Download HEENT Assessment

HEENT Assessment
Obtaining History
If head or neck trauma, gather CC and
current status info. Postpone rest of
history until x-rays obtained.
History: Head and Neck
• Head trauma, skull surgery, jaw/facial
fractures?
• Headaches?
• Swelling of face, jaws, mastoid process?
• Sinus infections/tenderness?
• Nasal discharge or post-nasal drip?
• Nosebleeds?
History: Head and Neck
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Mouth lesions, ulcers, or cold sores?
Any difficulty swallowing or chewing?
Any changes in sound of voice?
Any allergies causing breathing difficulty?
Any neck injury or surgery?
Additional Questions: Peds
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Drinking water treated with fluoride?
Use pacifier or thumb?
When did teething begin?
Tonsils present? If not, when removed?
Additional Questions: Elderly
• Do you wear dentures?
• If so, how well do they fit?
Health Promotion Questions
• Smoke a pipe? Chew tobacco or use snuff?
• Does relaxation, exercise, or massage help
relieve headaches?
• Is H/A associated with lack of sleep, missed
meals, or stress?
• Job: sitting at computer terminal?, risk of
head injury? (hard hat?)
• Do you grind your teeth? Last exam? Floss?
• Use seat belts?
Examination of Head, Neck, and
Lymph
Hair and Scalp: Inspection
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Quality and thickness
Distribution, pattern of loss (if any)
Texture
Lesions
Presence of nits
Skull: Inspection/Palpation
• General size and contour
• Deformities, lumps and tenderness
• Palpate sinus areas and mastoid areas for
tenderness
• Palpate temporal artery
• Check TMJ
Face: Inspection
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Facial expression
Symmetry
Involuntary movements
Edema
Masses or lesions
Color and texture of skin
Exopthalmos
Rash
Neck: Inspection
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Asymmetry
Range of motion
Abnormal pulsations, vein distension
Enlargement of thyroid, lymph, salivary
glands
• Deviation of trachea
• Skin lesions
• Neck muscles
Neck: Palpation
• Assess lymph nodes, noting:
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exact location
size and shape
tender?
freely movable, adherent or matted together?
texture: hard, soft, firm
• Thyroid gland
• Trachea
Neck: Auscultation
• Check for bruits:
– carotid arteries
– temporal arteries
– thyroid, if enlarged
Lymph Nodes: When to Biopsy?
• Immediate biopsy is indicated for:
– painless
– rubbery node of recent onset
– especially if > 1-2 cm in diameter
• A smaller, rapidly enlarging node is also a
biopsy candidate.
• Unilateral nodes should have a biopsy
sooner than bilateral ones.
• More conservative with stable node.
Eyes
History: Eyes
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Corrective lenses? Glasses/contacts?
When lenses last changed?
Blurred vision?
Spots, floaters, halos around lights?
Frequent eye infections/inflammation?
Eye surgery or injury?
Styes?
History: Eyes
• History of high blood pressure or diabetes?
• Any prescription medications for your
eyes?
• Family history: cataracts, glaucoma,
blindness?
Eye History: Peds
• Infant: gaze at you or other objects; blink at
bright lights or quick movements?
• Eyes ever crossed? Ever move in different
directions?
• Does child bump into things?
• Does child sit near television at home?
• How is child’s progress in school?
Eye History: Elderly
• Do eyes feel dry?
• Difficulty seeing in front of you but not to
the sides?
• Problems with glare?
• Problems discerning colors?
• Difficulty seeing at night?
Health Promotion Questions
• Last eye examination?
• Eye care insurance?
• Occupation: prolonged reading or use of
video display terminal?
• Any eye problems from air at work/home?
• Use goggles when appropriate? (when
using tools, sports, swimming?)
Examination of the Eye
• Visual acuity
• External Eye Exam (SIMPLE):
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Symmetry
Inflammation
Masses
Puncta
Lacrimal duct
Eyelinds
Abnormalities: External Eye Exam
• Lid lag
• Lid ophthalmus
(incomplete closure)
• Ptosis (drooping)
• Blepharospasm
• Xanthelasma
• Ectropion (rolling out)
• Entropion (rolling in)
• Infections:
– hordeolum (sty)
– chalazion
– blepharitis
Conjunctiva
• Palpebral conjunctiva: lines lid
• Bulbar conjunctiva: over sclera
• Conjunctivitis: viral, bacterial, allergic
• Pterygium: thickening of bulbar
conjunctiva
Ocular Muscles
CN III
Upper Outer
Superior Rectus
CN III
Upper Inner
Inferior Oblique
CN III
Lower Outer
Inferior Rectus
CN III
Lateral Inner
Medial Rectus
CN IV
Lower Inner
Superior Oblique
CN VI
Lateral Outer
Lateral Rectus
Strabismus: Deviation of Eye
• Tropia: Malalignment
or deviation of eye
• Phoria: Mild
weakness apparent
only with cover test
• Exotropia: outward
turning
• Esotropia: inward
turning
• Exophoria: outward
drift
• Esophoria: inward
drift
Globe
• Cornea
– Clear, smooth
– Arcus senilis
– Corneal reflex
• CN V
• CN VII
• Sclera
Trigeminal
Facial
Globe
• Pupil
– Size (3-5 mm)
• Anisocoria: unequal pupils
– Light reflex
– Convergence
– Accommodation
• Iris
• Lens
Testing Peripheral Vision
• 60o Nasal
• 90o Temporal
• 60o Superior
• 70o Inferior
With Any Eye Pain:
• Numb eye with Tetracaine
• Use fluorescein paper (wet with sterile
saline or water)
• Use Wood’s light to check for abrasions,
foreign body
The “Red Eye”
Differential Diagnosis
Conjunctivitis
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If blurring: intermittent, clears on blinking
Discharge: usually, crusting of lashes
Pain: none or minor and superficial
Pupils: Normal size and response
Conjunctival Injection: Diffuse
IOP: Normal (don’t measure if discharge)
Cornea: Clear
Iritis
• Vision: slightly blurred
• No discharge
• Pain: Moderately severe, aching,
photophobia
• Pupil: constricted, minimal response
• Conjunctival injection: Circumcorneal
• IOP: Normal to low
• Cornea: clear or slightly hazy
Keratitis (Corneal inflammation
or foreign body)
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Vision: slightly blurred
Discharge: none to mild
Pain: sharp, severe foreign body sensation
Pupil: normal or constricted, normal
response
• Conjunctival injection: circumcorneal
• IOP: Normal (Caution: do not measure)
• Cornea: Opacification present; altered light reflex; (+)
fluorescein staining
Acute Glaucoma (REFER)
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Vision: marked blurring
Discharge: none
Pain: very severe, frequently N & V
Pupil: dilated, minimal or no reaction
Conjunctival injection: diffuse with
prominent circumcorneal injection
• IOP: elevated
• Cornea: hazy; altered light reflex
• Anterior chamber depth: shallow
Fundoscopic Exam
When to do Fundoscopic Exam
• Suspected neuro problems
– headache
– dizziness
• Diabetes
• Hypertension
• Toxoplasmosis
Optic Disk
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Size: 1.5 mm
Shape: round--> slightly oval
Color: salmon pink, yellowish-white
Margins: distinct, fuzzy nasally
Disc-cup ratio: Physiologic cup/Optic disk
should be < .5
• Normal variations
Retinal Vessels
• Number: Branches to all four quadrants
• Color: arteries brighter than veins (veins
slightly darker and larger than arteries)
• A-V ratio (diameters): A/V > 1/2 (1/2 or less
may mean diabetes)
• A-V Crossing: should cross with no
disruption of blood flow (if flow impaired =
A-V nicking)
Macula (central vision)
• Location: 2 disc diameters temporally from
disc
• Fovea = center of macula
• NOTE: Uncomfortable for patients to have
light shined on macula; aim for disc
instead
• Abnormalities
General Background of Fundus
• Color: bright orange/red; consistent OU
• Abnormalities:
– microaneurysms
– hemorrhage
– hard exudate: creamy or yellowish, well-
defined borders
– cotton wood spots (soft exudate): white/gray
ovoid lesions with irregular borders
Ears
History: Ears
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Any hearing differences in one/both ears?
Ear pain?
Trouble with earwax? What is done?
Ear injury? Ear surgery?
Ringing or cracking in your ears?
Foreign body in ear?
Frequent ear infections? Drainage?
Problems with balance, dizziness, vertigo?
History: Ears
• Rx or OTC meds or home remedies for the
ears or any other conditions?
• Family: anyone with hearing problems?
• Occupational history
Ear History: Peds
• Infant: respond to loud or unusual noises?
• If > 6 months, does infant babble?
• If > 15 months, does toddle rely on gestures
and make no attempt at sound?
• Child tugging at either ear?
• Any coordination problems?
• Hx: meningitis, recurrent OM, mumps,
encephalitis?
Ear History: Elderly
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Any recent change in hearing?
Wear a hearing aid?
If so, for how long?
How do you care for it?
Health Promotion Questions
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Last ear exam/hearing test?
Results of test?
Any meds for ears?
Any concerns about ears/hearing?
Do you work around loud equipment or
machinery? (or LOUD MUSIC!)
Ear Assessment: Concepts
• Lightheadedness: detachment
• Vertigo: surroundings swirling around
• Dizziness: disturbance in relationship to
space
Hearing Loss
• Otosclerosis: Bones fuse; ages 40-50 have
some degree of hearing loss
• Conductive hearing loss: sound not getting
to hearing apparatus
• Sensory hearing loss: High pitched sounds
are the first to NOT be heard.
• Mixed hearing loss
External Ear: Inspection
• Pinna (auricle)
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Size and shape
Level on head
Flat or protruding
Tophi or nodules
• External Auditory Canal
– Cerumen, discharge, foreign bodies
– Signs of infection
External Ear: Palpation
• Tophi and nodules
• Assess for tenderness (with ear pain,
discharge or inflammation)
– move auricle
– press on tragus
– press on mastoid
Otoscopic Exam
• Technique
– Pinna up, back and out in adults
– Pinna down and out in children
– Advance slowly; ANCHOR the otoscope
• Observe canal: blood, tumors, wax, foreign
bodies
Otoscopic Exam: Tympanic
membrane (drum)
• Note color and luster
• Oval thin, partially transparent grey
• Gently move speculum to inspect entire ear
drum
• Landmarks
• NOTE: The more scarring on the TM from
healed ruptures, the less mobile it
becomes ---> conductive hearing loss.
Testing Hearing
• Crude Tests
– Watch test
– Whisper test
• Tuning Fork
• Weber test
• Rinne’s test
Types of Hearing Loss
Hearing Loss
Weber Test
Rinne Test
Sensorineural Hear in good
ear
AC>BC
(normal)
Conductive
BC> or = AC
(abnormal)
Hear in
impaired ear
Vestibular Testing
• Romberg’s sign
• Post pointing
• Nystagmus
Nose, Throat, Mouth and Sinus
Nose
• Inspect for deformity, asymmetry, and
inflammation
• Test for patency of each nostril
• Using speculum, note:
– color of nasal mucosa
– spectum, bleeding, perforation, deviation
– turbinates: visible, color, swelling, exudate,
polyps
Mouth and Throat
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Lips, Tongue, Gums and teeth
Buccal mucosa
Palata and uvula
Tonsils and pharyngeal wall
Ducts
Frenulum
Note: sore throat may be due to PND
Sinuses
• Able to assess:
– frontal sinus
– maxillary sinuses
• Others
– ethmoid sinus
– sphenoid sinus
• Palpate for sinus tenderness in adult
• Transillumination