Clinical Assessment - Heent (2-2)

Front 1

Common concerns

Back 1

Pain - ear, throat, etc.

Headache

Facial pain, paresis, paralysis

Visual changes

Hearing changes

Vertigo/dizziness

Epitaxis

Pharyngitis

Laryngitis

Lyphadenopathy

Goiter

Lumps/bumps

Pt Concerns

Front 2

Head and neck: inspection

Back 2

Face: Appearance, expression (CNV dysfunction, pain), symmetry and structure of features (CN VII), skin color movements

Head: Size, shape/symmetry, skin condition, hair, scalp, unusual movements

Neck: Symmetry, mobility, range of motion, neck vessels

Front 3

Some things which may be observed

Back 3

1. Xanthelasma

2. Acanthosis nigricans, Skin tags = INSULIN RESISTANCE

Front 4

Cranial Nerve V examination

Back 4

TRIGEMINAL

1. Corneal reflex - cotton wool, blink tests (V = sensory test, VII = blink test)

2. Facial sensation - sterile sharp item on forehead, cheek, jaw VS dull. If abnormal, temp and light touch.

3. Motor: pt opens mouth, clenches teeth (pterygoid) - palpate temporal, masseters

4. Jaw jerk - if INCREASED closure, UMNL

Front 5

CN VII

Back 5

1. Facial droop/asymmetry?

2. Fascial expression: Look up and wrinkle forehead. Shut eyes tightly. Grins. (frown, show teeth, puff cheeks, whistle - optional)

3. Corneal blink (w/CN5 testing)

Front 6

Bell's palsy: signs

Back 6

1. Wrinkling on ONE side with no other abnormalities in other nerves.

2. Wrinkling only on one half = supranuclearlesion .

3. Bell's usually resolves itself

Front 7

Other CN VII defects

Back 7

1. Paresis/paralysis

2. Acromegally??

Front 8

How to palpate head/neck

Back 8

1. Head: Scalp (tenderness, deformities, lesions), hair, temporal artery pulse, TMJ, lymph nodes

2. Neck: anterior midline structures, thyroid gland, carotid artery pulses, lymph nodes, muscle strength, cervical vertebrae

Front 9

Head and neck: auscultation

Back 9

Neck: carotid arteries, thyroid gland for BRUITS (using bell)

Front 10

Neck exam summary

Back 10

1. Inspect: Extension asymmetry, scars, midline position of trachea, lesions, lumps, bumps, size of thyroid. Watch w/sip of water

2. Palpate neck for tenderness, deformity, masses while swallowing water.

3. Assess cranial nerve XI: shoulder resistance to force. Note asymmetry too. Shoulder shrug and turn head with resisting force from PA.

4. Auscultate, palpate each carotid.

Front 11

CN XI defect signs

Back 11

1. Trapezius wasting

2. Weakened shoulder elevation (SCM doesn't work)

3. Usually due to surgery, blunt trauma, traction injury, penetrating injury.

Front 12

Head and neck exam - PAIN

Back 12

Inspect with facial expression, body position

Palpate to elicit pain

See if pain is referred (spreads out from frontal sinus, maxillary sinus, ethnoid sinus, posterior suboccipital region)

Use pain scale

Front 13

TMJ exam (*2 parts) + common causes

Back 13

1. Place fingers DIRECTLY in front of tragus of each ear. Feel for clicking, crepitus, swelling, deviation

2. Place fingers behind tragus, anterior to external canal meatus. Repeat.

3. Arthritis, degenerative process, bruxism/clenching, trauma

Front 14

Lymph node, gland exam

Back 14

1. Palpate with pad of index/middle fingers in small circular motions:

a) Preauricular

b) Postauricular

c) Occipital

d) Tonsillar

e) Submandibular

f) Submental

g) Superficial (anterior) cervical

h) Supraclavicular

I) have pt turn towards side, palpate for deep cervical

Front 15

Lymph node defects (3)

Back 15

1. Tonsilitis

2. Congenital: Branchial cleft cyst. Need to remove - potential to be cancerous

3. Congential: Thyroglossal duct cyst - rises out when pt sticks out tongue. Refer to ENT.

Front 16

Thyroid exam

Back 16

1. Inspect for symmetry, visibility of thyroid

2. Move behind pt, ID cricoid cartilage with both hands

3. Move down 2-3 tracheal rings while palpating isthmus

4. Move laterally, note size and symmetry of lobes, presence of nodules

5. Have pt trip head to left, displace thyroid and trachea, feel right lobe. Repeat on other side.

Front 17

Throid defects to look for

Back 17

1. Goiter (hyperthyroidism)
2. Exopthalmos

Front 18

Anatomy of outer ear

Back 18

Front 19

External ear inspection/palpation

Back 19

Inspect: Position, size, symmetry, discharge, swelling, redness, deformities, postauricular

Palpate: Auricle, Tragus, Mastoid

Front 20

Otoscope examination

Back 20

1. Tip shoulder down, Tilt head

2. Grasp auricle, pull back

3. Angle speculum anteriorly to see TM

4. Hold otoscope STEM UP or angled, brace hand on pt's head

5. Stay on anterior 1/3 - hair line - cartilaginous area!

OPT: Use insuffalator bulb to see if eardrum will move. If it does, that means no fluid (good).

Front 21

Defects of external and internal ear

Back 21

1. Keloids

2. Uric acid deposits (GOUT)

3. Congenital defects

4. Basal cell carcinoma

5. Too much cerumen (If can't see 1/2 TM, clean)

6. Foreign body (ear plug, bug)

7. Collapsing canal

8. Exostosis - bony growth - benign, assoc. w/cold water

9. Candidiasis

10. Aspergillus Niger

11. Lichenification - itching with key - abraded, thick skin

12. Tympanosclerosis (scarring - due to infection, perforation, surgery)

13. Acute otitis media w/effusion (AOME): pink, retracted --> red, bulging, potential for perforation. Most common in pars tensa.

14. Otitis media w. effusion

15. Tympanic membrane perforation

NOTE: Red reflex IS NORMAL

Front 22

Label parts of tympanic membrane **

Back 22

Front 23

Tympanic membrane perforation **

Back 23

If margin is part of it, harder to heal. Central heal on their own

Front 24

Hearing screening tests

Back 24

TEST CN 8 (Auditory)

1. Whispered voice test - repeat if wrong. Need 3/6 to pass. One ear at a time.

Front 25

Nasal/sinus examination

Back 25

1. Inspect and palpate external nose and sinuses - swelling, pain, tenderness, deformity

2. Inspect w/ otoscope: Septum, mucous membranes, inferior turbinates, middle turbinates.

3. Test CN1 if indicated.

Front 26

Nose defects

Back 26

1. Bloody nose - kiesselbach's plexus is more common site of anterior bleed**

2. Septum deviation

3. Polyps (on turbinates)

Front 27

Oral cavity examination

Back 27

1. Inspect: Buccal mucosa, floor of mouth, soft/hard palate, salivary glands, tongue (CN12), Teeth

Front 29

Oropharyngeal exam

Back 29

1. Inspect pharynx, posterior pharynx: Tonsillar pillars, presence/absence of tonsils, symmetric elevation of uvula/soft palate, vocalization

*Test by asking pt to say "ahh", "kahh" (CN 9/10)

Front 30

Oropharyngeal exam steps

Back 30

Front 31

Oral defects

Back 31

1. Torus palatinus ***

2. Leukoplakia

3. Squamous cell carcinoma

4. Tonsillar hypertrophy (ALWAYS abnormal*)

5. Kissing tonsils

6. Supperative tonsils

7. Peritonsillar abscess

Front 32

How to test CN via oral exam

Back 32

1. CN IX lesion - uvula deviates away from lesion

2. CN X (Vagus) - assymetrical palate elevation, vocal change - hoarseness, aphonia

3. XII (Hypoglossal) - Upper motor neuron = contralateral deviation of tongue. Lower motor neuron = ipsilateral deviation of tongue.

Front 33

Rinne's test

Back 33

IF failed whispered voice test

1. Hold tuning fork on masteoid

2. When pt can't hear it anymore, bring it out in front

3. Ask if pt can still hear

Front 34

Weber's test

Back 34

Hold tuning fork on top of midline scalp.

PT should hear sound everywhere - not just one ear = sensory neural hearing loss.

Refer to audiologist for hearing test

Front 35

Dix-Hallpike maneuver

Back 35

Used to diagnose vertigo

Tilt head, slowly lower - observe 30 seconds.

Raise back up - observe 30 seconds

Note any nystagmus (positive)

Repeat with head tilted to other side.

Front 36

Transillumination

Back 36

1. Frontal sinuses

2. maxillary sinuses (with mouth open)