■ Change in vision: hyperopia, presbyopia, myopia, scotomas
■ Double vision, or diplopia
■ Hearing loss, earache; tinnitus
■ Nosebleed, or epistaxis
■ Sore throat; hoarseness
■ Swollen glands
Headache is an extremely common symptom that always requires careful evaluation, since a small fraction of headaches arise from life-threatening conditions. It is important to elicit a full description of the headache and all seven attributes of the patient's pain (see p. 27). Is the headache one-sided or bilateral? Steady or throbbing? Continuous or comes and goes? After your usual open-ended approach, ask the patient to point to the area of pain or discomfort.
The most important attributes of headache are the chronologic pattern and severity. Is the problem new and acute? Chronic and recurring, with little change in pattern? Chronic and recurring but with recent change in pattern or progressively severe? Does the pain recur at the same time every day?
See Table 5-1, Headaches, pp. 170-173. Tension and migraine headaches are the most common kinds of recurring headaches.
Tension headaches often arise in the temporal areas; cluster headaches may be retro-orbital.
Changing or progressively severe headaches increase the likelihood of tumor, abscess, or other mass lesion. Extremely severe headaches suggest subarachnoid hemorrhage or meningitis.
Ask about associated symptoms. Inquire specifically about associated nausea and vomiting and neurologic symptoms such as change in vision or motor-sensory deficits.
Ask whether coughing, sneezing, or changing the position of the head have any effect (better, worse, or no effect) on the headache.
Ask about family history.
Start your inquiry about eye and vision problems with open-ended questions such as "How is your vision?" and "Have you had any trouble with your eyes?" If the patient reports a change in vision, pursue the related details:
■ Is the onset sudden or gradual?
■ Is the problem worse during close work or at distances?
■ Is there blurring of the entire field of vision or only parts of it? If the visual field defect is partial, is it central, peripheral, or only on one side?
■ Are there specks in the vision or areas where the patient cannot see (scotomas)? If so, do they move around in the visual field with shifts in gaze or are they fixed?
■ Has the patient seen lights flashing across the field of vision? This symptom may be accompanied by vitreous floaters.
■ Does the patient wear glasses?
Visual aura or scintillating scotomas with migraine. Nausea and vomiting common with migraine but also occur with brain tumors and subarachnoid hemorrhage.
Such maneuvers may increase pain from brain tumor and acute sinusitis.
Family history may be positive in patients with migraine.
Refractive errors most commonly explain gradual blurring. High blood sugar levels may cause blurring.
Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery.
Difficulty with close work suggests hyperopia (farsightedness) or presbyopia (aging vision); with distances, myopia (near-sightedness).
Slow central loss in nuclear cataract (p. 180), macular degeneration (p. 155); peripheral loss in advanced open-angle glaucoma (p. 148); one-sided loss in hemianopsia and quadrantic defects (p. 145).
Moving specks or strands suggest vitreous floaters; fixed defects (scotomas) suggest lesions in the retinas or visual pathways.
Flashing lights or new vitreous floaters suggest detachment of vitreous from retina. Prompt eye consultation is indicated.
Ask about pain in or around the eyes, redness, and excessive tearing or watering.
Check for presence of diplopia, or double vision. If present, find out whether the images are side by side (horizontal diplopia) or on top of each other (vertical diplopia). Does diplopia persist with one eye closed? Which eye is affected?
One kind of horizontal diplopia is physiologic. Hold one finger upright about 6 inches in front of your face, a second at arm's length. When you focus on either finger, the image of the other is double. A patient who notices this phenomenon can be reassured.
Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles as in horizontal diplopia from palsy of CN III or VI, or vertical diplopia from palsy of CN III or IV. Diplopia in one eye, with the other closed, suggests a problem in the cornea or lens.
Opening questions for the ears are "How is your hearing?" and "Have you had any trouble with your ears?" If the patient has noticed a hearing loss, does it involve one or both ears? Did it start suddenly or gradually? What are the associated symptoms, if any?
Try to distinguish between two basic types of hearing impairment: conductive loss, which results from problems in the external or middle ear, and sen-sorineural loss, from problems in the inner ear, the cochlear nerve, or its central connections in the brain. Two questions may be helpful . . . Does the patient have special difficulty understanding people as they talk? . . . What difference does a noisy environment make?
See Table 5-19, Patterns of Hearing Loss, pp. 196-197.
Persons with sensorineural loss have particular trouble understanding speech, often complaining that others mumble; noisy environments make hearing worse. In conductive loss, noisy environments may help.
Symptoms associated with hearing loss, such as earache or vertigo, help you to assess likely causes. In addition, inquire specifically about medications that might affect hearing and ask about sustained exposure to loud noise.
Infants may fail to respond to the parent's voice or to sounds in the environment (see p. 677). Toddlers may exhibit a delay in developing speech. Such findings deserve thorough investigation.
Medications that affect hearing include aminoglycosides, aspirin, NSAIDs, quinine, furosemide, and others.
Complaints of earache, or pain in the ear, are especially common in office visits. Ask about associated fever, sore throat, cough, and concurrent upper respiratory infection.
Pain suggests a problem in the external ear, such as otitis externa, or, if associated with symptoms of respiratory infection, in the inner ear, as in otitis media. It may also be referred from other structures in the mouth, throat, or neck.
Ask about discharge from the ear, especially if associated with earache or trauma.
Tinnitus is a perceived sound that has no external stimulus—commonly, a musical ringing or a rushing or roaring noise. It can involve one or both ears. Tinnitus may accompany hearing loss and often remains unexplained. Occasionally, popping sounds originate in the temporomandibular joint, or vascular noises from the neck may be audible.
Vertigo refers to the perception that the patient or the environment is rotating or spinning. These sensations point primarily to a problem in the labyrinths of the inner ear, peripheral lesions of CN VIII or lesions in its central pathways, or nuclei in the brain.
Vertigo is a challenging symptom for you as clinician, since patients differ widely in what they mean by the word "dizzy." "Are there times when you feel dizzy?" is an appropriate first question, but patients often find it difficult to be more specific. Ask "Do you feel unsteady, as if you are going to fall or black out? ... Or do you feel the room is spinning (true vertigo)?" Get the story without biasing it. You may need to offer the patient several choices of wording. Ask if the patient feels pulled to the ground or off to one side. And if the dizziness is related to a change in body position. Pursue any associated feelings of clamminess or flushing, nausea, or vomiting. Check if any medications may be contributing.
H The Nose and Sinuses_
Rhinorrhea refers to drainage from the nose and is often associated with nasal congestion, a sense of stuffiness or obstruction. These symptoms are frequently accompanied by sneezing, watery eyes, and throat discomfort, and also by itching in the eyes, nose, and throat.
Assess the chronology of the illness. Does it last for a week or so, especially when common colds and related syndromes are prevalent, or does it occur seasonally when pollens are in the air? Is it associated with specific contacts or environments? What remedies has the patient used? For how long? And how well do they work?
Inquire about drugs that might cause stuffiness.
Are there symptoms in addition to rhinorrhea or congestion, such as pain and tenderness in the face or over the sinuses, local headache, or fever?
Is the patient's nasal congestion limited to one side? If so, you may be dealing with a different problem that requires careful physical examination.
Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum secondary to acute or chronic otitis media
Tinnitus is a common symptom, increasing in frequency with age. When associated with hearing loss and vertigo it suggests Ménière's disease.
Feeling unsteady, light-headed, or "dizzy in the legs" sometimes suggests a cardiovascular etiology. A feeling of being pulled suggests true vertigo from an inner ear problem or a central or peripheral lesion of CN VIII.
Causes include viral infections, allergic rhinitis ("hay fever"), and vasomotor rhinitis. Itching favors an allergic cause.
Relation to seasons or environmental contacts suggests allergy.
Excessive use of decongestants can worsen the symptoms.
Oral contraceptives, reserpine, guanethidine, and alcohol
These together suggest sinusitis.
Consider a deviated nasal septum, foreign body, or tumor.
Epistaxis means bleeding from the nose. The blood usually originates from the nose itself, but may come from a paranasal sinus or the nasopharynx. The history is usually quite graphic! However, in patients who are lying down, or whose bleeding originates in posterior structures, blood may pass into the throat instead of out the nostrils. You must identify the source of the bleeding carefully—is it from the nose or has it been coughed up or vomited? Assess the site of bleeding, its severity, and associated symptoms. Is it a recurrent problem? Has there been easy bruising or bleeding elsewhere in the body?
Local causes of epistaxis include trauma (especially nose picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies.
Bleeding disorders may contribute to epistaxis.
The Mouth, Throat, and Neck
Sore throat is a frequent complaint, usually developing in the setting of acute upper respiratory symptoms.
A sore tongue may be caused by local lesions as well as by systemic illness.
Bleeding from the gums is a common symptom, especially when brushing teeth. Ask about local lesions and any tendency to bleed or bruise elsewhere.
Hoarseness refers to an altered quality of the voice, often described as husky, rough, or harsh. The pitch may be lower than before. Hoarseness usually arises from disease of the larynx, but may also develop as extralaryngeal lesions press on the laryngeal nerves. Check for overuse of the voice, allergy, smoking or other inhaled irritants, and any associated symptoms. Is the problem acute or chronic? If hoarseness lasts more than 2 weeks, visual examination of the larynx by indirect or direct laryngoscopy is advisable.
Fever, pharyngeal exudates, and anterior lymphadenopathy, especially in the absence of cough, suggest streptococcal pharyngitis, or strep throat (p. 200)
Aphthous ulcers (p. 207); sore smooth tongue of nutritional deficiency (p. 206).
Bleeding gums are most often caused by gingivitis (p. 203).
Overuse of the voice (as in cheering) and acute infections are the most likely causes.
Causes of chronic hoarseness include smoking, allergy, voice abuse, hypothyroidism, chronic infections such as tuberculosis, and tumors.
Asking "Have you noticed any swollen glands or lumps in your neck?" is advisable, since patients are more familiar with the lay terms than with "lymph nodes."
Enlarged tender lymph nodes commonly accompany pharyngitis.
Assess thyroid function and ask about any evidence of an enlarged thyroid gland or goiter. To evaluate thyroid function, ask about temperature intolerance and sweating. Opening questions include "Do you prefer hot or cold weather?" "Do you dress more warmly or less warmly than other people?" "What about blankets ... do you use more or fewer than others at home?" "Do you perspire more or less than others?" "Any new palpitations or change in weight?" Note that as people grow older, they sweat less, have less tolerance for cold, and tend to prefer warmer environments.
With goiter, thyroid function may be increased, decreased, or normal.
Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations and involuntary weight loss suggest hyperthyroidism (p. 208).
Important Topics for Health Promotion and Counseling
■ Changes in vision: cataracts, macular degeneration, glaucoma
Vision and hearing, critical senses for experiencing the world around us, are two areas of special importance for health promotion and counseling. Oral health, often overlooked, also merits clinical attention.
Disorders of vision shift with age. Healthy young adults generally have refractive errors. Up to 25% of adults over 65 have refractive errors; however, cataracts, macular degeneration, and glaucoma become more prevalent. These disorders reduce awareness of the social and physical environment and contribute to falls and injuries. To improve detection of visual defects, test visual acuity with a Snellen chart or handheld card (p. 675). Examine the lens and fundi for clouding of the lens (cataracts); mottling of the macula, variations in the retinal pigmentation, subretinal hemorrhage or exudate ( macular degeneration); and change in size and color of the optic cup (glaucoma). After diagnosis, review effective treatments—corrective lenses, cataract surgery, photocoagulation for choroidal neovascularization in macular degeneration, and topical medications for glaucoma.
Surveillance for glaucoma is especially important. Glaucoma is the leading cause of blindness in African Americans and the second leading cause of blindness overall. There is gradual loss of vision with damage to the optic nerve, loss of visual fields beginning usually at the periphery, and pallor and increasing size of the optic cup (enlarging to more than half the diameter of the optic disc). Elevated intraocular pressure (IOP) is seen in up to 80% of cases and is linked to damage of the optic nerve. Risk factors include age over 65, African American origin, diabetes mellitus, myopia, family history of glaucoma, and ocular hypertension (IOP > 21 mm Hg). Screening tests include tonometry to measure IOP, ophthalmoscopy or slit-lamp examination of the optic nerve head, and perimetry to map the visual fields. In the hands of general clinicians, however, all three tests lack accuracy, so attention to risk factors and referral to eye specialists remain important tools for clinical care.
Hearing loss can also trouble the later years. More than a third of adults over age 65 have detectable hearing deficits, contributing to emotional isolation and social withdrawal. These losses may go undetected—unlike vision prerequisites for driving and vision, there is no mandate for widespread testing and many seniors avoid use of hearing aids. Questionnaires and hand-held audioscopes work well for periodic screening. Less sensitive are the clinical "whisper test," rubbing fingers, or use of the tuning fork. Groups at risk are those with a history of congenital or familial hearing loss, syphilis, rubella, meningitis, or exposure to hazardous noise levels at work or on the battlefield.
Clinicians should play an active role in promoting oral health: up to half of all children ages 5 to 17 have from one to eight cavities, and the average US adult has 10 to 17 teeth that are decayed, missing, or filled. In adults, the prevalence of gingivitis and periodontal disease is 50% and 80% respectively. In the U.S., more than half of all adults over age 65 have no teeth at all!* Effective screening begins with careful examination of the mouth. Inspect the oral cavity for decayed or loose teeth, inflammation of the gingiva, and signs of periodontal disease (bleeding, pus, recession of the gums, and bad breath). Inspect the mucous membranes, the palate, the oral floor, and the surfaces of the tongue for ulcers and leukoplakia, warning signs for oral cancer and HIV disease.
To improve oral health, counsel patients to adopt daily hygiene measures. Use of fluoride-containing toothpastes reduces tooth decay, and brushing and flossing retard periodontal disease by removing bacterial plaques. Urge patients to seek dental care at least annually to receive the benefits of more specialized preventive care such as scaling, planing of roots, and topical fluorides.
Diet, tobacco and alcohol use, changes in salivary flow from medication, and proper use of dentures should also be addressed.** As with children, adults should avoid excessive intake of foods high in refined sugars, such as sucrose, which enhance attachment and colonization of cariogenic bacteria. Use of all tobacco products and excessive alcohol, the principal risk factors for oral cancers, should be avoided.
Saliva cleanses and lubricates the mouth. Many medications reduce salivary flow, increasing risk of tooth decay, mucositis, and gum disease from xerostomia, especially for the elderly. For those wearing dentures, be sure to counsel removal and cleaning each night to reduce bacterial plaque and risk of malodor. Regular massage of the gums relieves soreness and pressure from dentures on the underlying soft tissue.
*U.S. Preventive Services Task Force: Guide to Clinical Preventive Services (2nd ed), pp. 711-721. Baltimore, Williams & Wilkins, 1996.
**Greene JC, Greene AR: Chapter 15: Oral Health. In Woolf SH, Jonas S, Lawrence RS (eds): Health Promotion and Disease Prevention in Clinical Practice, pp. 315-334. Baltimore, Williams & Wilkins, 1996.
Preview: Recording the Physical Examination— The Head, Eyes, Ears, Nose, and Throat (HEENT)
Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination.
HEENT: Head—The skull is normocephalic/atraumatic (NC/AT). Hair with average texture. Eyes—Visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm constricting to 2 mm, equally round and reactive to light and accommodations. Disc margins sharp; no hemorrhages or exudates, no arteriolar narrowing. Ears—Acuity good to whispered voice. Tympanic membranes (TMs) with good cone of light. Weber midline. AC > BC. Nose—Nasal mucosa pink, septum midline; no sinus tenderness. Throat (or Mouth)—Oral mucosa pink, dentition good, pharynx without exudates.
Neck—Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.
Lymph Nodes—No cervical, axillary, epitrochlear, inguinal adenopathy. OR
Head—The skull is normocephalic/atraumatic. Frontal balding. Eyes—
Visual acuity 20/100 bilaterally. Sclera white; conjunctiva infected. Suggests myopia and mild arteriolar
Pupils constrict 3 mm to 2 mm, equally round and reactive to light and narrowing. Also upper respiratory accommodation. Disc margins sharp; no hemorrhages or exudates. infection.
Arteriolar-to-venous ratio (AV ratio) 2:4; no A-V nicking. Ears—Acuity diminished to whispered voice; intact to spoken voice. TMs clear. Nose— Mucosa swollen with erythema and clear drainage. Septum midline. Tender over maxillary sinuses. Throat—Oral mucosa pink, dental caries in lower molars, pharynx erythematous, no exudates.
Neck—Trachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph Nodes—Submandibular and anterior cervical lymph nodes tender, 1 x 1 cm, rubbery and mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.
Because abnormalities covered by the hair are easily missed, ask if the patient has noticed anything wrong with the scalp or hair. If you note a hairpiece or wig, ask the patient to remove it.
The Hair. Note its quantity, distribution, texture, and pattern of loss, if any. You may see loose flakes of dandruff.
The Scalp. Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.
The Skull. Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or tenderness. Familiarize yourself with the irregularities in a normal skull, such as those near the suture lines between the parietal and occipital bones.
The Face. Note the patient's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.
The Skin. Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution, and any lesions.
Fine hair in hyperthyroidism; coarse hair in hypothyroidism. Tiny white ovoid granules that adhere to hairs may be nits, or eggs of lice.
Redness and scaling in seborrheic dermatitis, psoriasis; pilar cysts (wens)
Enlarged skull in hydrocephalus, Paget's disease of bone. Tenderness after trauma
See Table 5-3, Selected Facies (p. 175).
Acne in many adolescents. Hirsutism (excessive facial hair) in some women
Important Areas of Examination
■ Visual acuity
■ Visual fields
■ Conjunctiva and sclera
■ Extraocular movements
■ Fundi, including Optic disc and cup Retina
Visual Acuity. To test the acuity of central vision use a Snellen eye chart, if possible, and light it well. Position the patient 20 feet from the chart. Patients who use glasses other than for reading should put them on. Ask
Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision the patient to cover one eye with a card (to prevent peeking through the fingers) and to read the smallest line of print possible. Coaxing to attempt the next line may improve performance. A patient who cannot read the largest letter should be positioned closer to the chart; note the intervening distance. Determine the smallest line of print from which the patient can identify more than half the letters. Record the visual acuity designated at the side of this line, along with use of glasses, if any. Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of patient from chart, and the second, the distance at which a normal eye can read the line of letters.
Testing near vision with a special handheld card helps to identify the need for reading glasses or bifocals in patients over age 45. You can also use this card to test visual acuity at the bedside. Held 14 inches from the patient's eyes, the card simulates a Snellen chart. You may, however, let patients choose their own distance.
If you have no charts, screen visual acuity with any available print. If patients cannot read even the largest letters, test their ability to count your upraised fingers and distinguish light (such as your flashlight) from dark.
Visual Fields by Confrontation
Screening. Screening starts in the temporal fields because most defects involve these areas. Imagine the patient's visual fields projected onto a
could read at 200 feet. The larger the second number, the worse the vision. "20/40 corrected" means the patient could read the 40 line with glasses (a correction).
Myopia is impaired far vision.
Presbyopia is the impaired near vision, found in middle-aged and older people. A presbyopic person often sees better when the card is farther away.
In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less. Legal blindness also results from a constricted field of vision: 20° or less in the better eye.
Field defects that are all or partly temporal include homonymous hemianopsia, bitemporal hemianopsia,
and quadrantic defects.
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