HEENT and lymph

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HEENT and lymph
2014-10-12 23:42:51
head eyes ears nose throat lymph

How to examine HEENT and lymph nodes.
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  1. What are the major fontanels to look for in the examination of the head? until when are they palpable? what about sutures?
    • Anterior fontanel: towards the front of the head, palpable until 9-18 months. 
    • Posterior fontanel: towards the back of the head, palpable until 2 months. 
    • Ossification of sutures take years. 
    • Saggital suture: in the middle connecting the posterior and anterior fontanels. 
    • Coronal suttures: towards the front of the head. 
    • lambdoidal sutture: towards the back of the head. 
  2. What should be noted in the infants health history?
    • Birth 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. 
    • Acute illness: diarrhea, vomiting, fever, stiff neck, irritability. 
    • Congenital abnormalities. 
    • OFC: Occipitofrontal head circumference.
  3. Inspection of the Head and face:
    • Head position: upright and still. 
    • facial features: eyelids, eyebrows, palpebral fissures, nasolabial folds and mouth (shape, symmetry with rest, movement and expression). 
    • Facies: expression/appearance of the face and features of the head and neck.
  4. What are the 7 attributes?
    • Onset, duration, location, character, severity, pattern. 
    • severity and chronologic patter are very important.
  5. What are the 6 muscles of the eye?
    • Superior 
    • Inferior
    • Medial 
    • Lateral rectus. 
    • Superior and inferior oblique. 
    • Assessment: use finger to assess the 6 cardinal fields of gaze. (CN III, IV,VI) 
  6. What are the part of the eyes?
    • Sclera: white of the eye. 
    • Cornea: clear, sensory, refractory (optical) power . 
    • Uvea: Iris (color of the eye), ciliary body(aqueous humor), and choroids (oxygen to the retina). 
    • Lens: transmits images from varied distances. 
    • Retina: Sensory network of the eye (optic disc, retinal artery & veins, macula or fovea (central vision) 
  7. 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.
  8. Visual milestones of infancy: birth? 1 month? 1 1/2 - 2 months? 3 months? and 12 months?
    • birth: blinks, may regard face. 
    • 1 month: fixes on objects. 
    • 11/2-2 months: Coordinated eye movement. 
    • 3 months: eye converge, baby reaches. 
    • 12 months: acuity around 20/50.
  9. common finding in older adults? Common problems?
    • Presbyopia: lower ability to focus on near (reading glasses) 
    • Common problems: Cataract, glaucoma, and macular degeneration. 
    • cataract: lens (fiber) compressed to a central region (loos of clarity of the lens). Clouding, double vision, and loss of peripheral vision. 
    • Glaucoma: Increased pressure in eye. halos, tunnel vision and loss of peripheral vision. 
    • Macular degeneration: Loss of central vision.
  10. What equipment do you need for the eye exam?
    • Snellen chart
    • penlight. 
    • cotton wisp. 
    • Ophthalmoscope. 
    • Opaque card to cover eye.
  11. How to start the exam of the eyes? first step ...
    • external Inspection: eyebrows, eyelids, eyelashes, orbital and periorbital area etc.
    • Lacrimal apparatus.
  12. 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. 
  13. 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. 
  14. What is blepharitis?
    • could be bacterial infection. 
    • Psoriases, etc. 
  15. What is the sclera?
    The white part of the eye.
  16. 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.
  17. what is purulent conjunctivitis?
    • Pink eye, bacterial. 
    • Puss coming out. 
  18. Subconjunctival hemorrhage:
    • Frequent in Lasik surgery, it could also be some type of abuse ... 
  19. 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): blink.
  20. 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. 
  21. 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.
  22. 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.
    • Near vision: tests 14 inches, especially used for over 45.
  23. How the eye's external exams?
    • Accommodate: 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. 
    • Cover-uncover: it tests muscle control, amount of eye deviation. 
    • Convergence: Eye move in as object moves closer to maintain binocular vision.
  24. what are the different dx of light reflex?
    • Esotropia: the light reflects to the side in one of the eyes. 
    • Hypertropia: the light reflects down in one of the eyes. 
    • Pseudoesotropia: The eyes are not straight but they look straight under the light.
  25. 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. 
    • Fundus: background no exudates or hemorrhages, color red to purplish. 
    • Macula: located 2.5 disc distance temporal to disc, no vessels are noted around Macula, it may be slightly pigmented. 
  26. what is AV nicking?
    • Causes the veins to collapse. 
    • Not a normal finding. 
    • Usually found in HTN. 
  27. 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. 

  28. What is Cotton wool spots?
    • Usually caused by HTN and DM. 
    • Yellow spots are the cotton wood spots. 
  29. What is papilledema?
    • Not a nice round disk. We see this with cranial pressure, head injury maybe ... 
  30. 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.
  31. 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) 
  32. what are Cataract?
    • Loss of visual acuity. 
    • Clouding of the lens. 
    • The lenses could be replaced. 
  33. What are the most important parts of the external ear?
    • Auricle (pinna) 
    • External auditory canal. 
    • Cartilage covered skin. 
  34. What are important parts in the middle ear?
    • Ossicles.
    • 3 small bones (malleus, incus, stapes) 
    • Tympanic membrane (translucent) 
    • Oblique position to the canal & conical shape account for the triangle light reflex.
  35. Infants and children ears, how is the canal different? Eustachian tube? 
    Are the sinus present? 
    When do teeth erupt? permanent teeth?
    • Ear canal: 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). 
    • Eustachian tube: it is wider, shorter, horizontal. 
    • Sinus: Sinus are present but small, totally developed by adolescence. 
    • Teeth: Teeth eruption 6 and 24 months of age. 
    • Permanent teeth 6 yrs of age, completed by 14 yrs.
  36. What are the main differences with pregnant women?
    • Strogen: 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.
  37. HX: important things to ask abt ear, nose, and mouth?
    • Vertigo: a false sense of motion- falling in adults. 
    • ear pain: methods of cleaning (no Qtips) 
    • Hearing loss: speech, do they ask for things to be repeated? 
    • Nasal disrcharge: seasonal, tenderness over face? 
    • Snoring: daytime sleepiness could mean apnea. 
    • Nosebleeds: epistaxis. 
    • Sinus pain. 
    • Dental problems: gums, malocclusion, mouth lesions. 
    • Sore throat, hoarseness, difficulty swallowing.
  38. How to do an otoscopic examination? Adult? infant? What landmarks to look for?
    • Adult: Pull the pinna upward and back. 
    • Infant: Pull pinna down and out. Examine the meatus and the walls (redness, swelling, tenderness) 
    • Landmarks: Tympanic membrane, cone of light, pars tens a (bottom) pars flaccid (top), slightly conical and concave. 

  39. What are the hearing evaluation tests?
    • whisper test: mask 1 ear, be 2-3 feet away and whisper "1,2,3". Whisper in high frequency. 
    • Weber test: Test of lateralization. 
    • Rinne test: Compares air conduction to bone conduction. Conductive losses.
  40. 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 DEFECTIVE ear.
  41. 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.
  42. 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: allergies 
    • Read and swollen: infection, URI. 
    • Pink and moist: Normal
  43. what should be check in the mouth?
    • Number of teeth. Wisdom tooth is #1. Should be 32 teeth. 
    • Mucus membrane. 
    • Gingiva. 
    • gums. 
    • count caries and missing teeth.
    • tongue.
  44. what should be assess in the Oropharynx?
    • Palatine tonsiles (note the size- +1,2,3,4) 
    • Pharynx (pink color) 
    • Uvula (position) 
    • Soft palate (color) 
    • gag reflex (CN IX and X)
  45. how to examine for lymph nodes? what findings should be concerning?
    • Inspect head, neck, axillae, arm, and groin. 
    • Concerns: > 1cm, hard-fixed- nontender nodule.
  46. what are the lymph nodes in the head?