1. HEENT Assessment

2. Obtaining History
If head or neck trauma, gather CC and current status info. Postpone rest of history until x-rays obtained.

3. History: Head and Neck
Head trauma, skull surgery, jaw/facial fractures?
Headaches?
Swelling of face, jaws, mastoid process?
Sinus infections/tenderness?
Nasal discharge or post-nasal drip?
Nosebleeds?

4. History: Head and Neck Mouth lesions, ulcers, or cold sores?
Any difficulty swallowing or chewing?
Any changes in sound of voice?
Any allergies causing breathing difficulty?
Any neck injury or surgery?

5. Additional Questions: Peds
Drinking water treated with fluoride?
Use pacifier or thumb?
When did teething begin?
Tonsils present? If not, when removed?

6. Additional Questions: Elderly
Do you wear dentures?
If so, how well do they fit?

7. Health Promotion Questions
Smoke a pipe? Chew tobacco or use snuff?
Does relaxation, exercise, or massage help relieve headaches?
Is H/A associated with lack of sleep, missed meals, or stress?
Job: sitting at computer terminal?, risk of head injury? (hard hat?)
Do you grind your teeth? Last exam? Floss?
Use seat belts?

8. Examination of Head, Neck, and Lymph

9. Hair and Scalp: Inspection
Quality and thickness
Distribution, pattern of loss (if any)
Texture
Lesions
Presence of nits

10. Skull: Inspection/Palpation
General size and contour
Deformities, lumps and tenderness
Palpate sinus areas and mastoid areas for tenderness
Palpate temporal artery
Check TMJ

11. Face: Inspection Facial expression Symmetry Involuntary movements
Edema
Masses or lesions
Color and texture of skin
Exopthalmos
Rash

12. Neck: Inspection Asymmetry Range of motion
Abnormal pulsations, vein distension
Enlargement of thyroid, lymph, salivary glands
Deviation of trachea
Skin lesions
Neck muscles

13. Neck: Palpation Assess lymph nodes, noting: Thyroid gland Trachea
exact location
size and shape
tender?
freely movable, adherent or matted together?
texture: hard, soft, firm
Thyroid gland
Trachea

14. Neck: Auscultation Check for bruits: carotid arteries
temporal arteries
thyroid, if enlarged

15. Lymph Nodes: When to Biopsy?
Immediate biopsy is indicated for:
painless
rubbery node of recent onset
especially if > 1-2 cm in diameter
A smaller, rapidly enlarging node is also a biopsy candidate.
Unilateral nodes should have a biopsy sooner than bilateral ones.
More conservative with stable node.

16. Eyes

17. History: Eyes Corrective lenses? Glasses/contacts?
When lenses last changed?
Blurred vision?
Spots, floaters, halos around lights?
Frequent eye infections/inflammation?
Eye surgery or injury?
Styes?

18. History: Eyes History of high blood pressure or diabetes?
Any prescription medications for your eyes?
Family history: cataracts, glaucoma, blindness?

19. Eye History: Peds
Infant: gaze at you or other objects; blink at bright lights or quick movements?
Eyes ever crossed? Ever move in different directions?
Does child bump into things?
Does child sit near television at home?
How is child’s progress in school?

20. Eye History: Elderly Do eyes feel dry?
Difficulty seeing in front of you but not to the sides?
Problems with glare?
Problems discerning colors?
Difficulty seeing at night?

21. Health Promotion Questions
Last eye examination?
Eye care insurance?
Occupation: prolonged reading or use of video display terminal?
Any eye problems from air at work/home?
Use goggles when appropriate? (when using tools, sports, swimming?)

22. Examination of the Eye Visual acuity External Eye Exam (SIMPLE):
Symmetry
Inflammation
Masses
Puncta
Lacrimal duct
Eyelinds

23. Abnormalities: External Eye Exam
Lid lag
Lid ophthalmus (incomplete closure)
Ptosis (drooping)
Blepharospasm
Xanthelasma
Ectropion (rolling out)
Entropion (rolling in)
Infections:
hordeolum (sty)
chalazion
blepharitis

24. Conjunctiva Palpebral conjunctiva: lines lid
Bulbar conjunctiva: over sclera
Conjunctivitis: viral, bacterial, allergic
Pterygium: thickening of bulbar conjunctiva

25. Ocular Muscles

26. Strabismus: Deviation of Eye
Tropia: Malalignment or deviation of eye
Exotropia: outward turning
Esotropia: inward turning
Phoria: Mild weakness apparent only with cover test
Exophoria: outward drift
Esophoria: inward drift

27. Globe Cornea Sclera Clear, smooth Arcus senilis Corneal reflex
CN V Trigeminal
CN VII Facial
Sclera

28. Globe Pupil Iris Lens Size (3-5 mm) Light reflex Convergence
Anisocoria: unequal pupils
Light reflex
Convergence
Accommodation
Iris
Lens

29. Testing Peripheral Vision
60o Nasal
90o Temporal
60o Superior
70o Inferior

30. With Any Eye Pain: Numb eye with Tetracaine
Use fluorescein paper (wet with sterile saline or water)
Use Wood’s light to check for abrasions, foreign body

31. Differential Diagnosis
The “Red Eye”
Differential Diagnosis

32. Conjunctivitis If blurring: intermittent, clears on blinking
Discharge: usually, crusting of lashes
Pain: none or minor and superficial
Pupils: Normal size and response
Conjunctival Injection: Diffuse
IOP: Normal (don’t measure if discharge)
Cornea: Clear

33. Iritis Vision: slightly blurred No discharge
Pain: Moderately severe, aching, photophobia
Pupil: constricted, minimal response
Conjunctival injection: Circumcorneal
IOP: Normal to low
Cornea: clear or slightly hazy

34. Keratitis (Corneal inflammation or foreign body)
Vision: slightly blurred
Discharge: none to mild
Pain: sharp, severe foreign body sensation
Pupil: normal or constricted, normal response
Conjunctival injection: circumcorneal
IOP: Normal (Caution: do not measure)
Cornea: Opacification present; altered light reflex; (+) fluorescein staining

35. Acute Glaucoma (REFER)
Vision: marked blurring
Discharge: none
Pain: very severe, frequently N & V
Pupil: dilated, minimal or no reaction
Conjunctival injection: diffuse with prominent circumcorneal injection
IOP: elevated
Cornea: hazy; altered light reflex
Anterior chamber depth: shallow

36. Fundoscopic Exam

37. When to do Fundoscopic Exam
Suspected neuro problems
headache
dizziness
Diabetes
Hypertension
Toxoplasmosis

38. Optic Disk Size: 1.5 mm Shape: round--> slightly oval
Color: salmon pink, yellowish-white
Margins: distinct, fuzzy nasally
Disc-cup ratio: Physiologic cup/Optic disk should be < .5
Normal variations

39. Retinal Vessels Number: Branches to all four quadrants
Color: arteries brighter than veins (veins slightly darker and larger than arteries)
A-V ratio (diameters): A/V > 1/2 (1/2 or less may mean diabetes)
A-V Crossing: should cross with no disruption of blood flow (if flow impaired = A-V nicking)

40. Macula (central vision)
Location: 2 disc diameters temporally from disc
Fovea = center of macula
NOTE: Uncomfortable for patients to have light shined on macula; aim for disc instead
Abnormalities

41. General Background of Fundus
Color: bright orange/red; consistent OU
Abnormalities:
microaneurysms
hemorrhage
hard exudate: creamy or yellowish, well-defined borders
cotton wood spots (soft exudate): white/gray ovoid lesions with irregular borders

42. Ears

43. History: Ears Any hearing differences in one/both ears? Ear pain?
Trouble with earwax? What is done?
Ear injury? Ear surgery?
Ringing or cracking in your ears?
Foreign body in ear?
Frequent ear infections? Drainage?
Problems with balance, dizziness, vertigo?

44. History: Ears
Rx or OTC meds or home remedies for the ears or any other conditions?
Family: anyone with hearing problems?
Occupational history

45. Ear History: Peds Infant: respond to loud or unusual noises?
If > 6 months, does infant babble?
If > 15 months, does toddle rely on gestures and make no attempt at sound?
Child tugging at either ear?
Any coordination problems?
Hx: meningitis, recurrent OM, mumps, encephalitis?

46. Ear History: Elderly Any recent change in hearing? Wear a hearing aid?
If so, for how long?
How do you care for it?

47. Health Promotion Questions
Last ear exam/hearing test?
Results of test?
Any meds for ears?
Any concerns about ears/hearing?
Do you work around loud equipment or machinery? (or LOUD MUSIC!)

48. Ear Assessment: Concepts
Lightheadedness: detachment
Vertigo: surroundings swirling around
Dizziness: disturbance in relationship to space

49. Hearing Loss
Otosclerosis: Bones fuse; ages have some degree of hearing loss
Conductive hearing loss: sound not getting to hearing apparatus
Sensory hearing loss: High pitched sounds are the first to NOT be heard.
Mixed hearing loss

50. External Ear: Inspection
Pinna (auricle)
Size and shape
Level on head
Flat or protruding
Tophi or nodules
External Auditory Canal
Cerumen, discharge, foreign bodies
Signs of infection

51. External Ear: Palpation
Tophi and nodules
Assess for tenderness (with ear pain, discharge or inflammation)
move auricle
press on tragus
press on mastoid

52. Otoscopic Exam Technique
Pinna up, back and out in adults
Pinna down and out in children
Advance slowly; ANCHOR the otoscope
Observe canal: blood, tumors, wax, foreign bodies

53. Otoscopic Exam: Tympanic membrane (drum)
Note color and luster
Oval thin, partially transparent grey
Gently move speculum to inspect entire ear drum
Landmarks
NOTE: The more scarring on the TM from healed ruptures, the less mobile it becomes ---> conductive hearing loss.

54. Testing Hearing Crude Tests Tuning Fork Weber test Rinne’s test
Watch test
Whisper test
Tuning Fork
Weber test
Rinne’s test

55. Types of Hearing Loss

56. Vestibular Testing
Romberg’s sign
Post pointing
Nystagmus

57. Nose, Throat, Mouth and Sinus

58. Nose Inspect for deformity, asymmetry, and inflammation
Test for patency of each nostril
Using speculum, note:
color of nasal mucosa
spectum, bleeding, perforation, deviation
turbinates: visible, color, swelling, exudate, polyps

59. Mouth and Throat Lips, Tongue, Gums and teeth Buccal mucosa
Palata and uvula
Tonsils and pharyngeal wall
Ducts
Frenulum
Note: sore throat may be due to PND

60. Sinuses Able to assess: Others Palpate for sinus tenderness in adult
frontal sinus
maxillary sinuses
Others
ethmoid sinus
sphenoid sinus
Palpate for sinus tenderness in adult
Transillumination