HEENT and lymph
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HEENT and lymph
head eyes ears nose throat lymph
How to examine HEENT and lymph nodes.
What are the major fontanels to look for in the examination of the head? until when are they palpable? what about sutures?
: towards the front of the head, palpable until 9-18 months.
: towards the back of the head, palpable until 2 months.
Ossification of sutures take years.
: in the middle connecting the posterior and anterior fontanels.
: towards the front of the head.
: towards the back of the head.
What should be noted in the infants health history?
: vaginal or cesarean, presentation, difficulty of delivery, use of forceps.
Unusual head shape
: bulging or flattening, head heal at angle.
Quality of head control.
: diarrhea, vomiting, fever, stiff neck, irritability.
: Occipitofrontal head circumference.
Inspection of the Head and face:
: upright and still.
: eyelids, eyebrows, palpebral fissures, nasolabial folds and mouth (shape, symmetry with rest, movement and expression).
: expression/appearance of the face and features of the head and neck.
What are the 7 attributes?
Onset, duration, location, character, severity, pattern.
severity and chronologic patter are very important.
What are the 6 muscles of the eye?
Superior and inferior oblique.
: use finger to assess the 6 cardinal fields of gaze. (CN III, IV,VI)
What are the part of the eyes?
: white of the eye.
: clear, sensory, refractory (optical) power .
: Iris (color of the eye), ciliary body(aqueous humor), and choroids (oxygen to the retina).
: transmits images from varied distances.
: Sensory network of the eye (optic disc, retinal artery & veins, macula or fovea (central vision)
Characteristics of infants and children's eyes: development? Peripheral vision? Lacrimal ducts? Binocular vision? distinguish color? 20/20 vision?
eyes develop 8 weeks of gestation.
peripheral vision is fully developed at birth, central vision matures later.
2-3 weeks lacrimal duct produces full tear.
3-4 months binocular vision is complete.
6 months the infant can distinguish colors.
globe of the eye grows as the head and brain grow
: 20/20 vision 6-8 yrs of age.
Visual milestones of infancy: birth? 1 month? 1 1/2 - 2 months? 3 months? and 12 months?
: blinks, may regard face.
: fixes on objects.
: Coordinated eye movement.
: eye converge, baby reaches.
: acuity around 20/50.
common finding in older adults? Common problems?
: lower ability to focus on near (reading glasses)
: Cataract, glaucoma, and macular degeneration.
: lens (fiber) compressed to a central region (loos of clarity of the lens). Clouding, double vision, and loss of peripheral vision.
: Increased pressure in eye. halos, tunnel vision and loss of peripheral vision.
: Loss of central vision.
What equipment do you need for the eye exam?
Opaque card to cover eye.
How to start the exam of the eyes? first step ...
eyebrows, eyelids, eyelashes, orbital and periorbital area etc.
what is xanthelasma?
Slightly raised, yellowish, well-circumscribed plaques that appear along the nasal portions of one or both eyelids.
Specially if they have high lipid levels, high cholesterol.
What is Ptosis?
It is the dropping of the upper lid.
Could be a muscle issue. Also with age, the eye leads start to fall. could be a paralysis or cranial nerve.
What is blepharitis?
could be bacterial infection.
What is the sclera?
The white part of the eye.
What is the conjunctiva?
It is the clear membrane that cover the eye and some part of the inner eyelids.
Pull the eyelid down as the pt looks upwards.
Note the translucency and vascular pattern of both the sclera and palpebral conjuctivae and the color of the sclera.
what is purulent conjunctivitis?
Pink eye, bacterial.
Puss coming out.
Frequent in Lasik surgery, it could also be some type of abuse ...
What should be examined abt the cornea?
The corneal light reflex
: with the penlight, light is reflected off the cornea (red reflex)
wisp of cotton (CN V)
what is Pterygium?
A triangular thickening of the bulbar conductive grows slowly across the outer surface of the cornea, usually from the nasal side.
Triangular thicken of the conjunctiva.
what is Arcus senilis?
tends to get acutter with age.
Maybe related with a lipid disorder (high chol)
Focusing in the gray around the eye.
How to perform the acuity testing? distance? what CN?Near vision?
20 ft from the Snellen chart, test each eye.
Tests CN II (optic nerve) - central vision.
Starts on children 3 yrs of age.
visual maturity 20/20 it is reached around 9-10 yrs.
: tests 14 inches, especially used for over 45.
How the eye's external exams?
: Pupil dilate when looking at a distance and constricts when looking at closer objects.
Corneal light reflex
: the light should reflect equally in both eyes.
: it tests muscle control, amount of eye deviation.
: Eye move in as object moves closer to maintain binocular vision.
what are the different dx of light reflex?
: the light reflects to the side in one of the eyes.
: the light reflects down in one of the eyes.
: The eyes are not straight but they look straight under the light.
what is a normal exam findings in the eye?
Disc margins are sharp
: Color, yellowish to creamy pink, shape, round or oval, cup to disc ratio, Less than half.
Vessels AV ratio
: AV crossing (no identation), No arterial light reflex.
: background no exudates or hemorrhages, color red to purplish.
: located 2.5 disc distance temporal to disc, no vessels are noted around Macula, it may be slightly pigmented.
what is AV nicking?
Causes the veins to collapse.
Not a normal finding.
Usually found in HTN.
what is Diabetic retinopathy?
Pt looses spots of their vision.
The color is not nice and smooth. There are come patches here and there.
Droosing bodies under the macula.
What is Cotton wool spots?
Usually caused by HTN and DM.
Yellow spots are the cotton wood spots.
What is papilledema?
Not a nice round disk. We see this with cranial pressure, head injury maybe ...
What happens when there is Macula degeneration?
the Central and fine vision get affected.
Vision loss in center of vision.
Affects center of retina - Macula.
Macula is for fine central vision.
This is age related.
What is glaucoma?
It is an increased fluid pressure in the eye.
Can lead to permanent damage of the optic nerve.
Leading cause of blindness.
Increase in cut to disc ratio (normal is less than 0.5)
what are Cataract?
Loss of visual acuity.
Clouding of the lens.
The lenses could be replaced.
What are the most important parts of the external ear?
External auditory canal.
Cartilage covered skin.
What are important parts in the middle ear?
3 small bones (malleus, incus, stapes)
Tympanic membrane (translucent)
Oblique position to the canal & conical shape account for the triangle light reflex.
Infants and children ears, how is the canal different? Eustachian tube?
Are the sinus present?
When do teeth erupt? permanent teeth?
: External auditory canal is shorter, upward curve. Therefore the odoscope is inserted differently, Puna down (young children) PUB: puna up and back (oder than 3).
: it is wider, shorter, horizontal.
: Sinus are present but small, totally developed by adolescence.
: Teeth eruption 6 and 24 months of age.
Permanent teeth 6 yrs of age, completed by 14 yrs.
What are the main differences with pregnant women?
: the level are elevated causing increase vascularity of upper respiratory tract.
This causes nasal stuffiness, decreased sense of smell, epistaxis, fullness in the ear, impaired hearing.
HX: important things to ask abt ear, nose, and mouth?
: a false sense of motion- falling in adults.
: methods of cleaning (no Qtips)
: speech, do they ask for things to be repeated?
: seasonal, tenderness over face?
: daytime sleepiness could mean apnea.
: gums, malocclusion, mouth lesions.
Sore throat, hoarseness, difficulty swallowing.
How to do an otoscopic examination? Adult? infant? What landmarks to look for?
Pull the pinna upward and back.
Pull pinna down and out. Examine the meatus and the walls (redness, swelling, tenderness)
Tympanic membrane, cone of light, pars tens a (bottom) pars flaccid (top), slightly conical and concave.
What are the hearing evaluation tests?
: mask 1 ear, be 2-3 feet away and whisper "1,2,3". Whisper in high frequency.
: Test of lateralization.
: Compares air conduction to bone conduction. Conductive losses.
What is the weber test?
It is a test for lateralization.
warp the running fork strongly and then place it on to of the pt's head the midline and ask patient where they hear the sound.
In a conductive loss, sound materializes to the
what is the Rinne test?
Place the butt of the mastoid eminence firmly.
pt needs to tell when they don't hear the vibration.
Then place the U part of the fork near the ear w/o touching it, pt. should tell you when they stop hearing it.
It should be hear by air conduction 2x more that bone conduction.
What to look for when examining the nose? what does blue, red, pink finding mean?
Look inside the nose and need to be able to see nice turbinates.
Swollen, blue and boggy
Read and swollen
: infection, URI.
Pink and moist
what should be check in the mouth?
Number of teeth. Wisdom tooth is #1. Should be 32 teeth.
count caries and missing teeth.
what should be assess in the Oropharynx?
Palatine tonsiles (note the size- +1,2,3,4)
Pharynx (pink color)
Soft palate (color)
gag reflex (CN IX and X)
how to examine for lymph nodes? what findings should be concerning?
Inspect head, neck, axillae, arm, and groin.
: > 1cm, hard-fixed- nontender nodule.
what are the lymph nodes in the head?