H&P HEENT exam

acromegaly

overproduction of GH, pronounced facial features, nose/ lips/ ears/ forehead become broader and larger, underbite

hypothyroidism

facial edema, apathetic facies, dry/ course/pale skin, absence of lateral eyebrows

hyperthyroidism

weight loss, fine brittle hair, bilateral exophthalmos, lid lag

Cushing's disease

excess cortisol, moon facies, acne, facial hair growth and scalp hair loss

Nephrotic syndrome

edema on face, periorbital edema, most pronounced in the morning

Parkinson's disease

progressive neurologic disease, "masked" facies, bradykinesia, distal tremor

Hydrocephalus

enlarged skull circumference, secondary to excess accumulation of fluid in brain, blockage of CSF flow or absorption

Paget's disease

frontal bossing, prognathism (jaw protrusion), often asymptomatic, bone pain most common symptom

migraine headache

unilateral, improves with sleep, provoked by lack of sleep stress alcohol foods infections and menses, pounding or throbbing

scintillating scotoma

common aura that includes flashes or zigzag arcs of light

complex migraine

associated focal neurologic symptoms with headache

cluster headache

abrupt, peak within minutes, unilateral, retro-orbital headache, deep continuous severe, clustered several daily for weeks; lacrimation, rhinorrhea, scleral injection, ipsilateral miosis or ptosis (Horners); "Suicide headaches"

tension headache

gradual onset, bilateral localized to base of skull or retro-orbital, aggravated by sustained muscle tension, band-like

meningitis

classic triad: fever, headaches, nuchal rigidity

acute glaucoma

sudden onset unilateral retro-orbital pain, provoked by pupillary dilation (movie theater), triad: cloudy cornea, scleral injection, fixed mid-position pupil (does not react to light)

trigeminal neuralgia

aka tic douloureux; unilateral compression of cranial nerve V; affects ipsilateral cheek, jaw, lips, gums; electric shock quality; provoked by brushing teeth, shaving, eating, exposure to cold air

anterior triangle

borders: SCM, mandible, trachea

posterior triangle

borders: SCM, clavicle, trapezius

supraclavicular lymphadenopathy

major red flag for cancer on neck exam

occipital nodes

lymphadenopathy suggest scalp infection

posterior auricular nodes

lymphadenopathy suggest rubella or roseola

preauricular nodes

lymphadenopathy suggest conjunctivitis

cervical nodes

lymphadenopathy suggest URI, strep, EBV, primary bacterial adenitis

palpebral fissure

elliptical opening between eyelids

limbus

junction between sclera and cornea

palpebral conjunctiva

lines the eyelids

levator palpebrae

muscle that raises the upper eyelid

tarsal plate

fibrous layer that gives lids shape, strength, and place for muscular attachment

meibomian glands

lie within tarsal plate, 1 place where tears originate

lacrimal gland

within superior and lateral bony orbit; produces tears that drain medially through lacrimal punctac

cornea

transparent part of anterior eye, covers iris and pupil; highly innervated

corneal reflex

mediated by cranial nerves V (trigeminal; detects threat) and VII (facial; motor response)

sclera

tough, protective, white covering beneath bulbar conjunctiva and continuous anteriorly with cornea; may be yellow in jaundiced patients

iris

pigmented circular contractile disc, contains smooth and radial muscles; controls pupillary size

lens

transparent structure located behind pupil; keeps objects in focus on retina via accommodation; separates anterior and posterior chambers from vitreous chamber

ciliary body

controls shape of lens and produces aqueous humor

introcular pressure

controlled by flow of aqueous humor

aqueous humor

clear fluid located in chambers posterior to cornea and anterior to lens, ciliary body, and suspensory ligament

vitreous humor

gelatinous fluid located in chamber posterior to lens and anterior to retinam

macula

lateral to optic disc; sharp, central vision (reading, faces)

strabismus

inability to align both eyes simultaneously

esotropia

affected eye deviated nasally

exotropia

affected eye deviated temporally

chalazion

chronic painless nodule of upper or lower lid due to chronically obstructed meibomian gland

hordeolum

tender, red swelling at lid margin; acutely obstructed meibomian gland; causes inflammation and secondary infection

blepharitis

flaking of base of eyelashes; foreign body sensation, red swollen eyelids

xanthelasma

raised, yellow plaques along nasal portion of eyelids; dyslipidemias

entropion

inward turning of lid margin; lashes irritate conjunctiva and cornea

ectropion

outward turning of lid margin; exposed palpebral conjunctiva results in excess tearing

conjunctivitis

diffuse scleral injection; watery mucoid or purulent discharge; no effect on visual acuity, pupil reactivity, or extraocular movements; buzz words: chemosis and cobblestoning

pingecula

benign yellow triangular node on bulbar conjuctiva near limbus; UV light exposure is #1 risk factors; does not affect vision

pterygium

aka surfer's eye; elevated pink fleshy tissue begins on bulbar conjunctiva and may extend over cornea; UV light #1 risk; may reduce visual acuity if extends over cornea

subconjunctival hemorrhage

usually benign; blood leaks into sclera producing sharply demarcated lesion; no pain, drainage, or vision changes; may follow sudden increase in BP

episcleritis

local inflammation of episcleral vessels; mild discomfort; consider underlying RA, lupus, Sjorgren's

icterus

yellow sclera; may also have RUQ pain, clay colored stool, dark urine

arcus senilis

grey-ish white arc near corneal edge; benign in elderly, suggest hyperlipidemia in young patients

Kayser-fleischer ring

gold or reddish-brown ring around cornea due to copper deposition (Wilson's disease); presents with liver disease, renal failure, neuro and psych symptoms

corneal abrasion

moderate to severe pain and tearing; scleral redness; no effect on eye function

keratitis

severe pain and scleral redness especially at limbus; HSV results in classic dendrite formation of fluorescein stain

corneal scar

superficial grey-ish white opacity; from old injury

cataract

clouding of lens; very common cause of vision loss over 40yo; risks: DM, HTN, smoking, prolonged steroid use

dacryoadenitis

inflammation or infection of lacrimal gland (lateral upper lid)

dacryocystitis

inflammation or infection of lacrimal sac (medial); may progress to periorbital cellulitis

dacryostenosis

nasolacrimal duct obstruction; chronic tearing

anisocoria

difference in pupil size by 0.4mm or more; greater in bright light, larger pupil is abnormal; greater in dim light, smaller pupil is abnormal

mydriasis

dilation of pupils; sympathetic control; closed head injury

miosis

pupil constriction; parasympathetic control; opiate OD, stroke, Horner's

oculomotor nerve

cranial nerve that mediated pupillary near response

Argyll robertson pupil

small bilateral irregular pupils; accommodate but do not react to light; tertiary syphilis

lateral rectus muscle

lateral gaze (abduction); cranial nerve VI

medial rectus muscle

medial gaze (adduction); cranial nerve III

superior oblique and inferior rectus

downward gaze; cranial nerves IV and III

inferior oblique and superior rectus

upward gaze; cranial nerve III

third nerve palsy

pupil is fixed and dilated; eye deviated down and laterally; concern for cerebral aneurysm

Adie's pupil

benign idiopathic condition; unilateral dilated round pupil; poor/absent reaction to light; may lose deep tendon reflexes

bitemporal hemianopsia

bilateral temporal defects; aka tunnel vision; problem at optic chiasm, seen with pituitary lesions

homonymous hemianopsia

R or L field of vision in both eyes lost; lesion/stroke involving optic tract on opposite side

fundus

includes retina, retinal vessels, optic disc, optic nerve, macula, fovea

papilledema

bilateral swelling of optic nerves resulting in irregular disc borders; due to increased intracranial pressure; no visible spontaneous venous pulsations

cotton wool patches

yellow-white slightly elevated lesions resembling clouds; located 1-2 disc diameters from optic nerve at 11 and 12 oclock; caused by retinal nerve microinfarcts (DM or HTN retinopathy)

retinal hemorrhages

areas of bleeding within retina; seen in DM retinopathy, central retinal vein occlusion; pathognomonic for shaken baby syndrome

AV nicking

focus on site where arteriole crosses a venule, venule appears nicked from pressure of thickened overlying arteriole; sign of poorly controlled HTN

diabetic retinopathy

#1 diabetic eye disease; leading cause of blindness; microaneurysms, hemorrhages, cotton wool spots, neovascularization are hallmark findings

Roth spots

white-centered hemorrhages; originally described with endocarditis; also seen in leukemia, DM, collagen vascular diseases

central retinal artery occlusion

sudden onset profound unilateral vision loss; painless!; cherry red macula

central retinal vein occlusion

sudden onset profound unilateral vision loss; painless! optic disc edema and diffuse hemorrhage in all 4 quadrants; blood and thunder fundus

retinal detachment

sudden onset painless sensation of black curtain dropping over visual field; flashing dots or lights; severe vision loss if macula affected

vitreous hemorrhage

common cause of acute vision loss; sudden onset, painless; visual haze, floaters, cloudy visions, perceptions of shadows/ cobwebs; pathognomonic for shaken baby syndrome; diabetic retinopathy also common cause

age-related macular degeneration

gradual loss of central vision; painless; elderly at highest risk; macula atrophies (dry AMD) then neovascularizes (wet AMD)

cataracts

gradual onset, painless, clouding of lens; #1 cause of blindness in world; complain of increased glare at night

corneal ulcers

painful FB sensation; depressed white corneal lesion, red sclera; location determines degree of vision loss; extended contact lens wearers at risk

iritis

severe deep aching pain; irregular or small pupil; scleral erythema with ciliary flush; secondary to IBD, connective tissue disease, malignancy

hyphema

collection of RBCs in anterior chamber causing pain and loss of vision; posttraumatic (paintball), spontaneous, post-op

acute glaucoma

sudden onset retro-orbital pain and vomiting; provoked by pupil dilation (movies); severe aching pain, halos around lights; triad: fixed mid-position pupil size, cloudy cornea, marked scleral erythema; increased IOP confirms Dx

optic neuritis

inflammation of optic nerve results in retro-orbital pain provoked by eye movement and vision loss; central scotoma; associated with MS; unilateral swollen optic disc

temporal arteritis

unilateral temporal HA, unilateral temporal artery tenderness and weak temporal artery pulse; jaw claudication

horizontal diplopia

cranial nerve III or VI palsy

vertical diplopia

Cranial nerve III or IV palsy

otitis externa

swimmers ear; inflammation of external auditory canal; pain with movement of pinna or palpation of tragus; red and swollen with discharge

acute otitis media

inflammation of TM and middle ear fluid; red bulging immobile TM