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UC Adv. Health Assessment HEENT Part 3 (KMH)
Terms in this set (84)
Done with room darkened, "Look at my shoulder not the light.", Elicit Red Reflex 8-10" away with lens at Zero, Come in really close with hand on pts forehead, Close in with lens in the black (+) & focus on the optic disc at the nasal side of the retina, Change lens to Red (-) to view posterior structures, follow vessels centrally.
On NASAL Side of retina, creamy yellow orange in color, round or oval shape, distinct sharply demarcated margins, Cup-disc ratio: Horizontal diameter not > 1/2 disc diameter, Normal cup looks recessed, Papiledema looks like cup is coming toward you, Fovea Centralis is where vision occurs
Ocular Findings: Eye vessels:
Follow a paired artery with vein to periphery
Ocular Findings: Color
Arteries bright light red with a central white reflex stripe, veins are 1/4 larger and darker and have NO white reflex stripe
Ocular Findings: A:V width ratio:
2/3 or 4/5 diameter of vein, abnormal is constricted or dilated
Ocular Findings: Caliber:
A/V decrease as they extend outward
Ocular Findings: A-V Crossing:
Should be within 2DD of disc, Abnormal is nicking, piinching, engorged, > 2DD
Ocular Findings: Tortuosity:
mild in both eyes usually congenital, Abnormal: thick and twisted vessels, extreme or asymmetry
Ocular Findings: Macula:
1 DD in size 2DD TEMPORAL side to the disc, do this last b/c may cause discomfort, Fova Centralis site of sharpest and keenest vision, the macula looks slightly darker than rest of the fundus
Ocular Findings: Background Abnormalities:
Papilledema-bulging disc is a medical emergency, when it comes toward you it is a sign of HTN or IICP
Ocular Findings: Background Abnormalities:
A-V nicking: long term HTN (narrowing), Flame Hemorrhage: little flames, HTN, Retinal Hemorrhage: "red dots" s/o bleeding-seen in DM, Microaneurysms: "red dots" s/o bleeding-seen in DM and HTN, Neovascularization: small collateral tortuous vessels-s/o longstanding DM
Cotton Wool Patches in eye
"white fluffy spots" s/o HTN and DM
Hard Exudates in eye
"hard white spots" s/o HTN and DM
random white bodies normally seen increase with age earliest feature of age related macular degeneration
Looks like a "sandy beach"
White hard bodies
loss of central vision, may see a macula hole
FB: use fluorescein stan & slit lamp: rust ring--get to opthamology ASAP, Red eye- hyperemic & congested may be vision-threatening, always evaluate thoroughly, Pain, Blurred Vision, Red eye= send to Opthalmology
Eye Emergency: Acute Angle closure Glaucoma:
build up of pressure=pain, nausea, change in visual acuity, red teary eye, cloudy cornea, forward bowing iris, mid-dilation of the pupil, high intraocular pressure (as high as 4x normal pressure)
Subconjuctival hemorrhage (not usually an emergency)
caused by trauma, may indicate fragility of vessels
Middle Ear Anatomy
Tympanic Membrane separates external from internal-translucent pearly gray
Bones of the middle ear:
malleus, incus, stapes
Function of middle ear:
conducts sound vibration from outer to internal, protects inner ear by reducing amplitude, allows equalization of pressures
Inner ear anatomy:
Bony labyrinth, chochlea (sensory organ for hearing), Vestibule and Semicircular Canals (sensory organs for Equillibrium)
Ear, Hearing Mechanism:
Ear transmits sound, converts to vibration, analyzed by brain, binaural arrangement, pathways, Normal is AC air conduction, Alternate is BC bone conduction vibrations transmitted directly to CN 8
Ear, Hearing Loss
2 types: Sensorineural and Conductive
sensorineural hearing loss
the most common form of hearing loss, also called nerve deafness; caused by damage to the cochlea's receptor cells or to the auditory nerves, CN 8, auditory area of cerebral cortex
Conductive hearing loss
dysfunction of external or middle ear, > cerumen, FB, perf TM, ososclerosis
Labyrinth gives us:
Equilibrium, informs brain of place in space
If Labyrinth is inflammed it causes:
What is vertigo?
strong, spinning, whirling sensation
caused by imflamed labrynth
External ear inspection and palpation, if tender when push tragus:
Otitis Externa, swimmers ear
Inspect the external meatus for:
size of opening and swelling
Size and shape of ear:
Microtia < 4cm, Macrotia > 10cm, Check for Nodules: Tophi are seen in gout (uric acid crystals), keloid
Weber (place vibrating tuning fork midline of skull) Normal is heard equally in both ears, louder in ear with cerumen b/c solid conducts sound better than air, Louder in good ear with sensory loss and Rinne (compares air to bone conduction) Normal is air conduction is 2x as long as bone conduction,
Voice Test, Hearing Test
testing 1 ear at time grossly by closing off ear and whispering word, document how far way pt can hear
Acoustic blink reflex
blinking of the infants eyes in response to a sharp sound. Many children are not dx with a hearing disorder until there are 2 clues: Parental concern and delayed speech
Ear Exam, Otoscope use:
Adult pull pinna up only, Child pull pinna up AND back
Tympanic membrane-Normal is shiny pearly gray, Cone shapes light reflex 5:00 right ear, 7:00 left ear
Abnormal Otoscopic findings for Otitis Media:
Otitis Media: Yellow-amber color of drum, red color, absent or distorted landmarks, air/fluid bubbles behind drum
Abnormal Otoscopic findings for Bulging Drum:
Abnormal Otoscopic findings for other problems:
Blue/Dark red color is blood/trauma, decreased or absent landmarks is chronic OM, Black/white dots in canal or drum is fungal infection
Function of the nose
moistens, filters, and warms air. Is the resonating chamber for speech with olfactory receptors for smell
External anatomy of nose:
Nares open at base, Vestibule widening of nares, Collumella divides the 2 nares, Ala is outside wing
Internal anatomy of nose:
Nasal cavity-Olfactory receptors CN1, Septum-rich vascular network Keisselbach's, Turbinates-3 parallel to increase surface area, Paranasal sinuses-air filled pockets- Frontal, Maxillary, Ethmoid (between eyes), Sphenoid
Maxillary sinuses at age 4, Sphenoid in place by age 6, Fontal by age 6-7, Transillumination of paranasal sinuses of younger kids has poor sensitivity and specificity for Dx sinusitis
What could a change in smell be?
A nerve problem, CN1 Olfactory
What is rhinophyma?
Rosacea, enlarged nose, Risk factors: fair skin, light colored hair, blue/green eyes, family hx of rosacea
Normal transillumination of nose:
Use penlight press against superior orbital ridge, normal is a diffuse red glow, inflamed sinuses do not transilluminate
Common findings on nose transillumination (abnormal):
Allergic rhinitis: red mucosa, Chronic allergic rhinitis-boggy and pale, perforated septum: cocaine abuser, possible nasal polyps, Epistaxis-nasal bleed
What is the purpose of the Frenulum under the tongue?
Holds tongue down
What are the 3 salivary glands?
parotid, submandibular, sublingual
What are the main risk factors for oral cancer?
Smoking, ETOH, HPV (orally)--is ahead of smoking and ETOH together
Why is oral HPV so important to check for?
#1 cause of oral cancer, HPV 16 causes 70% of all oral cancers, HPV 16 and 18 strains are r/t pharyngeal and tonsillar cancers
Important stats regarding HPV:
Overal last decade there has been a 4-5 fold increase in # of oropharynx cancers in US, r/t # people engaging in oral sex w/ multiple partners, # lifetime sexual partners is important risk factor: risk is doubled in ppl with 1-5 lifetime partners, risk is increased 5 x with 6+ oral sexual partners compared to those who have not had oral sex
Oral cancer risks:
When tobacco and ETOH use are combined, the r/o oral cancer increases 15 x's more than non-users.
Smokeless tobacco and oral cancer:
Usage of snuff, increases r/o oral cancer to the cheek and gum by 50 fold among long term snuff users.
obstructive sleep apnea (OSA)
a temporary lack of breathing that occurs during sleep when the posterior pharynx relaxes and covers the trachea, snoring leads to dry mouth and throat, then morning h/a, then memory loss, then attention deficit, then depression/moodiness, then fatigue, then nocturia, then impotence, then insomnia
Risk factors for Obstructive Sleep Apnea (OSA)
male, age 40-70 yrs, women who are post-menopausal, highte BMI, and craniofacial/upper airway abnormalities
Inspection of Mouth/Lips:
Check color, moisture, cracking or lesions?, Circumoral pallor= shock or anemia, Cyanosis= hypoxemia, Cherry Red = CO, ASA poisoning, Chelitis = cracking at corners of mouth
Normal appearance of tongue:
Ventral surface smooth and shiny with veins, Abnl is dry cracked, tremor or fasciculation
What is angular chelitis?
Tissue degeneration, risk factor for Squamous Cell Carcinoma, Early sign of Chron's
What is Cheilosis saliva leaking + Dentures =
What is Saliva + own teeth?
What is scurrvy?
Vit C Deficiency
When do we see Karposi's Sarcoma?
What do we see with the teeth in Bulemia?
tooth erosion from tooth enamel due to the HCL from stomach (vomiting)
What does a fissured tongue mean?
What is black hairy tongue?
Not hair but elongation of filiform papillae
Painless overgrowth of mycelia like threads of fungus infection
Color black brown to yellow
Occurs after use of antibiotics, meds containing Bismuth like Pepto-Bismol, Regular use of mouthwashes containing oxidizing agents such as peroxide, or astringents such as witchhazel or menthol, tobacco use, drinking excessive amounts of coffee or tea
a white rough patch that arises on the LATERAL tongue. Usually seen in immunocompromised such as HIV, multiple white, warty , painless plagues on lateral aspect of tongue, cannot be scraped off
Inspect tonsils: What is normal?
pink, always use a light, graded 1-4, Abnormal is bright red, swollen, exudate with large white spots = acute infection, white membrane covering= mono, leukemia, diptheria, Tonsils 2+-4+ = infection, Halitosis 4+ tonsils are touching each other
What is a peritonsilar abscess?
Mouth inspection: Buccal Mucosa:
Normal is Pink, smooth, moist, Stenson's duct patent, Abnl: brown patches = Addisons, Stenson's opening red w/ mumps, Koplick spots prodromal for measles, leukoplakia
Mouth Inspection: Palate:
Shine light, Normal: anterior is white, posterior pink, smooth and uvula rises on phonation (CNX), this is "say ah"--we are checking CN 10; Abnormal: Polyps, hard looks yellow with jaundice, oral Kaposi's sarcoma
What do we do if we see Leukoplakia?
Work up as malignancy
What are Koplik spots?
Seen with Rubeola or measles. They appears 2 days prior to onset of rash. Presents on oral mucosa as white spots with blue rings within red spots. Happens in 1/3 of cases, named after Henry Koplick-American Pediatrician who first described them in 1896
Mr. White comes to your office & during exam you notice a black tongue--what do you ask next?
Do you have an upset stomach?
Microtia refers to the size of the:
With a chronic allergy the nasal mucosa appear:
Swollen, boggy, pale and gray
How would you grade tonsils that touch the uvula?
Grade 3+, Grade 4+ is when tonsils touch tonsil to tonsil
During the eye exam the NP should attempt to visualize the physiologic cup. What is true about the physiologic cup?
Blurring of the nasal outline is normal
A 22 yr old nursing assistant presents to you clinic b/c of a painful bump on the edge of her eyelid that appeared this morning. On exam, there is a red bump that is tender to palpation on the lower lid margin, located around a hair follicle. What is your most likely Dx?
A 3 yr old boy is brought to the office b/c he has had a fever and has been tugging on his right ear since yesterday. He has had clear drainage from nose. On exam of the ear, the right TM is red and bulging with loss of landmarks. No purulent drainage. What is most likely Dx?
Your pt has herpes simplex on bottom lip. Which lymph gland should you pay most attention to?
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