • Increased intraocular pressure within eye leads to increased cupping and atrophy
    • Base of the enlarged cup is pale
  • Appearance: death of optic nerve fibers leads to loss of tiny disc vessels


What would you expect to see in a patient with cataracts? (1)

No red reflex


What are some normal variations of the optic disc? What do these look like on exam? (3)

  • Physiologic cupping: small whitish depression of the optic disc with grayish spots at the base
  • Medullated nerve fibers: irregular large white patches with feathered margins,
  • Rings and crescents around the optic disc


What are some reasons for lumps or swelling around the eye and how would these present on exam? (6)

  1. Pinguecula: harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris; appears with aging, first on the nasal then on the temporal side
  2. Episcleritis: benign usually painless localized ocular inflammation of the episcleral vessels; vessels appear movable over the scleral surface; may be nodular or show only redness and dilated vessels
  3. Stye: painful, tender, red infection at the inner or outer margin of the eyelid (usually d/t s.aureus)
  4. Chalazion: subacute nontender usually painless nodule caused by a blocked meibomian gland
  5. Xanthelasma: slightly raised, yellowish, well-circumscribed cholesterol-filled plaques that appear along the nasal portions of one or both eyelids - occurs in pts with hyperlipidemia and primary biliary cirrhosis
  6. Blepharitis: chronic inflammation of the eyelids at the base of the hair follicles (S.aureus); scaling seborrheic variant


What are some etiologies for unilateral/bilateral painful/painless vision loss?

  • Unilateral
    • Painless: vascular occlusion, retinal detachment, hemorrhage
    • Painful: giant-cell arteritis
  • Bilateral
    • Painless: vascular etiologies, stroke, non-physiologic
    • Painful: intoxication, trauma, chemical or radiation exposures


What are some abnormal eye movements in the pediatric patient? (4) How are these described? How would the FNP assess for these? 

  1. Congenital ptosis: newborn who cannot open an eye
  2. Nystagmus that persists after a few days may indicate poor vision or CNS disease
  3. Strabismus persisting beyond 3 months may indicate oculomotor weakness
    • Esotropia: eye or eyes inward
    • Exotropia: eye or eyes outward
  4. Pseudostrabismus
  • Test: Cover/uncover test


How do you assess for a red reflex? What would the absence of a red reflex indicate?

  • Shine ophthalmoscope beam on the pupil and look for the orange glow (red reflex)
  • Absence indicates cataract, artificial eye, detached retina, mass, retinoblastoma


What do the results of the Weber vs. Rinne tests indicate?


  • unilateral conductive hearing loss: sound is heard in the impaired ear
  • Unilateral sensorineural hearing loss: sound is heard in umpaired ear


  • Conductive hearing loss: sound heard through bone as long as or longer than it is through air
  • Sensorineural: sound heard longer through air


Define conductive loss, what are some etiologies? (External [5] vs. middle [5] ear)

  • Results from problems in external or middle ear; noisy environment improve hearing
  • Etiologies
    • External ear
      • Structural deformities
      • Cerumen impaction
      • Infection
      • Benign growths like exostoses or osteomas
      • SCC
    • Middle ear
      • Otitis media
      • Congenital conditions
      • Cholesteatomas
      • Tumors
      • Perforation


Define sensorineural loss, what are some etiologies (9)?

  • problems in the inner ear, cochlear nerve or central connections to brain; noisy environments more difficult
  • Etiologies
    • Presbycusis
    • Ototoxic drug exposure
    • Noise exposure
    • Systemic disease
    • Congenital/hereditary
    • Rubella
    • CMV
    • Meniere's disease
    • Acoustic neuroma


How would you assess for hearing in a newborn? 

  • Acoustic blink reflex: blinking in response to sudden sharp sound
  • Computer testing


How would you describe/define this tympanic membrane exam?

  • Normal
  • Pinkish gray
  • Malleus can be seen lying behind the upper part of the drum
  • Incus visible next to malleus
  • Cone of light visible @ 5:00 R ear, 7:00 L ear (umbo)
  • Small blood vessels visible


How would you describe/define this tympanic membrane exam?

Acute otitis media: bulging with fluid, diffuse redness, may have green or yellow discharge; tug test won't be tender