Nurs 713: Eyes, Ears, Nose, and Throat Notes

Eye Examination

History

• PMH: Eye

  • Frequent eye infections/inflammation

  • Styes

  • Chronic illnesses: Diabetes, hypertension, allergies, thyroid

  • Eye trauma or surgery

  • Last eye exam & results

  • Use of corrective lenses

  • Use of eye drops or other medications

• PMH: Pediatrics

  • Prenatal / birth factors

  • ROP (retinopathy of prematurity)

  • Infant: gaze at you or other objects; blink at bright lights or quick movements

  • Amblyopia/strabismus: Eyes ever crossed; ever move in different directions?

  • Does child bump into things?

  • Does child sit near television or hold books close to face at home?

  • How is child’s progress in school?

• PMH: Geriatrics

  • Do eyes feel dry? Excessive tearing?

  • Decrease in central or peripheral vision?

  • Problems with glare?

  • Problems discerning colors?

  • Difficulty seeing at night? Pain at night?

  • Personal Hx of eye disease: glaucoma, cataracts, retinal detachment, macular degeneration, vision problems

• ROS : Eye

  • Pain, itching, or dryness

  • Changes in eyelids (masses, ptosis, crusting)

  • Redness or drainage

  • Excessive tearing

  • Change in visual field or acuity

  • Exposure to infection or irritants

• Related History: Personal/Social History

  • Employment exposure

  • Activities

  • Allergies

  • Protective eyewear

• Family History : Eye

  • Strabismus & Amblyopia

  • Retinoblastoma

  • Glaucoma

  • Retinitis pigmentosa

  • Color blindness

  • Retinal detachment

  • Macular degeneration

  • Cataracts (non traumatic)

Physical Examination

• PE: Visual Acuity (CN II) & Visual Fields (CN III)

  • Use age-appropriate chart at correct distance to test

  • Test each eye individually, then both eyes – OD, OS and OU

  • Test with & without corrective lenses

  • Use Rosenbaum pocket screener at 14 inches to test near vision in older patients

  • Test peripheral visual fields by confrontation

• Visual Acuity in Children

  • Newborn: 20/200

  • 3 years: 20/50

  • 4 years: 20/40

  • 5 years: 20/30

  • 6 years: 20/20

• External Eye Exam - SIMPLE

  • Symmetry

  • Inflammation

  • Masses

  • Puncta

  • Lacrimal duct

  • Eyelids

  • Lacrimal gland

• Inspection

  • Periorbital structures

    • Inspect eyebrows - quantity & distribution, scaling, infestations

    • Note edema, skin changes

    • Look for swelling or drainage from lacrimal gland

    • Fatty deposits around eyes

  • Eyelids

    • Fasciculations & tremors

    • Width, slant of palpebral fissures & presence of epicanthal folds

    • Ability to open & fully close – Lids (CN IV, VII)

    • Flakiness, redness, swelling, crusting, lesions of lid or lash line

    • Condition of eyelashes

    • Eversion or inversion of lid

• Hordeolum (stye) vs. Chalazion

  • Hordeolum

    • Location: Follicle or Tarsal Gland

    • Etiology: Sterile or purulent inflammation

    • Pain: Tender

    • Plan: Warm compress, possible antibiotics

  • Chalazion

    • Location: Tarsal Gland

    • Etiology: Obstruction

    • Pain: Non-tender

    • Plan: Warm compress, possible referral for incision and drainage

• Palpation

  • Periorbital structures

    • Lacrimal gland (note swelling, discharge)

    • Bony orbit

  • Eyelids

    • Palpate nodules / plaques

    • Palpate globe through closed lids assessing for hardness, pain

  • Conjunctivae inspection

    • Inspect lower portion by pulling down lower lid

    • Upper lid inspected only if foreign body is in the eye

  • Conjunctiva & Sclera

    • Pull down on lower lid to expose conjunctiva

    • Color of sclera & conjunctiva

    • Vascular pattern (note hemorrhage, injection)

    • Nodules, swelling

    • Exudate

• Conjunctivitis

  • Bacterial

    • Bilateral involvement: 50%

    • Discharge: Mucopurulent

    • Redness: Yes

    • Pruritus: Rare

  • Viral

    • Bilateral involvement: 25%

    • Discharge: Watery

    • Redness: Yes

    • Pruritus: Rare

  • Allergic

    • Bilateral involvement: Mostly

    • Discharge: Rare

    • Redness: Yes

    • Pruritus: Yes

• Cornea & Lens

  • Both should be clear (note opacities)

  • Test sensitivity by touching the cornea with a cotton wisp to elicit blink (CN V & VII)

  • Note corneal arcus senilis, pterygium, pinguecula

• Iris and pupil

  • Inspect iris for color, shape, symmetry

  • Pupil size, shape, symmetry

    • Note anisocoria (inequality in pupillary size of >0.04mm)

  • Direct/consensual pupillary light reaction (CN II & III)

    • if abnormal, check pupils for accommodation

• Extraocular Muscles

  • Corneal light reflex (ocular alignment)

  • Cover-uncover test (muscle imbalance)

  • Test EOMs using 6 cardinal directions of gaze (CN III, IV, VI)

    • Note nystagmus

    • Note lid lag

• Red Eye Differential Diagnosis

  • Conjunctivitis

    • Vision: intermittent, clears on blinking

    • Discharge: usually, crusting of lashes

    • Pain: none or minor and superficial

    • Pupils: normal size and response

    • Conjunctival Injection: diffuse

    • Cornea: clear

  • Iritis

    • Vision: slightly blurred

    • Discharge: No discharge

    • Pain: moderately severe, aching, photophobia

    • Pupil: constricted, minimal response

    • Conjunctival injection: circumcorneal

    • Cornea: clear or slightly hazy

  • Keratitis (Corneal inflammation or foreign body)

    • Vision: slightly blurred

    • Discharge: none to mild

    • Pain: sharp, severe foreign body sensation

    • Pupil: normal or constricted, typical pupillary response

    • Conjunctival injection: circumcorneal

    • Cornea: Opacification present; altered light reflex; (+) fluorescein staining

  • 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

    • Cornea: hazy; altered light reflex

    • Anterior chamber depth: shallow

• Essentials of the Eye Exam

  • External observations

    • SIMPLE – symmetry, inflammation, masses, puncta, lacrimal duct, eyelids

  • Eye globe inspection

    • Sclera, iris, pupil, cornea, conjunctiva

  • Eye movements

    • Nystagmus, lid lag, eye movements

• Fundoscopic

  • Red reflex

  • Locate vessels

  • Look for AV nicking

  • Track vessel nasally to locate the optic disc

  • Optic disc

    • cream or pale-yellow color

    • concave appearance

    • vessels come from the center of the optic disc

• When to do a fundoscopic exam?

  • Suspected neuro problems: headache, dizziness

  • Diabetes

  • Hypertension

  • Toxoplasmosis: retinal scars in both eyes

  • Strabismus

  • Microphthalmia (eyes abnormally small) with malformations

  • Cataract

  • Optic atrophy (vision loss)

  • Nystagmus

• Fundoscopic Examination

  • Look for unexpected findings such as:

    • Myelinated nerve fibers (not pathologic)

    • Papilledema

    • Glaucomatous cupping

    • Drusen bodies

    • Hemorrhages

    • AV nicking

• Fundoscopic Exam

  • Symmetrical red reflex

  • Retinoblastoma

  • Examine Fundus (retina)

    • Optic disc

      • Sharp well-defined margin

      • Color

      • Physiologic cup size < ½ disc diameter

      • Symmetry between eyes

    • Vessels

    • Macula & central fovea

    • Retinal lesions

    • AV nicking

• Tips for Using the Ophthalmoscope

  • Switch the ophthalmoscope light and turn the lens disc to the large round beam of white light

  • Turn lens disc to the 0 diopter if you have 20/20 vision, contacts or use your glasses

  • Darken the room and have the patient look over your shoulder

  • Hold ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye

  • Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision

  • Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex

  • Move slowly towards patient, and adjust lens strength until retina is visible. (The hyperopic eye requires more plus or green numbers for clear focus. The myopic eye requires more minus or red numbers.)

  • Follow the red reflex and move inward towards the nasal aspect of the visual field

Examination of Ears, Nose, Mouth, and Throat

History

• PMH: ENOT

  • Chronic diseases, bleeding disorders, malignancy

  • Chronic problems including frequent ear infections, sinusitis or pharyngitis, allergies, nosebleeds, enlarged tonsils, gingivitis, or periodontitis

  • Dizziness or vertigo

  • Obstructive sleep apnea

  • Hearing loss

  • Dental or gum problems/surgeries

  • ENT surgeries

• Assess risk factors for hearing loss:

  • Prematurity, LBW

  • Hyperbilirubinemia (severe)

  • Craniofacial anomalies (cleft palate, ear anomalies)

  • Bacterial meningitis

  • Ototoxic drugs (antibiotics, NSAIDs, loop diuretics, platinum-based chemotherapeutics)

  • Head trauma

  • Noise exposure

• Additional PMH for Peds

  • Infant: respond to loud or unusual noises?

  • If > 6 months, does infant babble?

  • If > 15 months, does toddler rely on gestures and make no attempt at sound?

  • Child tugging at either ear?

  • Any coordination problems?

  • Hx: meningitis, recurrent OM, mumps, encephalitis?

• Additional PMH: Adults and Older People

  • Any recent change in hearing?

  • Wear a hearing aid?

    • If so, for how long?

    • How do you care for it?

  • 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?

• Health Care Maintenance

  • Last eye exam – date Any changes

  • Last dental exam – date Cavities? Gum disease? Other issues?

• ROS : ENOT

  • Ears: pain, drainage, change in hearing, vertigo or balance problems

  • Nose/Sinuses: pain, congestion, nasal discharge, postnasal drip, cough, snoring, epistaxis

  • Mouth / throat: lesions, sore throat, hoarseness, difficulty swallowing, tooth pain, loose teeth, bleeding gums, non-healing ulcers, numbness

  • Don’t forget associated symptoms with ENOT (fever, N/V, rash, abdominal pain, etc.)

• Personal & Social History

  • Ear & oral care routines

  • Daycare

  • Swimming

  • Feeding routines (infants)

  • Use of earphones/earbuds

  • Smoking/vaping/use of recreational drugs

Examination

• Location of Ears

  • Low set Ears

• Inspection of Ears

  • Size shape, position, & symmetry auricles

  • Anomalies

  • Lesions/nodules/redness

• Auditory canal (with otoscope)

  • Discharge, crusting, cerumen

  • Erythema or edema

  • Foreign bodies

• Palpation: Outer Ears

  • Auricles

  • Mastoid

  • Note tenderness or pain, especially with movement, lumps

• Inspection: TM

  • Landmarks (bony, light reflex)

  • Color

  • Contour

  • Mobility (use pneumatic attachment)

• Ears - Hearing

  • Auditory acuity

    • Test one ear at a time

    • Whisper test OR stand 1-2 feet behind patient, softly say “nine, car, baseball”

• Air and bone conduction

  • Weber

    • Lateralization of sound to unimpaired ear; suspect unilateral conductive hearing loss

  • Rinne

    • Compare time of air vs. bone conduction

    • If bone conduction is equal or greater than air conduction, then suspect conductive loss

• Essentials of the Ear Exam

  • Inspect the auricle/pinna for skin abnormalities

  • Observe for ear position/shape in infants/young children

  • Inspect for any auditory canal discharge

  • Assess hearing by rubbing fingers together in front of auditory canals

  • Insert otoscope into auditory canal

  • Observe hair and skin of the canal for cerumen, other discharge, lesions

  • Inspect tympanic membranes for:

    • Bony landmarks

    • Cone of light

    • Color of membrane/scarring

    • Retractions or bulging

    • Any perforations, fluid/pus behind the membrane, tympanostomy tubes

• Inspection: Nose/Nasopharynx

  • Shape, size, & color of nose

  • Nares for flaring, discharge

  • Patency of nares

  • Nasal mucosa (with otoscope & nasal speculum)

    • Color

    • Discharge/drainage

    • Lesions or polyps

    • Swelling of turbinates

• Nasal septum

  • Color

  • Edema

  • Lesions, polyps, bleeding

  • Note deviation or perforation

• Assessment for nasal obstruction

  • Occlude one nostril, have patient inhale

  • Repeat with the other nostril

  • Have patient note which side is easiest to breathe through

• Palpation: Nose & Sinuses

  • Nasal bridge & soft tissues

    • Note displacement or masses

  • Palpate frontal & maxillary sinuses for tenderness

• Oral Examination

  • Four L’s for Oral Screening Exam

    • Lift/Lower Lips

    • Look at Teeth

    • Lasso the Tongue

    • Lap with finger around gumline

• Inspection: Mouth

  • Lips

    • Symmetry

    • Color

    • Edema

    • Cracking or scaling

    • Lesions

• Inspection: Occlusion and Alignment of Teeth

  • Malocclusions (Bite Problems)

• Inspection: Buccal Mucosa

  • Mucosa

    • Color & moisture

  • Opening of parotid duct

    • Note ulcers, white patches, lesions

• Tongue

  • Symmetry (CN XII)

  • Note texture & size, red areas, nodules, ulcerations

  • Careful attention to sides and undersurface

• Palate/uvula rise (CN X)

• Gag reflex (CN IX, X)

• Posterior pharyngeal wall

  • Note swelling, deviations

• Inspection: Tonsils

  • Tonsillar pillars

    • Note size, crypts, exudate

• Mallampati

  • Class I: Full visibility of tonsils, uvula, and soft palate

  • Class II: Visibility of hard and soft palate, upper portion of tonsils and uvula

  • Class III: Soft and hard palate and base of the uvula are visible

  • Class IV: Only hard palate visible

Documentation

• Documenting the HEENT & Neck Exam : Head & Neck

  • Normocephalic. Head held erect, midline. Scalp pink without lesions. Hair thinning at crown. Temporal arteries nontender. TMJ with full mobility, no tenderness or crepitus. Neck supple with full ROM, trachea midline. Thyroid without enlargement or nodules. No cervical lymphadenopathy.

• Documentation: Eyes

  • Visual acuity 20/20 bilaterally w/o correction. Sclera and conjunctiva clear. Red reflex present & equal x2. Symmetric corneal light reflex. PERRL. Disc margins sharp, no hemorrhages or exudates. AV ratio 2:4, no AV nicking. EOMs intact, visual fields equal to the examiner.

• Documentation: Ears

  • External ear w/o lesions or tenderness, canals clear. TMs mobile, translucent with clear landmarks & light reflex. Hearing grossly intact.

• Documentation: Nose & Sinuses

  • Nares patent, septum midline. Mucosa pink w/o edema, drainage, or lesions. Frontal & maxillary sinuses nontender.

• Documentation: Mouth & Throat

  • Buccal mucosa pink, moist & w/o lesions. Teeth without fillings or crowns, none missing. Gingiva & tongue pink w/o edema or lesions. Pharynx w/o erythema, tonsils 2+ w/o exudate. Uvula midline, soft palate elevates, gag reflex intact.### Added code to handle backslash required by Latex. For example command

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HEENT Study Guide – N713 Advanced Health Assessment

1. Eye Assessment

History

• PMH: Eye infections, styes, diabetes, HTN, thyroid disease, trauma, surgery, corrective lenses

• Pediatrics: Gaze, blinking, strabismus, school progress

• Geriatrics: Dryness, tearing, color vision, night vision, personal hx of glaucoma, cataracts

• Social Hx: Eye protection, exposure, activities

• FHx: Glaucoma, macular degeneration, cataracts, strabismus

Physical Exam (PE)

• Visual Acuity (CN II): Snellen (distance), Rosenbaum (near), test OD, OS, OU

• Visual Fields (CN III): Confrontation test

• External Inspection – “SIMPLE”: Symmetry, Inflammation, Masses, Puncta, Lacrimal Duct, Eyelids

• Conjunctiva/Sclera: Color, injection, discharge, nodules

• Cornea/Lens: Clear, arcus senilis, pterygium

• Iris/Pupils: Anisocoria, PERRLA (CN II, III), accommodation

• EOMs (CN III, IV, VI): 6 cardinal gazes, nystagmus, lid lag, cover-uncover test

• Palpation: Lacrimal gland, globe, orbital bones

Fundoscopic Exam

• Indications: DM, HTN, headaches, dizziness

• Steps: Red reflex → optic disc → vessels → macula

• Findings: AV nicking, hemorrhages, papilledema, drusen, glaucoma

Red Eye Differentials

2. Ear Assessment

History

• PMH: OM, sinusitis, allergies, vertigo, OSA, surgeries, ototoxic meds

• Pediatrics: Babbling, gestures, coordination, hx of meningitis

• Adults: Hearing aids, exposure to loud noise, last exam

• Risk Factors: Prematurity, hyperbilirubinemia, craniofacial anomalies

ROS

• Ear pain, drainage, hearing changes, vertigo/balance issues

Physical Exam

• Inspect: Auricle size/shape, discharge, lesions, auditory canal

• Palpate: Auricle, tragus, mastoid

• TM Inspection: Color, cone of light, mobility (pneumatic)

• Hearing Tests:
  

  • Whisper Test

  • Weber: Lateralization = conductive loss (toward bad ear)

  • Rinne: AC > BC = normal; BC ≥ AC = conductive loss

3. Nose & Sinus Assessment

History

• Chronic rhinitis/sinusitis, allergies, nasal trauma, epistaxis

• Smoking, drug use, daycare, swimming

ROS

• Congestion, postnasal drip, discharge, sinus pressure, snoring

Physical Exam

• Inspect: Shape, nares, discharge, mucosa color, turbinates

• Septum: Midline, edema, bleeding

• Palpate: Nasal bridge, frontal/maxillary sinuses for tenderness

• Assess: Patency (occlude one nostril)

4. Mouth & Throat Assessment

History

• Dental hygiene, last dental visit, surgeries, sore throat, dysphagia

• Infants: feeding routines, oral care

ROS

• Tooth pain, ulcers, hoarseness, bleeding gums, lesions

Physical Exam

• Lips: Symmetry, color, lesions, cracking

• Teeth/Gingiva: Cavities, alignment, color, tight frenulum

• Mucosa: Ulcers, parotid duct, lesions

• Tongue (CN XII): Size, symmetry, texture

• Palate/Uvula (CN IX, X): Elevation, midline, gag reflex

• Tonsils: Size, crypts, exudate

• Pharynx: Redness, swelling

5. Documentation Templates

Head/Neck

Normocephalic. Head midline. Scalp clear. TMJ non-tender. Neck supple, full ROM. Trachea midline. Thyroid non-enlarged. No cervical lymphadenopathy.

Eyes

Visual acuity 20/20 bilaterally. Sclera/conjunctiva clear. Red reflex present. PERRLA. Disc margins sharp. No hemorrhages. EOMs intact.

Ears

External ears WNL. Canals clear. TMs mobile with clear landmarks. Hearing grossly intact.

Nose/Sinuses

Nares patent. Septum midline. Mucosa pink without discharge. Sinuses nontender.

Mouth/Throat

Mucosa moist and pink. Teeth intact. Gingiva healthy. Tongue midline. Tonsils 2+ without exudate. Uvula midline. Gag reflex intact.