HEENT NUR631 Spring 2023 (student copy).pptx

+ HEENT NUR 631 + Techniques of Examination The Hair: quantity, distribution, texture, pattern of loss Scalp: Part the hair in several places, look for scales, limps, nevi Skull: Size, deformities, depressions, lumps, tenderness Face: Facial expressions observe...

+ HEENT NUR 631 + Techniques of Examination The Hair: quantity, distribution, texture, pattern of loss Scalp: Part the hair in several places, look for scales, limps, nevi Skull: Size, deformities, depressions, lumps, tenderness Face: Facial expressions observe for asymmetry, involuntary movements, edema, masses Skin: Observe color, pigmentation, texture, thickness, hair distribution, lesions + Head Hair Eyes Nose Lips Mouth Ears + Anatomy: Head + Trauma/Head Size Atraumatic Normocephalic/ micro/macro Symmetrical + Headache Headache warning signs RED FLAGS on HPI/Physical Exam Progressively frequent over 3 month period Sudden onset “thunderclap” or “worst headache of my life” New onset after age of 50 Aggravated by change in position Precipitated by valsalva maneuver Associated symptoms (fever, diaphoresis, weight loss) Presence of cancer, HIV, pregnancy (immunosuppression) Recent head trauma Associated papilledema, neck stiffness, focal neurological deficits + The Eye + + Vision – how it occurs Images reflected in reverse from right to left and upside down. Light stimulates nerve impulses which are conducted through the retina to the optic nerve (II) and ending at the visual cortex (part of occipital lobe) Visual fields – the area of vision that can be visualized when the eye is not moving + Foreign Body Sensation + Review of Systems: HEENT Subjective information the patient tells you/YOU AS PROVIDER ASK regarding their HEENT complaints…  Erythema (Redness)  Swelling  Foreign Body sensation  How long/time frame?  Vision loss/cut?  Photophobia?  Floaters  Glasses/contact wearers  Tearing  Associated symptoms + Physical Exam Snellen chart Rosenbaum handheld vision screen Penlight Ophthalmoscope Color vision plates (primary care mainly) Visual acuity (patient 20ft from chart) – cover one eye, read smallest line possible ex. 20/200 first number indicated the distance the patient is from the chart, and the second, the distance the normal eye can read the line of letters Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision can read at 200 feet…the larger the second number the worse the vision Visual fields Inspection and palpation – Extraocular movements, corneal light reflex, consensual and direct responses Note deviation from straight ward gaze (muscle laxity) Fundoscopic exam + Conjunctival Exam + Fundoscopic Exam  Red Reflex  Disc to Cup ratio 2:1  Normal Exam = No A/V nicking or narrowing + + Why is the disc to cup ratio important to mention? + What does AV nicking or narrowing mean? This is when the retinal artery is seen crossing the retinal vein which results in the compression of the vein with bulging on either side of the crossing. Most common in hypertension patients (Hypertensive retinopathy). High risk microaneurysms, cotton-wool spots, retinal hemorrhages, hard exudates, and stroke if not treated. + Light Reaction Direct and Consensual Response + Extra-ocular Movement (EOM) + Eye convergence + Visual fields by Confrontation Wiggle Finger Test EOM + Special Considerations Elderly – tearing is diminished, decreased corneal sensitivity, color perception becomes altered Pediatric – high flow oxygen at birth can cause retinopathy (ROP). Lazy eye (weak muscle, strabismus) can occur early on must be identified (cover uncover test), lacrimal ducts don’t function properly until several months old) + The Ear + Anatomy review Three components (external ear, middle ear, inner ear) External ear- auricle, helix, tragus, opening to ear canal Middle ear – ossicles, eustachian tube Inner Ear – Cochlea, semicircular canals, distal end of CNVIII auditory nerve + Review of Systems-Ear Drainage Erythema Foreign body Tinnitus Pain Associated systems PMHx of ear procedures (tubes) + Ear Physical Exam Penlight Otoscope – Right sized specula – done before hearing tests Pneumatic otoscope Tuning fork – Weber, Rinne Tests Whisper Test Inspect-palpate, otoscopic exam (Tympanic membrane visualization, cerumen, cone of light) Adults (up and back ) + Internal Ear Exam + Air conduction v. Bone conduction Air conduction describes the normal first phase in the hearing pathway. In alternate pathway is known as bone conduction, which bypasses the external and middle ear and is used for testing purposes Normal = AC>BC + Hearing Loss Third to only arthritis and HTN as chronic health problem for Americans 2 types: conductive (poor transmission of sound waves through outer and middle ear) or sensorineural (disease of cochlea or poor conduction sound- generated impulses along CN VIII to the brain stem) WHAT QUESTIONS DO YOU WANT TO ASK FOR THIS COMPLAINT? + Tinnitus Onset Location Frequency of occurrence Quality Pitch Intensity Severity Precipitating factors Aggravating or alleviating factors Associated symptoms + Otorrhea Can be acute or chronic etiology Often associated with TM perforation Questions to ask? + Vertigo Dizziness second to LBP as a medical complaint (about 40% of all adults seek medical care) Vertigo is a sense of spinning or turning May occur when the head and body are not moving, or with sudden position change of the head Let’s go over the questions again and why we ask them… + Special Ear Considerations Neonatal problems stem from in utero issues (smoking, viral exposure, maternal DM and others) Pediatric patient – OM accounts for 42% abx use in kids Game during exam (Kids) Frightened – play with equipment, sit on lap, invasive tests last Elderly – presbycusis common cause of hearing loss Vertigo and tinnitus incidence increases with age Cerumen impaction also common reason for hearing loss + Nose, Sinus + Anatomy Review Air enters the nasal cavity by way of the anterior naris bilaterally, then passes into a widened area known as the vestibule, then onto the nasopharynx. Nasal septum Nasal turbinates- covered by highly vascular membranes + Nasal Discharge (rhinorrhea)/ Congestion Duration, pattern, onset Quality and severity Associated symptoms Precipitating factors Alleviating factors Other medications taken + Bleeding, Decreased sense of smell, Sinus pain and pressure Onset Location Amount Duration, frequency Precipitating factors Alleviating factors Medications taken + Health History CC: “I cannot breathe, I’ve been congested for the past 3 days.” CR is a 45-yr old female. Ms. R says that she has experienced congestion, watery eyes, and fatigue for the past 3 days. Nasal Discharge has been clear. Ms. R states that she experiences these symptoms every spring. Ms. R has a history of seasonal allergies. She denies any history of asthma or eczema. She denies any nasal trauma and/or surgeries. She denies any recent colds or flu-like illnesses. She reports that she sees a dentist regularly and her teeth are in good condition. Family HX: Ms. R’s parents are alive and well. She has a 42 yr-old sister. Ms. R. denies a family history of asthma, cancer, or eczema. Her parents and sister suffer from seasonal (spring and fall) allergies Social Hx: Ms. R. denies any use of cigarettes or second-hand smoke exposure. She lives alone, in an air-conditioned new home. Ms. R has a pet dog. She denies any air travel. She is a computer programmer and enjoys reading and cooking in her spare time. Her alcohol intake is infrequent, and she denies using any recreational drugs. + Review of Systems How do you review body systems (focused versus complete) Which would be your focused ROS here? WHAT ARE YOUR CLUES IN THIS CASE? Physical Exam NAD, slightly overweight Skin light tan, warm to touch HEENT: normocephalic. External ear, canal, and TM normal. Eyes with bilateral conjunctival injection, no exudates, and mild bilateral shiners. Nose with bilateral boggy turbinates. Scant clear nasal discharge. Frontal and maxillary sinuses non-tender with pressure. Transillumination is normal. Mouth and throat normal, no adenopathy What are your diagnoses? + Techniques of Examination: Nose Inspection (pressure) Note asymmetry Test for nasal Obstruction Inspect inside of noes (light source) + Physical Exam Penlight or other light source Otoscope Nasal speculum or largest ear speculum available Gloves (Observe)Inspect/palpate/percuss + Special Considerations Pregnant – hormone changes may cause increased congestion, also increased circulatory volume, increased vascularity due to hormone changes can contribute to nosebleeds (epistaxis) Pediatrics – always assess for FOREIGN BODY. Palpating sinuses before age 6 (and then only frontal) useless because sinuses not fully developed yet. Geriatric – may have decreased hydration and ability to maintain tissue integrity, increasing fragility of the mucosa. ANTICOAGULANT THERAPY + Neck + Lymphnodes Preauricular/Posterior Auricular Occipital Tonsillar Submandibular Submental Superficial/Deep Cervical chain Supraclavicular Epitrochlear + Mouth and Throat + Mouth/throat complaints Dysphagia Halitosis Toothache Bleeding Gums Mouth Ulcerations Provoke Throat pain Quality Tongue pain Hoarseness Radiation Dental pain Severity Throat/mouth swelling Time/Triggering factors Neck pain + Anatomy Review Lips Gingiva Tongue Teeth (32 adult) Pharynx Uvula Hard/soft palate Tonsils + Mouth/Throat Case… CC: sore throat x 2 days HL, a 29 yr-old Caucasian male, states that he has had a sore throat for 2 days. He has not noticed being feverish. Mr. L reports that he has experienced a mild runny nose. He has an occasional cough but denies any sputum with the cough. He denies any earache and/or eye irritation. He has a son in day care who is being treated for strep pharyngitis. Mr. L is taking acetaminophen with some relief. Mr. L had a tonsillectomy as a preschool child. He reports experiencing one to two URI each year. He denies any chronic illnesses, such as diabetes. Mr. L. has no known allergies. He has regular dental care. He denies any recent mouth trauma. Why are : past health conditions important? Dental history? Traumas or injuries to the mouth and throat? Eating disorders? Mr. L’s family history is positive for seasonal allergies and negative for eczema and asthma. His mother is alive with mild HTN and diabetes that is controlled by diet and oral medications. His father died of a stroke at age 67. Mr. L has 2 older brothers, both of whom are in good health.  Mr. L is divorced. He has a 4 yr-old son who is in a day care program and visits on the weekend. Mr. L smokes one pack of cigarettes per day. He denies any drug use or oral sexual activity. He works in an investment firm. He lives in a modern townhouse. WHY DO THESE THINGS MATTER? + Physical Exam (Mr. L) Wt 210#, T 98.6, BP 142/89, Ht 6’, HR 76, RR 12 General – NAD Skin warm, dry, no rashes HEENT – normocephalic. External ear, canal, and TM’s normal. Eyes with bilateral mild conjunctival injection, no exudate. Normal nasal turbinates. Scant clear discharge noted. Frontal and maxillary sinuses nontender with pressure. Mouth normal. Posterior pharynx mild erythema, cervical lymphadenopathy BL, White patches on BL tonsils, Tonsils BL 3+, Uvula midline What are your differentials? + Review of Systems How do you review body systems (focused versus complete) Which would be your focused ROS here? WHAT ARE YOUR CLUES IN THIS CASE? + Techniques of Exam: mouth The lips: Observe color, moisture, look for lumps, ulcers, cracks, scaliness Oral Mucosa: look into patient’s mouth, have a good light source and with the help of the tongue blade inspecting the mucosa for color, ulcers, white patches, nodules Teeth & Gums: note the color of the guns, normally pink. Inspect the tees, are they missing, discolored, fractured Roof of Mouth: inspect the color and architecture of the part pallet. Inspect symmetry and test the hypoglossal nerve (CN XII) + Physical Exam –Mouth/Throat Gloves Light source (otoscope or pen light) Tongue depressor Gauze Inspect/palpate + Thyroid Exam Inspect the trachea for any deviation from its you will midline. Inspect the neck for the thyroid gland Observe the patient swallowing Palpate the Thyroid gland, using landmarks, this is done from standing behind the patient + Special Considerations Pregnant pts at risk for caries r/t increased nutritional demands of pregnancy Pediatrics/neonatal – white patches with thrush common Inspect for cleft lip/palate Epstein pearls (cysts) – not significant on palate, also can have cysts on gums too Monitor teeth eruption Geriatrics – problems involve loss of teeth, periodontal disease, dentures, change in tastes, dry mouth due to decreased salivary production, leading to potential nutritional compromise + Health Promotion and Counseling USPTF visual and hearing screening early detection are standard components of older adult health care Refer patients with vision impairment >20/50 Screening for glaucoma. This is leading cause of blindness in AA, and 2nd leading cause of blindness overall (2.5 million Americans). USPTF recommends screening adults > 50yo (whisper test, tuning fork with exam) Inspect oral cavity with every annual exam; recommend toothpaste with fluoride USPTF shows that ½ of children 5-17yo have 1-8 cavities & avg US adult has 10-17 decayed teeth Counsel on Diet, tobacco, and ETOH use Health Promotion and Counseling Refer to health screening and promotion in Bates assigned readings!!