HEENT/Clinical reasoning/Documentation PCCR

Conductive hearing loss

Turn the volume louder on tv

Hear better in noisy environments

Soft speaking voice

Have info repeated often

Sensorineural hearing loss

Not be able to hear in noisy environments

Loud speaky voice

Complain that people are mumbling

Difficulty understanding speech

Menieres disease

Inner ear disorder;

Episodic vertigo lasting 20 min to hours

Tinnitus

Sensorineural hearing loss

Nystagmus

Imbalance

Vertigo

exaggerate sense of motion in response to movement

dizziness

nonspecific term

disequilibrium

feeling of unsteadiness, imbalance, or sensation of floating

syncope

transient loss of consciousness with the loss of tone

peripheral vertigo

sudden, more severe, with horizontal/rotary nystagmus dt dysfunction of cranial nerve 8

central vertigo

gradual, less severe, vertical nystagmus dt to dysfunction of the CNS

Benign Paroxysmal Positional Vertigo (BPPV)

episodic vertigo with head or body movement lasting less than 1 minute dt otoliths in semicircular canals, dx: dix-hallpike to test for nystagmus, tx: epley maneuver

vestibular neuritis

episodic vertigo that's less severe over days causing difficultly walking, and horizontal nystagmus dt inflammation of vestibular nerve after a viral URI

labyrinthitis

Vertigo, UNILATERAL hearing loss, nystagmus dt inflammation of vestibular nerve after a viral URI

Acoustic neuroma

Sensorineural hearing loss and tinnitus dt cranial nerve 8 compression

ROS of the ear

hearing loss, pain, discharge, tinnitus, vertigo, infections, masses/lesions

PMH for the ear

Frequent ear infections during childhood

Trauma

Surgery

Labyrinthitis

Antibiotic usage

Ototoxic medications

FH for the ear

Hearing problems or loss

Menieres disease

SH for the ear

Environmental hazards

Use of protective hearing devices

external ear exam

Inspect auricle, tragus, and posterior ear for deformities, lumps, lesions, redness, swelling

palpate external ear

auricle, tragus, mastoid process for warmth and tenderness

keloid

firm, rubbery, fibrous nodule after piercing or surgery

Chondrodermatitis nodularis helicis

benign, painful nodule on helix looks like BCC/SCC

Tophi

Hx of gout

Discharge, chalky white nodules

rheumatoid nodules on ear

small lumps on helix and additional areas

Cutaneous cyst on ear

dome shaped, fluid filled nodule

Inspect ear canal

patency, redness, scaliness, cerumen, discharge, foreign bodies

inspect TM

color, contour, injection, perforation, opacities, deformities, landmarks: handle, short process, and umbo of malleus, incus, pars tensa/flaccida, cone of light

Cerumen impaction

plug of ear wax

Otitis externa

Pain with manipulation

After swimming

Itching

Conductive HL dt exudate/swelling

Erythema

otitis media with effusion

NOT INFECTED

Cracking when yawning

Discomfort/aural fullness

Conductive HL dt to fluid

TM retracted with air bubbles

Acute otitis media

INFECTION of middle ear

TM bulging

Pain/pulling ear

Conductive HL dt purulent material

Erythema

Tympansclerosis

white scarring on TM dt ear infection/ear tubes

Bullous myringitis

M/C strep pneumoniae

Bullae filled with blood on TM

Conductive hearing pathway

Sound travels through auditory canal striking TM causing ossicles to move

Sensorineural hearing pathway

Sound travels through oval window to cochlear causing vibrations that are transmitted to the vestibulocochlear nerve

Weber test in conductive hearing loss

affected ear

weber test sensorineural hearing loss

unaffected ear

M/C cause of conductive hearing loss

cerumen impaction

M/C of sensorineural hearing loss

acoustic neuroma

ROS for the nose

sense of smell, frequency of colds, obstruction, epistaxis, post nasal discharge, sinus pain

PMH for the nose

HTN/bleeding disorders

Nasal trauma/surgery

Chronic nose bleeds

Chronic post nasal drip

Recurrent/chronic sinusitis

Allergies

Asthma

FH for the nose

Allergies

Bleeding disorders

SH for the nose

Intranasal cocaine use

inspect external nose for

assymetry and deformities

Inspect nares for

foreign bodies and symmetry

inspect nasal mucosa and turbinates for

Color

Swelling/Hypertrophy

Discharge/Bleeding

Exudates

Nasal polyps

Edema

Inspect nasal septum for

Deviation

Redness

Swelling

Bleeding

Perforations

Ulceractions

Palpate front and maxillary sinus for

tenderness

sinusitis

Bacterial infection

URI worsens after 7-10 days

Frontal headache/Sinus pain

Purulent nasal discharge

Tenderness over sinuses

Swelling over sinuses

ROS for the head

Frequent or unusual headaches + location

Dizziness

Syncope

Severe head injuries

Concussion

Periods of loss of consciousness

ROS for the neck

thyroid nodule

Range of motion

Redness/Skin irritation

Masses/Lesions

Tracheal deviation

LN - tenderness, enlargement, suppuration

PMH for head and neck

TBI

Subdural hematoma

Recent LP

Radiation to head and neck

Recent surgery/Intubation

Headaches

Seizures

Thyroid dysfunction

FH for the head and neck

Hx of headaches or thyroid dysfunction

Hx of cancer

SH for head and neck

Employment

Stress

Risk of injury

Nutrition

Illicit drugs

Sports participation

HPV, sexual hx

inspect the external neck for

masses, scars, goiter

inspect the thyroid gland for

size, shape, consistency, enlargement, masses, tenderness

inspect the lymph nodes for

symmetry, masses, size, shape, consistency, mobility, tenderness

inspect the head and scalp for

size, shape, symmetry, lice, signs of trauma, scaliness, lumps, lesions, dryness, ecchymosis, lacerations, redness, nevi

inspect the hair for

distribution, texture, quantity, pattern of loss, nits, dandruff

inspect the face for

expression, contours, symmetry, involuntary movement, masses, edema

palpate head and scalp for

tenderness and lesions

inspect the trachea for

deviation noting space between SCM and bony landmarks

hypothyroidism

weight gain, constipation, fatigue, cold intolerance

hyperthyroidism

weight loss, tachycardia, diarrhea, heat intolerance

diffuse thyroid enlargement

uniform, no nodules

graves disease, hashimoto thyroiditis, endemic goiter

Single nodule on thyroid gland

may be a cyst or benign tumor

multinodular goiter

multiple nodules

malignancy

cushing's syndrome

red/moon face

red cheeks

excessive hair growth

hyperthyroidism facies

moist skin

fine hair

prominent eyes/lid retraction

Staring/startled expression

myxedema

dull, puffy skin

non pitting periorbital edema

dry, course, thin eyebrows (missing lat 1/3)

course, thick skin

bell palsy

Asymmetry 1 side

eyelid doesn't close completely

Drooping lower eyelid/corner of mouth

Loss of nasolabial fold

acromegaly

elongated head

bony prominent features

enlargement of soft tissue

coarse facial features

nephrotic syndrome

periorbital edema

puffy, pale face

swollen lips

slit like eyes

occurs in the morning usually

parotid enlargement

swelling anterior ear

ROS of mouth and pharynx

Hoarseness

Frequent sore throats

Bleeding/swelling of gums

Recent tooth abscess/extractions

Soreness of tongue or buccal mucosa

Ulcers

Disturbance of taste

Dental care

PMH for mouth and pharynx

GERD

Frequent strep infections

Tonsillectomy/adenoidectomy

FH for mouth and pharynx

allergies

SH for mouth and pharynx

Excess sugar intake

Tooth brushing/flossing

Last dental care, frequency

Appliances: braces, denture crowns

Tobacco use, vaping

angular cheilitis

inflammation and painful cracking of the corners of the mouth

Nutritional deficiency

No teeth/ill-fitting dentures

Secondary infection with candida

Carcinoma of the lip

ulceration not healing

chancre of primary syphilis

usually round, small, painless

peutz-jeghers syndrome

mucocutaneous melanotic patches (dark spots)

hereditary hemorrhagic telangiectasia

small red spots on lips

Iron deficiency anemia

Nose bleeds

GI bleeding

angioedema

swollen lips

anaphylaxis

Actinic Cheilitis

scaly thickened everted lip

herpes simplex

painful vesicles on lips

HSV

large normal tonsils

peds

leukoplakia

white plaque, painless, cant scrape off

candidiasis/thrush

white thick plaques usually irritated to patient, can be scraped off

prolonged exposure to AB or corticosteroids

petechiae in mouth

small, red spots

decreased platelets

infection

trauma

koplik spots

small, white specks

measles

fordyce spots

small, yellow spots

torus palatine

midline bony growth in hard palate

kaposi sarcoma

deep purple, nontender lesions may be raised or flat

HHV 8

diphtheria

dull, red throat, gray exudate

pharyngitis

red throat without exudate

exudative tonsilitis

red throat with exudate on tonsils

strep

infectious mononucleosis

marginal gingivitis

red and swollen

brushing teeth too often

hutchinson's teeth

smaller teeth, widely spaced, notched surface

congenital syphilis

abrasion of teeth with notching

biting surface abraded or notched with normal contours, sizing, spacing

recurrent trauma

erosion of teeth

yellow brown dentition

Bulimia

Severed acid reflux