Small Group Session 17

SMALL GROUP SESSION 18

January 19th or January 21st

Head, Ears, Eyes, Nose and Throat (HEENT) and Ophthalmoscopy workshop

Suggested Readings:

· “The Eye Exam” at: http://medicine.ucsd.edu/clinicalmed/eyes.htm

Watch: The “Ophthalmoscopic Exam” video at:

http://www.med-ed.virginia.edu/courses/pom1/PhysicalExamLinkPage.cfm

Prepare by: Charging your scope handle.

Bring: Charged scope handle

Brief Outline: Section 1: Touch base (15 minutes)

Section 2: Case discussion (30 minutes)

Section 3: Ophthalmoscopy examination (70 minutes)

Section 4: HEENT examination (60 minutes)

Section 5: Evaluation (5 minutes)

Objectives for Session 18

By the end of this session, students will be able to:

· Develop an approach to analyzing a clinical case of head and neck cancer

· Apply knowledge of head and neck anatomy to the clinical discussion

· Practice the technique of ophthalmoscopy examination :

· Describe properties of the short and long focal length lenses of the ophthalmoscope

· Use the different lenses of the ophthalmoscope

· Use the short focal length lenses to look at the anterior chamber of the eye

· Focus on the anterior structures of the eye

· Position themselves correctly to see the retina and optic disc

· Look for the fundus and optic disc

· Demonstrate the components of the HEENT examination

Section 1: Touch base: (15 minutes)

How is the workload in medical school? Do you think you are coping?

How are the large group sessions?

Today’s session will be busy, keeping track of the allotted times for the different sections will be very important.

Section 2: Clinical case - A patient with trouble swallowing.

(30 minutes)

Logistics:

1. One student should read the medical history and physical examination Stop and discuss. Then read the laboratory or test findings and discuss

2. One student– the scribe – will take notes on the board. Findings or questions should be written in the following columns:

· History

· Physical findings

· Anatomy

· Diagnostic possibilities

· Laboratory and test findings, if any

A PATIENT WITH TROUBLE SWALLOWING:

Chief complaint: Difficulty swallowing for two and a half months

History of present illness: Ms XY, a 65 year old woman comes to you for trouble swallowing for two and a half months. She has always had trouble with heartburn. About three months ago, her heartburn seemed to get worse and she started having pain with swallowing solid foods. Since then the pain has worsened and she now has discomfort with eating soft foods, and it is becoming harder to swallow. The discomfort is located in her upper chest, in the mid-line.

She has become afraid to eat and has lost her appetite, so she has lost 10 pounds in 2 months.

She called you almost two months ago because of these symptoms and received a prescription for Nexium over the phone. It did not help.

Past medical history: mild high blood pressure on no regular medications. Chronic heartburn that she has treated with over the counter antacids. No other prescription or over-the-counter medications.

Social history: She is happily married with one son. She quit smoking ten years ago. She has 1 or 2 drinks a day before dinner, but has never had a drinking problem. CAGE questions have been negative.

Family history: Her father (a smoker) died of lung cancer, and her mother died of stomach cancer.

Physical examination:

On examination, your patient appears chronically ill. HEENT exam is normal, except for bilateral supraclavicular adenopathy. Cardiac and chest examination are normal. Abdominal exam is normal.

1. What are the important history and physical findings? What could they mean?

2. What are some diagnostic possibilities?

Lab findings:

You order an esophagoduodenostomy (EGD) and a CAT scan of the abdomen and chest. The EGD shows a large, circumferential ulcerated mass in the mid-esophagus. Biopsy shows squamous cell carcinoma. CAT scan shows extension of the tumor through the wall of the esophagus into mediastinal structures, mediastinal lymphadenopathy, and celiac (retrogastric) lymphadenopathy. This is consistent with a diagnosis of squamous cell cancer of the esophagus.

Section 3: Ophthalmoscopy workshop: (70 minutes)

EXERCISE 1: Using the Ophthalmoscope Lenses (15 minutes)

The ophthalmoscope has two colors of lenses: the green or black lenses (used to look at anterior chamber structures - those in front of the lens) and the red lenses (used to look at the retina, which is behind the lens). Get to know this first.

1. The skin exercise: use of short focal length lenses (15 minutes)

The green or black- numbered lenses look at things up close – at 1 to 5 inches or so from your eye. They are usually numbered up to 40; the closer you look, the higher the number.

Hold your hand 3 inches from the scope and look with a green lens at your hand. Find the number that gives you the sharpest image. Then, move your hand 1 ½ inches from the scope and dial the lens to focus again. What number lens is best now?

2. The wall exercise: use of long focal length lenses (15 minutes)

The red lenses require an intact patient lens to focus on the retina. The correct number for you is a function of your own lens’s refractive power - and the patient’s.

This exercise lets you find the correct number for each of your eyes. The lens of this number is the one you will use first to look for a patient’s retina. In patients with refractive errors, you may need to move one or a few lenses away from this to focus best - but always start with your unique number, which you can find with this exercise.

Look at a distant object on the wall and dial the lens that gives you the sharpest number. Make a mental note of this number. Now, do the same with your other eye. This is your unique number for viewing the retina.

EXERCISE 2: POSITIONING FOR EYE EXAMINATION (5 minutes)

In the ideal position, the examiner is 1 ½ to 2 inches from the patient’s cornea. To do this, and to stabilize your relationship to the patient, you will need to hold the scope in the same hand as the eye you are examining and to “find” the patient with your other hand.

So: to look in the patient’s right eye, hold the scope in your right hand and look through it with your right eye. Put your left hand on the patient’s head with your thumb just above the eyebrow. For the left eye, reverse everything.

Get as close to your patient as you can without bumping into his or her eyelashes or eyebrows. The closer you are to the patient, the wider your visual field.

EXERCISE 3: LANDING ON THE DISC (40 minutes)

For this exercise, keep the room as dark as you can - only enough light so that the patient can see something to focus on.

Dial your unique red lens for your dominant eye.

Have the patient look straight ahead at a fixed object behind you. Approach the eye from 20 to 30 degrees to the side of the patient in the sagittal plane, with the ophthalmoscope at a low level of light intensity. Move in to the ideal viewing distance. Make sure your patient can keep looking straight ahead.

The disc is a light-colored circular area with blood vessels converging into it. Try to see it. If you find a blood vessel, try to follow it to the disc. If you are in the correct position, the disc should be nearby.

Section 4: HEENT examination workshop (60 minutes)

Logistics:

Mentors demonstrate HEENT exam. Group can decide if they want to do one at a time, or demonstrate both in sequence.

Practice today the techniques on the HNE and ENT OSCE sheets. Your examination should include:

· Inspection of head and scalp for symmetry, facial weakness deformities, scars, hair distribution, etc.

· Inspection of ears

o Pinnae and external auditory canals

o Otoscope technique

o Viewing the tympanic membrane

o Tests of hearing (finger rub or whisper, Weber and Rinne)

· Inspection of nose: patency and turbinates

· Inspection of mouth and throat:

o Mucosal color and moistness

o Normal variants

o Teeth and gums

o Tongue

o Salivary duct openings

o Uvula

o Soft and hard palate

o Tonsils

· Palpation: for

o Sinus tenderness

o Temporal arteries

o Parotid and submandibular salivary glands

Examination of the neck:

· Inspection: for symmetry, masses

· Palpation: of

o Trachea

o Cricoid cartilage

o Hyoid bone

o Carotid pulses

o Thyroid gland

· Lymph node palpation:

o Preauricular

o Postauricular

o Tonsillar

o Submandibular

o Submental

o Anterior cervical

o Occipital

o Posterior cervical

o Supraclavicular

Section 4: Evaluate session (5 minutes)

How did this session go? What could make it work better in the future?

Head, Neck & Eyes

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt

Procedure A B C Comments

1-9. LYMPH NODES: The ex should palpate the following lymph nodes.
1. preauricular – in front of ears
2. postauricular – behind the ears
2. occipital – base of the back of the neck
4. posterior cervical – back of the sternomastoid muscle
5. cervical/tonsillar – angle of jaw
6. submandibular – halfway between angle of jaw and chin
7. submental – center of body under chin
8. cervical chain – along sternomastoid muscle
9. supraclavicular – in angle formed by collarbone and sternomastoid muscle.
10. TRACHEA: Ex should place his/her thumb along each side of the trachea in the lower portion of the neck. Pt should be asked to extend neck while Ex places index finger and thumb of one or both hands on each side of the trachea below the thyroid isthmus.
11. THYROID: Ex should stand behind Pt while seated. Ex should ask Pt to bend head to neutral position or slightly forward. Two fingers of each hand should be placed on either side of the trachea. Ex should then ask Pt to swallow (or to take a sip of water) while he/she feels the isthmus. The Ex should then displace trachea to the left and ask Pt to swallow while palpating trachea. Repeat on the left side.
12. EYE INSPECTION: Ex should ask you to look upward as Ex gently moves the LOWER LIDS of each eye downward. In the same way, you should look downward as Ex gently moves the UPPER LIDS upward. Cranial Nerve II (visual acuity) is examined in special circumstances.
13. PUPIL RESPONSE: With lights OFF, Ex should shine a penlight or the light of the ophthalmoscope on each pupil. Ex should avoid shining the light into both pupils simultaneously and should not allow you to focus on the light.
14. OPHTHALMOSCOPY: With lights OFF, Ex should instruct you to look at a distant point directly in front, and focus on that point. Ex should place his/her hand on your head to orient himself/herself. Ex should hold ophthalmoscope in right hand to view your right eye and left hand to view your left eye. Ex should begin from 10” – 15” laterally and move in slowly, changing lens strength if necessary in the process, and move to 1” – 3” away from the eye until foreheads almost touch. Ex should ask you to briefly look directly into the light at some point during the exam.
15. EXTRAOCULAR MOVEMENT: Ex should be positioned in front of you and request that without moving your head, your eyes follow Ex’s finger or a pencil in four directions (“H” or “+” pattern). Ex should also ask you to look at the tip of your nose. CNIII, IV, VI

Ears, Nose and Throat

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt

Procedure A B C Comments

1. OTOSCOPY: Ex should gently pull the auricle up and back. While holding the otoscope the Ex should slowly insert the speculum with a downward and forward movement into the ear canal. Repeat with opposite ear.
2. HEARING ACUITY: Ex should ask Pt to block one ear with finger while Ex checks the auditory acuity in the opposite ear. Ex will then rub fingers together 3 ft. from the unobstructed ear and then move fingers in until Pt can hear the rubbing.
AND / OR
The Ex should whisper a word or number while standing approximately 3 feet from Pt’s side and ask him/her to repeat word.
Weber & Rinne – These are special maneuvers and are not required.
3. PATENCY: Ex should ask Pt to inhale through each nostril separately while the opposite nostril is held shut. Cranial Nerve I (sense of smell) is examined in special circumstances.
4. SPECULUM: Ex should be positioned in front of Pt while gently inserting the short wide-tipped speculum into Pt’s nostril. Ex should examine the lower portions of the nose and then ask Pt to tilt head slightly backwards.
5-7. INSPECTION:
5. Ex should use a light to inspect the buccal mucosa and the BACK of the mouth and throat. Using a tongue depressor Ex should depress more than halfway back on the tongue. Ex may have Pt phonate while inspecting the throat.
6. Ex should ask Pt to bite down. Ex will probably inspect the TEETH and GUMS at the same time using a tongue depressor or gloved finger to move the lips out of the way.
7. Ex should ask Pt to extend TONGUE and move it from side to side. Ex should use a cotton gauze or gloved finger when touching tongue. (May inspect tongue at the same time Ex is inspecting the floor of mouth).