OnExam

Skin

Covered in greater details under the Integumentary System History

Ask about:

• Colour
• Texture/thickness
• Change in hair distribution
• Hirsutism: excess facial hair in women (increased androgen production)
• Alopecia
• Changes in hair
• Fine hair (hyperthyroidism)
• Coarse hair (hypothyroidism)
• Flakes of dandruff or redness and scaling (seborrheic dermatitis, psoriasis)
• Increased itching (if particularly at night: nits or lice)
• Rashes
• Lesions - Onset, location, duration, evolution, aggravating and alleviating factors
• Size
• Shape
• Colour
• Bleeding
• Pain
• Scaling
• Lumps
• Moles: change in colour or size
• Dryness or itching
• Associated Symptoms: Nausea, Vomiting, anorexia, malaise, weight loss, fever, chills, pain, pruritus
• Red flags: fever, weight loss, malaise and arthralgias

Head

• Trauma
  • Glasgow Coma Scale score
• Headache
• Onset and frequency
  • Early morning (increased intra-cranial pressure, depression headache)
  • Changing pattern from acute to chronic headache or progressively severe headaches increase likelihood of tumour, abscess or other mass lesion(s)
• Location
• Associated nausea
• Could signify brain tumour(s) or subarachnoid haemorrhage
• Chronic use of analgesics
• Analgesic rebound headaches: 50% of patients with chronic daily headaches
• Dizziness: light-headedness or vertigo
• Loss of balance
• Does the patient mean syncope or pre-syncope?
• Is it associated with positional change (as in orthostatic hypotension)
• Stressful precipitating events (as in vasovagal syncope)
• Tinnitus

Specific Types of Headaches

• Tension headache
• Occipital or temporal
• Unilateral or bilateral
• Cluster headache
• Usually unilateral
• Periorbital
• Occur daily
• Usually at night for several weeks
• Often present with ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of eye and ptosis
• Lasts between 15 min and 3 h
• Migraine
• Unilateral (sensitivity: 66%, specificity: 78%)
• Nausea and/or vomiting (sensitivity: 82%, specificity 96%)
• Aura
• Visual changes: visual aura, scintillating scotomas (sensitivity: 43%, specificity: 74%)
• Temporal/giant cell arteritis
• Tenderness of the adjacent scalp
• > 50 yo (99%)
• Fever (50%)
• New headache (60%)
• Jaw claudication (50%)
• Visual loss or blindness (15-20%)
• Polymyalgia rheumatica (50%)
• Fatigue
• Anorexia
• Weight loss
• Nausea and/or vomiting specificity: 74%)

Common Headaches
Primary	Secondary	Intracranial	Secondary
Tension Migraine Cluster	-Withdrawal (analgesic over use, caffeine, alcohol) -Infections -Electrolyte disturbances -Structures of skull (ears, eyes, sinuses and teeth) -Trauma -Cerebrovascular disorder -Pressure changes in cerebrospinal fluid	-Vascular (stroke, temporal arthritis, intracranial, hematoma) -Non-vascular (mass lesion, abscess)	-Glaucoma -Optic neuritis -TMJ -Co poisoning

Eyes

Covered in greater detail under the Ophthalmological History

Ask about:

• Use of corrective lenses
• Date of last eye examination
• Vision changes (hyperopia, myopia, presbyopia, astigmatism)
• Visual loss: gradual vs. sudden
  • Sudden: retinal detachment, vitreous haemorrhage, occlusion of the central retinal artery
  • Location of loss
• Diplopia: horizontal vs. vertical
• Blurred vision
• Floaters, flashing lights or a curtain/veil over vision
• Location of blurred vision
• Moving specks or strands suggest vitreous floaters
• Fixed defects suggests lesions in the retina or visual pathway
• May indicate detached retina (an ophthalmologic emergency)
• Eye pain
  • Narrow-angle glaucoma: eye pain, seeing halos around lights, nausea/vomiting and sudden change in vision
• Redness and discharge
  • Subconjunctival haemorrhage: sharply demarcated red area without pain, visual changes, discharge, change in pupil, and a clear cornea
  • Conjunctivitis: diffuse dilation of conjunctival vessels with redness that is maximal peripherally, mild discomfort, mild blurring of vision, watery discharge (viral), purulent discharge (bacterial)
• Excessive dryness/tearing eyes
  • Increased production (conjunctival inflammation, corneal inflammation)
  • Impaired drainage (ectropion, nasolacrimal duct obstruction)
• Itching
  • Seasonal/environmental allergies, asthma, eczema, hay fever, foreign body

Ears

Ask about:

• Hearing loss
  • Acute vs. gradual
  • Bilateral vs. unilateral
  • Family history of hearing loss
• Use of hearing aids
• Last hearing examination (audiometry)
• Tinnitus
  • Unilateral vs. bilateral
  • Intermittent vs. constant
  • Recent head trauma
  • Sound exposure (occupational, shooting ranges, MP3 players, etc.)
  • High vs. low pitch
  • Pulsating or continuous
  • Presence/absence of hearing loss
  • Presence/absence of vertigo
  • Recent medication exposure: aminoglycosides, ASA, loop diuretics, cisplatin (chemotherapy), anti-malarial agents
  • Concomitant neurological illness: MS, acoustic neuroma
  • Otologic source: Otitis media, otosclerosis, Meniere's disease
• Vertigo
  • Differentiate true vertigo from light-headedness
  • "Is environment spinning (true vertigo) or are you spinning"
  • Is vertigo reproducible with changes in movement? (As in benign paroxysmal positional vertigo)
  • Duration (Seconds with BPV, minutes with TIA's, days with Meniere's and viral labyrinthitis)
  • Associated with hearing loss/tinnitus? (As in Meniere's disease)
• Blurred vision
• Otalgia
  • History of ear infections
  • Foreign body in ear canal
  • Ramsay Hunt syndrome
  • Bell's palsy
  • Referred pain from the eustachian tube, TMJ, trismus, teeth, tonsils, throat, etc.
• Otorrhea
  • Amount
  • Colour
  • Smell

  Types of hearing loss
  Conductive	Sensorineural
  -External ear (obstructed, otitis externa, tumor, trauma, congenital) -Middle ear (congenital, otitis media, tumors, eustachian tube dysfunction, tympanic membrane perforation)	-Congenital/hereditary (teratogens, infections, meningitis) -Adults (noise exposure, ototoxic drugs, meniere's, Multiple sclerosis, CVA, syphilis, diabetes, trauma)

Nose and Sinuses

Ask about:

• Nasal congestion/obstruction
  • Unilateral vs. bilateral
  • Acute: < 4 weeks
  • Subacute: 1-3 months
  • Chronic: > 3 months
• Cough (acute vs. chronic)
• Rhinorrhea: watery vs. purulent, presence of blood
• Post-nasal drip
• Facial pressure/sinus pain
• Halitosis (bad breath)
• Known allergies: itching, sneezing
• Change in smell
• Recent or past traumas/surgeries
• Epistaxis
  • Air moisture content
  • Foreign body
  • Intranasal drug use
  • Facial trauma
  • Anticoagulation therapy
• Snoring
  • Obstructive sleep apnea: snoring, obesity and increased levels of fatigue
• Frequent sinus infections
  • Number of antibiotics last year
  • Use of nasal steroid sprays and saline solutions
  • Over-the-counter remedies
• Environmental exposures/allergies

Mouth

Ask about:

• Dental history
• Condition of teeth and gums
• Last dental examination
• Bleeding gums
• Cold sores (HSV1)
• Use of tobacco
  • Chewing and smoking tobacco are both associated with increased risk for oral cancer
• Use of dentures
  • Appropriate fit
  • Difficulty breathing
• Dry mouth (xerostomia)
  • Concomitant dry eyes may indicate Sjögren’s syndrome

Neck

Ask about:

• Neck Mass
• Location (lateral vs. midline)
• Unilateral vs. bilateral
• Onset, duration, rate of growth
• Tenderness
• Non-tender, slow growing mass is suggestive of malignancy
• Tender, rapid onset of swelling is more suggestive of acute infectious etiology
• Referred otalgia
• Dysphagia, globus sensation
• Hoarseness
• Age of patient: pediatric vs. adult
• Risk factors for cancer (tobacco use, alcohol, radiation)
• Consititutional symptoms (fever, chills, night sweats, weight loss)
• Previous infections, oral or skin lesions, biopsies
• Swollen neck or glands
• Symptoms of thyroid disease
• Iodine deficiency
• Presence of foreign body
• HIV infection
• Malignancy
• Dentures (sialadenitis)
• Pain or stiffness in the neck
  • Recent trauma/whiplash
  • Herpes zoster infection
  • Recent symptoms of infection
  • Rule out meningitis

Throat

Ask about:

• Sore throat
  • Assess strep throat score
• Odynophagia/dysphagia
  • Worse with solids or liquids
  • Location of pain/discomfort
• Globus
• Gastroesophageal reflux disease (GERD)
  • Heartburn
  • Differentiate from cardiac, pulmonary, or vascular chest pain
  • Acidic taste in the mouth
  • Chronic cough/clearing throat
  • Hoarseness
  • Alcohol and caffeine intake
  • Associations with postural changes (lying or bending over)
• Hoarseness
  • Smoking history
  • Recent inhalation of toxic fumes
  • Dysphagia
  • Hemoptysis
  • Hoarseness >2 wk: ENT referral
  • Trauma
  • Surgeries
  • Lymphoma
  • Shortness of breath
  • Ability to cough
• Chronic or acute cough
  • Production of sputum: purulent vs. mucoid
  • Medications
  • Foreign body
  • Signs of infection
  • Ability to cough
• Chronic halitosis

Thyroid
Hypothyroidism	Hyperthyroidism
-Impaired hearing, hoarseness -Dyspnea -Weight gain, decreased appetite, constipation -Menorrhagia -Arthralgia, myalgia, weakness, paresthesia, dry/itchy skin -Poor concentration or memory, depression -Fatigue -Cold intolerance	-Diplopia, eye irritation -Palpitations -Weight loss, increased appetite, diarrhea -Oligomenorrhea, loss of libido, polyuria -Weakness -Tremor, dysphoria -Irritability, heat intolerance, hyperactivity