642 Focused Assessment - HNEENT

Focused Assessment - HNEENT

Focused Subjective History

  • Head, Face, and Neck

    • Trauma or injury to the head

    • Presence of headaches

    • Reports of syncope or dizziness

    • Presence of enlarged lymph nodes

    • Changes in taste sensation

    • Difficulty swallowing (dysphagia)

    • Dental disease and practices history

  • Eye

    • Changes in vision:

    • Scotoma (an area of partial or complete loss of vision)

    • Floaters (spots that float across your vision)

    • Decreased, blurred, or double vision

    • Eye pain, discharge, and redness

    • Previous use of corrective lenses

  • Ear, Nose, Mouth & Throat

    • Recent respiratory infections

    • Reports of ear, sinus, or throat pain

    • Presence of nasal or ear discharge

    • Changes in hearing, taste, or smell

    • Presence of tinnitus (ringing in the ears)

    • Full symptom analysis indicated with HEENT complaints

    • Associated symptoms

    • Aggravating symptoms (e.g., allergens such as dust, pets)

    • Any self-treatment efforts

Focused Subjective Past Medical History (PMH)

  • Neurologic Events

    • History of syncope

    • Transient ischemic attacks (TIA) or cerebrovascular accidents (CVA)

  • Cancers

    • History of malignancies

  • Eye Disorders

    • Glaucoma

    • Cataracts

    • Retinopathy

    • Macular degeneration

  • Systemic Disorders Affecting Eyes

    • Diabetes Mellitus (DM)

    • Vascular disorders (impact on eye health)

    • Rhinitis and allergies

  • Prior Surgical History (PSH)

    • Any surgery specific to HEENT areas of interest

Focused Subjective Family History (FH)

  • Family history of:

    • Cerebrovascular disease

    • Thyroid diseases

    • Migraines

    • Asthma

Focused Subjective Social History (SH)

  • Lifestyle factors:

    • Tobacco, alcohol, and drug use

    • Activities that may expose the patient to eye trauma; necessity of protective equipment

    • Exposure to loud noises; need for protective equipment

    • Toxin exposure

    • Living conditions (e.g., heating/cooling, presence of pets, dust exposure)

Focused Objective Assessment of Head and Neck

  • Inspection

    • Assess for symmetry, sensation (cranial nerve involvement), lesions, or masses

  • Palpation

    • Evaluate for tenderness (especially TMJ pain), lymph nodes

Common or Concerning Symptoms of Head & Neck

  • Headache

  • Changes in vision: blurred vision, loss of vision, floaters, flashing lights

  • Eye pain, redness, or excessive tearing

  • Double vision (diplopia)

  • Hearing loss, earache, ringing in the ears (tinnitus)

  • Dizziness and vertigo

  • Nosebleed (epistaxis)

  • Sore throat, hoarseness

  • Swollen glands or goiter

Headache Warning Signs

  • Increasing frequency or severity over a three-month period

  • Sudden onset headache, described as a "thunderclap" or "the worst headache of my life"

  • New onset headache in patients over age 50

  • Headaches aggravated or relieved by change in position

  • Headaches precipitated by Valsalva maneuver or exertion

  • Associated symptoms:

    • Fever

    • Night sweats

    • Weight loss

    • History of cancers, HIV infection, or pregnancy

    • Recent head trauma

    • Changed pattern from previous headaches

    • Lack of similar headaches in the past

    • Associated findings of papilledema, neck stiffness, or focal neurologic deficits

Headache Differential Diagnosis

  • Migraine: Recurrent, idiopathic headache lasting from 4 to 76 hours; may occur with or without aura.

  • Cluster Headache: Severe pain experienced in episodic clusters.

  • Tension Headache: Mild to moderate non-throbbing pressure, squeezing pain experienced anywhere in the head or neck.

  • Subarachnoid Hemorrhage: Presents as "thunderclap" headache.

  • Tumors affecting intracranial pressure may also be a differential.

History of Present Illness (HPI) for TMJ and Myofacial Pain Dysfunction

  • Pertinent Positives

    • Reports of ear pain

    • Presence of tinnitus

    • Hearing disturbance

  • Pertinent Negatives

    • Dental disease

    • Poor fitting dentures

  • Symptoms

    • Mild to severe sharp pain in TMJ region

    • Pain aggravated by chewing or jaw clenching

    • Possible "clicking" sound upon movement

    • Pain may radiate to the ear

Thyroid Abnormalities

  • Goiter: Enlargement of the thyroid, can be associated with hypo- or hyperthyroidism, may also represent a nontoxic state.

  • Thyroid Nodules: Mostly asymptomatic but may mimic hyperthyroidism.

  • Hypothyroidism: Symptoms include fatigue, cold intolerance, constipation, modest weight gain, depression, menorrhagia, dry skin/hair, cool skin with slow capillary refill, paresthesias of the hands/feet, bradycardia, cognitive dullness, delayed deep tendon reflexes (DTR).

    • Causes: Hashimoto’s thyroiditis, iodine deficiency, genetic predispositions, medications, cancer, infiltrative disorders.

  • Hyperthyroidism: Symptoms consist of weight loss, insomnia, sweating, heat intolerance, tremors, hyperreflexia, nervousness/irritability, palpitations/tachycardia, menstrual irregularities.

Focused Objective Assessment of the Eye

  • Visual Acuity: Measured using the Snellen chart.

  • Peripheral Vision: Assessed via confrontation method.

  • Alignment: Tested during eye motion in all six cardinal positions, cover/uncover test, and light reflex.

  • Inspection of Accessory Structures: Includes examining eyebrows, eyelashes, eyelids.

  • External Eye Structures: Assessment of conjunctiva, cornea, and sclera.

  • Pupil Examination: Check for shape, symmetry, and reaction to light and accommodation.

  • Anterior Chamber and Lens: Evaluate using fundoscopic examination.

Eye Complaints

  • Common issues include:

    • Vision impairment

    • Refractive errors (e.g., presbyopia, myopia)

    • Cataracts

    • Macular degeneration

    • Diabetic retinopathy

    • Glaucoma

    • Dry eye syndrome

    • Blurred or double vision

    • Eye pain, discharge, or redness

    • Lid weakness

Red Flags in Eye Examination

  • Vision Disturbance: Eye pain, photophobia, and sudden onset may indicate serious conditions.

  • Associated Symptoms: Such as headache, weakness, slurred speech, scalp or temple tenderness, flashes of light, nausea, and vomiting.

  • History of Trauma: Indicates trauma-associated complications.

Visual Field Impairments

  • Bitemporal Hemianopsia: Blindness in half of the visual field nearest the temples (bilaterally).

  • Homonymous Hemianopsia: Blindness affecting one half of the visual field in both eyes.

  • Quadrantic Defect: Blindness in a quarter of the visual field on both sides.

External Inspection - Abnormalities

  • Ptosis: Drooping of the eyelid, associated with oculomotor nerve disturbances, diabetes mellitus, or tumors.

  • Myasthenia Gravis: Over 75% of patients present with ptosis. Diagnosis confirmed with Tensilon test.

  • Mechanical Reasons: Such as tumors causing ptosis.

Conjunctivitis Types

  • Allergic Conjunctivitis: Characterized by itchy sensation with clear watery discharge.

  • Viral Conjunctivitis: Presents as gritty sensation with mucoid discharge.

  • Bacterial Conjunctivitis: Results in burning sensation with mucopurulent, viscous discharge.

Subconjunctival Hemorrhage

  • No visual disturbance, photophobia, or pain associated.

Specific External Eye Abnormalities

  • Pinguecula: Abnormal growth on the conjunctiva.

  • Sty: Infection of the eyelash follicle.

  • Chalazion: Cyst in the eyelid due to blocked oil gland.

Corneal and Lens Abnormalities

  • Corneal Arcus: A gray or white arc sediment around the cornea.

  • Cataract: Opacity in the lens leading to impaired vision.

Normal vs. Abnormal Optic Disc and Retinas

  • Normal Optic Disc: Observed during fundoscopic examination.

  • Papilledema: Swelling of the optic disc due to increased intracranial pressure.

  • Glaucomatous Cupping: Depressed optic disc due to glaucoma.

  • Superficial Retinal Hemorrhage: Bleeding in the superficial layer of the retina.

  • Preretinal Hemorrhage: Occurs before the retina.

  • Deep Retinal Hemorrhages: Found deeper in the retina.

  • Cotton Wool Patches: Indicate retinal ischemia.

  • Drusen: Small yellow or white spots on the retina indicative of retinal aging or disease.

Hypertensive Retinopathy - Stages

  • Stage 1: Early changes - focal and diffuse arterial narrowing.

  • Stage 2: Further narrowing, may show arteriovenous nicking.

  • Stage 3: Includes retinal hemorrhages and cotton wool spots.

  • Stage 4: All above changes plus retinal edema, hard exudates, disc swelling (papilledema).

Diabetic Retinopathy Stages

  • Nonproliferative: Initial stages with mild changes.

  • Moderately Severe Nonproliferative: More pronounced vascular changes.

  • Severe Proliferative Retinopathy: Presence of new blood vessels (neovascularization).

Acute Vision Changes

  • Cataracts: Gradual vision impairment described.

  • Glaucoma: Open-angle and closed-angle variants exhibit different symptom severity and onset.

  • Age-related conditions including Amaurosis Fugax and retinal detachments.

Red Flags in Ear Assessment

  • Persistent or Profuse Epistaxis: May indicate significant pathology.

  • Severe Maxillary Pain: Consider possible sinus disease.

  • Clear Fluid from Ear: Indicative of potential cerebrospinal fluid leak following trauma.

Hearing Assessment Techniques

  • Assess auditory acuity by testing one ear at a time.

  • Utilize a whisper test: From a 1-2 foot distance, softly speak standard phrases.

  • Air and Bone Conduction Tests:

    • Weber Test: Lateralization to the impaired ear suggests conductive hearing loss.

    • Rinne Test: Determine if bone conduction is greater than or equal to air conduction, indicating conductive loss.

Ear Conditions

  • Cerumen Impaction: Common cause of reversible hearing loss.

  • Assessment of inner ear abnormalities:

    • Normal eardrum

    • Otitis externa

    • Otitis media with serous effusion

    • Otitis media with purulent effusion

Red Flags - Nose

  • Persistent or recurrent epistaxis, presence of severe maxillary pain, or unusual drainage after head trauma.

Differentiating Common Cold vs Bacterial Infections

  • Distinguishing viral illnesses from bacterial infections can be tricky; symptoms often overlap, influencing antibiotic use.

Evaluation of Sore Throat

  • Sore throat can range from mild scratchiness to severe pain; explore associated symptoms carefully.

Infectious Pharyngitis Differential Diagnosis

  • Respiratory Viruses: Variable onset with associated symptoms including malaise and rhinitis.

  • Herpes Pharyngitis: Presents during prodromal phase, includes ulcerative lesions.

  • Diphtheria: Sudden onset with thick gray membrane inflammation.

HEENT Focused Scenario Examples

  • Clinical examples depicting patient presentations for focused evaluations in HEENT conditions, highlighting pertinent histories and examination approaches.

Examining a Patient's Differential Diagnosis and Treatment Approaches

  • Diagnostic Testing: Engage in necessary laboratory and imaging evaluations as needed.

  • Therapeutic Measures: Develop treatment plans based on findings.

  • Patient Education: Discuss management options and safety precautions.

  • Follow-up/Referral: Consider the next steps for specialized care as indicated.