Download small group session 8 - University of Virginia

SMALL GROUP SESSION 8
October 14th or October 16th
Head, Ears, Eyes, Nose and Throat (HEENT) and Ophthalmoscopy
workshop
Suggested Readings:

“The Eye Exam” at: http://medicine.ucsd.edu/clinicalmed/eyes.htm
Watch: The “Ophthalmoscopic Exam” video at:
http://www.med-ed.virginia.edu/courses/pom1/PhysicalExamLinkPage.cfm
Prepare by:
Charging your scope handle.
Bring:
Charged scope handle
Brief Outline:
Section 1: Touch base (15 minutes)
Section 2: Case discussion (30 minutes)
Section 3: Ophthalmoscopy examination (70 minutes)
Section 4: HEENT examination (60 minutes)
Section 5: Evaluation (5 minutes)
Mentors: Please hand out the ‘substance abuse’ role plays for next week
©University of Virginia 2008
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Objectives for Session 8
By the end of this session, students will be able to:
 Develop an approach to analyzing a clinical case of head and neck cancer
 Apply knowledge of head and neck anatomy to the clinical discussion
 Practice the technique of ophthalmoscopy examination :
 Use the different lenses of your ophthalmoscope
 Focus on the anterior structures of the eye
 Look for the fundus and optic disc
 Describe use and properties of the short and long focal length
lenses
 Use the short focal length lenses to look at the anterior chamber of
the eye
 Position yourself correctly to see the retina and optic disc
 Demonstrate the components of the HEENT examination
Section 1: Touch base: (15 minutes)
How is the workload in medical school? Do you think you are coping?
How are the large group sessions? Today’s session will be busy, keeping track of
the allotted times for the different sections will be very important.
Section 2: Clinical case - A patient with trouble swallowing.
(30 minutes)
Logistics:
1. One student should read the medical history and physical examination
Stop and discuss. Then read the laboratory findings. Continue discussion.
2. One student– the scribe – will take notes on the board. Findings or
questions should be written in the following columns:





History
Physical findings
Anatomy
Diagnostic possibilities
Laboratory and test findings, if any
©University of Virginia 2008
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A PATIENT WITH TROUBLE SWALLOWING:
Chief complaint: Difficulty swallowing for two and a half months
History of present illness: Ms XY, a 65 year old woman comes to you for
trouble swallowing for two and a half months. She has always had trouble with
heartburn. About three months ago, her heartburn seemed to get worse and she
started having pain with swallowing solid foods. Since then the pain has
worsened and she now has discomfort with eating soft foods, and it is becoming
harder to swallow. The discomfort is located in her upper chest, in the mid-line.
She has become afraid to eat and has lost her appetite, so she has lost 10
pounds in 2 months.
She called you almost two months ago because of these symptoms and received
a prescription for Nexium over the phone. It did not help.
Past medical history: mild high blood pressure on no regular medications.
Chronic heartburn that she has treated with over the counter antacids. No other
prescription or over-the-counter medications.
Social history: She is happily married with one son. She quit smoking ten years
ago. She has 1 or 2 drinks a day before dinner, but has never had a drinking
problem. CAGE questions have been negative.
Family history: Her father (a smoker) died of lung cancer, and her mother died
of stomach cancer.
Physical examination:
On examination, your patient appears chronically ill. HEENT exam is normal,
except for bilateral supraclavicular adenopathy. Cardiac and chest examination
are normal. Abdominal exam is normal.
1. What are the important history and physical findings? What could they mean?
2. What are some diagnostic possibilities?
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Lab findings:
You order an esophagoduodenostomy (EGD) and a CAT scan of the abdomen
and chest. The EGD shows a large, circumferential ulcerated mass in the midesophagus. Biopsy shows squamous cell carcinoma. CAT scan shows extension
of the tumor through the wall of the esophagus into mediastinal structures,
mediastinal lymphadenopathy, and celiac (retrogastric) lymphadenopathy. This is
consistent with a diagnosis of squamous cell cancer of the esophagus.
©University of Virginia 2008
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Section 3: Ophthalmoscopy workshop: (70 minutes)
EXERCISE 1: Using the Ophthalmoscope Lenses (15 minutes)
The ophthalmoscope has two colors of lenses: the green or black lenses (used to
look at anterior chamber structures - those in front of the lens) and the red lenses
(used to look at the retina, which is behind the lens). Get to know it first.
1. The skin exercise: use of short focal length lenses (15 minutes)
The green or black- numbered lenses look at things up close – at 1 to 5 inches or
so from your eye. They are usually numbered up to 40; the closer up you look,
the higher the number.
Hold your hand 3 inches from the scope and look with a green lens at your hand.
Find the number that gives you the sharpest image. Then, move your hand 1 ½
inches from the scope and dial the lens to focus again. What number lens is best
now?
2. The wall exercise: use of long focal length lenses (15 minutes)
The red lenses require an intact patient lens to focus on the retina. The correct
number for you is a function of your own lens’s refractive power - and the
patient’s.
This exercise lets you find the correct number for each of your eyes. The lens of
this number is the one you will use first to look for a patient’s retina. In patients
with refractive errors, you may need to move one or a few lenses away from this
to focus best - but always start with your unique number, which you can find with
this exercise.
Look at a distant object on the wall and dial the lens that gives you the sharpest
number. Make a mental note of this number. Now, do the same with your other
eye. This is your unique number for viewing the retina.
EXERCISE 2: POSITIONING FOR EYE EXAMINATION (5 minutes)
In the ideal position, the examiner is 1 ½ to 2 inches from the patient’s cornea.
To do this, and to stabilize your relationship to the patient, you will need to hold
the scope in the same hand as the eye you are examining and to “find” the
patient with your other hand.
So: to look in the patient’s right eye, hold the scope in your right hand and look
through it with your right eye. Put your left hand on the patient’s head with your
thumb just above the eyebrow. For the left eye, reverse everything.
Get as close to your patient as you can without bumping into his or her eyelashes
or eyebrows. The closer you are to the patient, the wider your visual field.
©University of Virginia 2008
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EXERCISE 3: LANDING ON THE DISC (40 minutes)
For this exercise, keep the room as dark as you can - only enough light so that
the patient can see something to focus on.
Dial your unique red lens for your dominant eye.
Have the patient look straight ahead at a fixed object behind you. Approach the
eye from 20 to 30 degrees to the side of the patient in the sagittal plane, with the
ophthalmoscope at a low level of light intensity. Move in to the ideal viewing
distance. Make sure your patient can keep looking straight ahead.
The disc is a light-colored circular area with blood vessels converging into it. Try
to see it. If you find a blood vessel, try to follow it to the disc. If you are in the
correct position, the disc should be nearby.
Section 4: HEENT examination workshop (60 minutes)
Logistics:
Mentors demonstrate HEENT exam. Group can decide if they want to do one at
a time, or demonstrate both in sequence.
Practice today the techniques on the HNE and ENT OSCE sheets (available in
your packet and on the POM-1 website). While you are there, look for some
landmarks. Your examination may include:




Inspection of head and scalp for symmetry, facial weakness
deformities, scars, hair distribution, etc.
Inspection of ears
o Pinnae and external auditory canals
o Otoscope technique
o Viewing the tympanic membrane
o Tests of hearing (finger rub or whisper, Weber and Rinne)
Inspection of nose: patency and turbinates
Inspection of mouth and throat:
o Mucosal color and moistness
o Normal variants
o Teeth and gums
o Tongue
o Salivary duct openings
o Uvula
o Soft and hard palate
o Tonsils
©University of Virginia 2008
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
Palpation: for
o Sinus tenderness
o Temporal arteries
o Parotid and submandibular salivary glands
Examination of the neck:
 Inspection: for symmetry, masses
 Palpation: of
o Trachea
o Cricoid cartilage
o Hyoid bone
o Carotid pulses
o Thyroid gland
 Lymph node palpation:
o Preauricular
o Postauricular
o Tonsillar
o Submandibular
o Submental
o Anterior cervical
o Occipital
o Posterior cervical
o Supraclavicular
Section 4: Evaluate session (5 minutes)
How did this session go? What could make it work better in the future?
©University of Virginia 2008
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HAND OUTS FOR SESSION 9
SUBSTANCE ABUSE ROLE PLAYS
©University of Virginia 2008
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ROLE PLAY PATIENT #1- SESSION 9
You are a 20-year-old computer salesperson who is seeking medical help for
“palpitations.” You describe them as episodic fluttering in your chest or a sense
of your heart beating quickly. At times your chest may feel a bit tight with these
episodes. You have had them on and off for about two months, most often when
you are worried. They have not changed in the past several weeks, but you are
worried about them because they are not going away. You have not had
shortness of breath, lightheadedness, nausea or sweating. The chest tightness
feels like a band around your chest, and is mild in severity.
Past history is remarkable only for good health. You have had no serious
illnesses, no surgeries and no accidents.
You take no medications, nor do you use any herbal medications.
You are allergic to penicillin (you get a rash).
You have never smoked; you drink no more than 2 beers per weekend. CAGE
questions are negative; you have not had more than 3 drinks on any one
occasion in past month.
You use cocaine recreationally and at times to increase your energy during your
long work days. You always snort your cocaine. You have never smoked cocaine
or injected it. You use cocaine 3 or 4 days a week. Recently, your sales have
fallen, and you wonder if your supervisor suspects your cocaine use. You are
afraid you may be tested for drugs. You do not currently use other drugs. You
have tried marihuana in the past, but never really enjoyed it. You are spending
$150 to $200 a week on cocaine. While you can currently afford this, it is putting
a strain on your finances. Much of your social life revolves around getting high.
You graduated from high school and take courses at Piedmont community
college in business. You work at BestBuy. Your parents are both alive and well;
your father has high blood pressure and is a recovering alcoholic. You think your
older brother has a drinking problem – he is always drinking, and usually seems
to be a bit drunk. Your younger sister is still in high school.
©University of Virginia 2008
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ROLE PLAY PATIENT #2- SESSION 9
You are a 30-year-old schoolteacher who is seeking medical help for fatigue,
which has seemed to increase for the past five months (during this school year).
Your fatigue is not sleepiness; instead, it is a loss of energy and concentration.
You have trouble bringing yourself to grade papers or prepare next week’s
classes. You go to sleep quickly enough, but awaken at 4AM and can’t get back
to sleep. You are eating more in the evening and have gained eight pounds since
the summer. You have no other symptoms – you have had no fevers, chills, night
sweats, etc.
Your past medical history is remarkable for an appendectomy when you were 13.
You also have irritable bowel syndrome, which is fairly well controlled by taking a
fiber supplement.
You take Tylenol for occasional headaches.
You have taught 7th grade mathematics for eight years. You are not married and
do not have a partner at this time. When you come home in the evening, you
have a gin and tonic to calm down; it makes you feel relaxed and even a bit more
energetic. In the past year, you have needed more alcohol to have the same
effect. You now consume 5 or 6 ounces of gin a night - maybe more, though you
don’t pay too close attention.
You consume alcohol only at night and do not need an eye opener in the
morning. You have tried to cut down, but felt worse and quickly returned to your
current level of use. Your parents have suggested that you should cut down on
your drinking, which annoys you. You do not feel guilty about drinking and do not
consider it a problem.
You do not smoke and have never used illegal drugs.
©University of Virginia 2008
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ROLE PLAY PATIENT #3- SESSION 9
You are a 25 year old who is here for a “general physical and blood tests.” You
report no complaints or medical problems. When asked, you answer that you just
decided it was time to have a physical, after not having one for many years.
Your energy is good and you have no symptoms.
Your past medical history is remarkable only for surgery to repair an ACL torn
during a soccer game in high school. You take no medications, and have no
allergies.
Your principle reason for coming is that you are planning on getting married, but
you were pretty wild when you were younger, and you are worried that your past
could catch up to you.
In your teens, you experimented with a variety of drugs. You tried marijuana,
cocaine and ecstasy. Several times you used intravenous heroin. You were not a
regular user, and in fact shared a regular user’s needle each time. You have not
used any intravenous drugs in six years. You do not drink alcohol. You do smoke
one pack per day for the past nine years, and you still smoke occasional
marijuana.
You have been dating your now fiancée for 3 years. As marriage and children
loom, you have become afraid that you could carry hepatitis or HIV/AIDS, and
that you could pass this on to your partner and children. You are hoping to be
tested for these illnesses, but are afraid to ask outright.
You graduated from college at Christopher Newport University. You currently
work as a manager at Staples.
©University of Virginia 2008
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ROLE PLAY PATIENT #4 (if needed) - SESSION 9
You are a 50-year-old college professor who comes to the doctor for an injured
ankle. You fell at home last night while hurrying to answer the phone. You
missed the last step going downstairs and twisted your ankle. It is swollen and
painful, but you are able to bear weight on it. You didn’t fall, and you didn’t hit
your head.
Past medical history - hypertension and hyperlipidemia. No surgeries
Medications – hydrochlorothiazide, lisinopril and atorvastatin.
Habits – non-smoker; drinks alcohol. No drug use.
Family history – father was an alcoholic, and died from cirrhosis. Mother suffers
from depression. Older brother was killed in Vietnam in 1973.
You are separated from your spouse and nine year old son; you live alone. You
are unclear on why your spouse left you. You admit to “stress” at work and that
your department chairman gives you a hard time, but you can’t say why. Once
you were arrested for driving while intoxicated; you had to take a class, which
you found “poorly taught.”
You can’t quantify how much you drink, but will admit if asked specifically that a
fifth of scotch won’t last you a weekend. You drink every night, and you often
have an eye opener or two in the morning. Your spouse criticized your drinking,
and this annoyed you. You have tried to cut down before, but never lasted a day.
You do not feel guilty about your drinking. You are a bit annoyed when the
interviewer asks about your drinking, as this has “nothing to do with my ankle.”
If asked, you will admit to having several drinks last night before twisting your
ankle.
©University of Virginia 2008
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