Physical Exam (

HEENT)

Head / Hair Face Eyes Ears Nose Oral / Throat Neck

Headache Scalp Skull Hirsutism (excessive facial hair) may appear

1. Severity, 2. Chronologic Pattern, 3.
Associated Symptoms
Migraine and Tension HA are episodic
New and persisting raise concern for Tumor,
Abscess, Mass Lesions
Unilateral HA occurs in Migraine and Cluster
Tension arise in Temporal area
Cluster may be retro-orbital
Nausea and Vomitting common, also w/ brain
tumors and Subarachnoid Hemorrhage
60-70% Migraine have symptom prodrome,
visual aura: spark photopsias (flashes of
light), fortifications (zig zag arcs of light),
and scotomas (areas of visual loss with
surrounding normal vision
Valsalva and lying down may increase pain
due to mass lesions due to changing ICP
Tension HA predominates
Primary HA
Migrain, Tension, Cluster, Chonic Daily HA Meniningitis, Subarachnoid Hemorrhage
Thunderclap in 70% SubArachnoid, preceded
by sentinel leak HA (vascular leak)
on some women with Polycystic Ovary Random Hearing Loss Sinuses Pharyngitis Anterior Triangle
Syndrome
Inspect for: scaliness, lumps, nevi, or lesions Enlarged - hydrocephalus or Paget Dz of
bone (weakens) Sensorineural - Inner ear, cochlear nerve, or Conductive - External or middle ear Age related - most important risk factor for Valsalva and leaning forward may increase Acute, associated with URI. Large Tonsils Mandible, SCM, Midline Neck
Presbyopia - aging vision its central connections in brain hearing loss pain in Sinusitis.
Acne - common in adolescents
Redness or scaling may indicate Seborrheic
dermatitis or psoriasis Head trauma may present tenderness or bony External causes: Cerumen impaction, Centor's Criteria: Normal tonsils may be large without being Posterior Triangle
Often sees better when card is further away Sound is heard longer through Air (AC>BC) infection (otitis externa), trauma, squamous Presybycusis Congenital from single gene mutation Acute Bacterial Sinusitis (now Rhinosisnusitis) infected, esp in children- normally pink
step-offs
cell carcinoma, and benign bony growth such unlikely Viral URI symptoms persist more
Soft lumps may be Pilar Cysts (wens) as Exostoses or Osteomas than 7 days; both purulent drainage and Rules for Streptococcal and Fusobacterium SCM, Trapezius, Clavicle
Legally blind: Vision in the better eye, Trouble understanding speech, complaining Most common age-related cause Other factors: syphilis, rubella, meningitis, facial pain should be present for diagnosis necrphorum pharyngitis Exudative tonsils: red with white exudate
Temporal Artery
corrected by glasses is 20/200 or less. others mumble, worse in noisy environments diabets, inner ear infections, exposure to together with fever and enlarged cervical Great Vessels
Middle Ear causes: Otitis media, congenital ototoxic agents, frequent use of headphones, Rhinorrhea nodes suggest infection (STREP) or
Pigmented Nevi concern for Melanoma
Passes upward in front of ear, conditions, cholesteotomas and otosclerosis, Degenerating hair cells in the ear lead to exposure to hazardous noise, battlefield. CAFE: C - Cough (absent), A- Adenopathy, F- mononucleosis.
Also from constricted field of vision= 20* or Inner ear causes: Congenital and hereditary tumors and perforation of TM gradually progressive hearing loss, Fever (present), E- Exudate (tonsillar) Carotid Artery, Internal / External Jugular
less (in the better eye) conditions, Presbycusis, viral infection such particularly high-frequency sounds Drainage from nose associated with nasal Rhinitis
Hair
as Rubella and Cytomegalovirus, Meniere Dz, Medications affect hearing: Aminoglycosides, congestion, a sense of stuffiness or
noise exposure , ototoxic drug exposure and Noisy environments may help Aspirin, NSAIDs, Quinine, Furosemide obstruction Enlarged Lymph Nodes commonly Midline: Mobile Hyoid, Thyroid Cartilage, Lymph Nodes:
Ultraviolet (UV) light can damage eyes and acoustic neuroma Viral: mucosa is red and swollen accompany pharyngitis Cricoid Cartilage, Tracheal Rings, Thyroid
Texture
cause skin cancers on eyelids including: basal Gland
cell carcinoma, squamous cell carcinoma and Sound is heard through bone as long as or Causes include: Viral infection, Allergic Hoarseness Enlargement of a supraclavicular node (
melanoma longer than through air (BC=AC) or (BC>AC) Rhinitis "hay Fever" and Vasomotor Rhinitis ( Allergic: pale, bluish or red especially Left) suggests possible metastasis
Coarse hair - Hyperthyroidism Fine hair - Hypothyroidism
itching favors allergic reaction) JVD is hallmark of CHF from thoracic or an abdominal malignancy
Otitis-Pain Dz in larynx to extralaryngeal lesions pressing
Potential Cataracts - use sunscreen on face Nasal Polyps-pale saclike growths of on laryngeal nerves
and eyelids, sunglasses Season onset or environment triggers suggest inflamed tissue that can obstruct air passage Tender nodes suggest inflammation: hard or
Otitis Externa (external ear canal) Otitis Media (middle ear) Allergic Rhinitis or sinuses. fixed nodes suggest malignancy
Ask about environmental allergies, acid
Vitreous Floaters reflux, smoking, alcohol use, inhalation of Stridor- ominous, high pitched musical sound
Acute Otitis Externa / Acute or Chronic Otitis Tenderness behind the ear Drug induced in excessive use of topical fumes/irritants or talks a lot at work? from severe subglottic or tracheal
Media with perforation present with yellow- decongestants or Cocaine obstruction signals respiratory emergency.
Fixed defects, moving specks, between Lens green discharge
and Fundus. Scotomas (partial loss of vision / Acute: purulent, look for red bulging drum Epistaxis Acute: voice overuse, acute laryngeal Over 2 weeks: refer for laryngoscophy,
blind spot) and amber drum of serous effusion, decrease laryngitis, possible neck trauma Hypothyroidism, reflux, vocal cord nedules,
Painful movement of the auricle and tragus " mobility of TM head and neck cancers including thyroid Cause: epiglottitis, FB, goiter, stenosis from
tug test" Trauma, Nose-picking (common), masses, neurologic disorders (Parkinson Dz, artificial airway.
Protrusion - Graves Disease / Ocular tumors Inflammation, drying, crusting of nasal Amyotrophic Lateral Sclerosis, Myasthenia
mucosa, tumors and FB Gravis
Myopia - nearsightedness: light rays focus Acute: canal is often swollen, narrowed,
anterior to the retina moist, pale and tender and may be reddened Tongue
DDx: Hemoptysis - cough up blood, or
Secondary HA
Hematemesis - vomited blood
Hyperopia - farsightendness: light rays focus Chronic: skin of canal is often thick, red, and Aphthous Ulcers sore smooth tongue of Leukoplakia Asymmetric protrusion suggests lesion of CN
posterior to the retina itchy nutritional deficiencies XII (tongue points toward side of the lesion
Anticoagulants, NSAIDs, vascular
Tinnitus malformations, and coagulopathies can Thickened white patch in oral mucosa
Optic Nerve: contribute Chronic (>2 weeks) Prolonged tobacco or Geographic Tongue: benign condition of
alcohol use, cough or hemoptysis, weight tongue, scatter smooth red areas denuded of
A&P loss, or unilateral throat pain = thyroid? Oral Hairy Leukoplakia - sides of tongue, papillae, give map like appearance
RAPD - swinging flashlight test Common, increasing with age feathery or corrugated. Cannot be scrapped
off. Yellow-brown elongated papillae,
Tenderness of nasal tip or Alae suggest local benign. Fissured Tongue: fissures appear with
Marcus Gunn Pupil infection such as furuncle, if small increasing age/Down syndrome. Benign, food
When associated with hearing loss and erythematous and swollen debris may accumulate in crevices and irritate
vertigo suspect Meniere Dz
Miosis - constriction of pupils Caused by Epstein-Barr virus and is seen in
HIV/AIDS
Deviation of septum is common, rarely Smooth Tongue (ATROPHIC Glossitis)
Mydriasis - dilation of pupils obstructs airflow Smooth often sore tongue has lost its
Perceived sound has no external stimulus-
papillae, nutritional deficiency or
ringing.
chemotherapy
Fluid Fresh blood or crusting may be seen, septal
Dizziness & Vertigo
perforation may be from trauma, surgery, and Gums
intranasal use of cocaine or amphetamines,
also Septal Ulcerations
Excessive tearing caused by Junctival Vertigo - sensation of true rotational
Inflammation or Corneal irritation, or impaired Gingivitis
movement
drainage by Ectopian & Nasolacrimal duct
obstruction Malignant tumors of nasal cavity occur rarely,
assoc. with exposure to tobacco and Black line indicates lead poisoning
Vertigo represents Vestibular Dz
chronically inhaled toxins
Dryness from impaired secretion in Sjogren Periodontal Disease
syndrome Benign positional vertigo, labyrinthitis,
Deviated nasal septum, nasal polyp, Foreign
vestibular neuritis, Meniere Dz.
Body, Wegener Granuloma ( necrotizing
vasculitis ), or Carcinoma Risk Factors: low income, male gender,
Anterior Pathway
smoking, diabetes and poor oral hygiene
Ataxia, diplopia, and dysarthria signal central
neurologic cause in cerebellum or brain stem
Glaucoma, Optic Neuropathy, Optic Neuritis, such as cerebral vascular Dz or posterior
Glioma fossa tumor, also Migraine. S/S: bleeding, pus, recession of gums, bad
breath

Posterior Pathway Feeling lightheaded, weak in legs, or about to Thyroid

faint points to PREsyncope from Arrhythmia,
orthostatic HOTN, or Vaso-vagal stimulation
Stroke, Chiasmal Tumors Goiter Hypothyroidism Hyperthyroidism Graves Dz

Expophthalmos Sensations point primarily to Labyrinths of

Unusual forward protrusion, 50% of Grave's
Dz
Corneal Arcus: thin grayish white arc or circle
towards edge of cornea (normal aging)
Arcus Senilis: opacities of cornea may
present as thin gray arc or circle not yet at
edge (limbus) w/ aging
Hyphema: blood in Anterior chamber
Pinguecula: collection of fat medial or lateral
of iris does NOT extend into cornea
Pterygium: triangular thickening of bulbar
conjunctiva that grows slowly (insidious)
across outer cornea, usually nasal side and
may interfere w/ pupil
Blepharitis - red,inflamed lid margins, often
with crusting
Scales (suborrheic dermatitis) SCURF
Failure to close eye lids exposes Corneas to
serious damage
Lacrimal Apparatus: Lacrimal Gland swelling (
Dacryocystitis)
inner ear, lesions of CN VIII, or lesions of Enlarged Thyroid gland: Temperature Intolerance to cold, weight gain, dry skin and Intolerance to heat, weight loss, moist velvety Thyroid is soft and may be nodular. Localized
central pathways or nuclei in brain intolerance and sweating slowed heart rate skin, and palpitations systolic or continuous bruit may be heard
A&P
Lateral sparseness of Eyebrows Lid lag: rim of sclera is visible above iris with Hashimoto Thyroiditis
downward gaze
Exostosis: nontender nodular swelling
covered by normal skin deep in the ear Thyroid is firm, although not always
canals, nonmalignant overgrowth may Proptosis: abnormal protrusion of eyeballs ( uniformly and malignancy
obscure the drum rim of sclera) characteristic 'stare' on frontal
gaze
Thyroiditis - tender
Unusually prominent short process of malleus
and handle more horizontal suggest a A&P
RETRACTED drum
Torus Palatinus is a startling but benign
Perforated Ear Drum = no mobility midline lump
Keloid: Firm hypertrophic mass of scar tissue Uvula: CN X paralysis-soft palate fails to rise
extening beyond area of injury. Trouble and Uvula deviates to the opposite side (
cosmetically; recurrence is high. points away from lesion)
Chondrodermatitis Helicic: chronic Tonsils: have crypts, or deep infoldings of
inflammatory lesion, painful tender nodule on squamous epithelium, where whitish spots to
Eyelids helix or antihelix, then ulcerates and cruts (r/ normal exfoliating epithelium may be seen
o carcinoma)
Lips:
Eyebrows: Ptosis: drooping eyelid
Tophi: A deposit of URIC acid crystals with
chronic tophaceous gout. Hard nodules on Angular Cheilitis: starts with softening of skin
Sty: Painful, tender red infection in a gland at helix or antihelix may change to chalky white at angles of the mouth followed by fissure.
lid margin crystals through skin Causes: nutritional difficiency or overclosure
of mouth (no teeth). Saliva wets and
macerates the infolded skin, leading to 2*
Chalazion: nontender, painless nodule of the Carcinoma (BCC/SCC): raised nodules with infection of Candida
Meibomian Gland irregular borders appear smooth with rolled
or crusty with scales, telangectatic vessels.
More frequent in fair-skinned overexposed to Actinic Cheilitis: Precancerous condition -
Xanthelasma: yellowish, rasied plaques- sunlight (BCC grows more slowly to SCC) * results from excessive exposure to sunlight
lipidema Must Biopsy and affects primarily lower lip. Fair skinned
me who work outdoors most often, Lip loses
its normal color and may become scaly, thick,
Entropian: inward turning of lid margin Cyst: dome-shaped lump in dermis forms and everted.
benign closed firm sac attached to epidermis.
Dark dot (blackhead) may be visible,
sometimes inflammed Herpes Simplex (cold sore): HSV recurrent
Ectropian: outward turning of lid margin
and painful vesicular eruptions of lips and
surrounding skin. Small clusters of vesicles,
Exophthalmous: eye ball protrudes forward ( these break and form yellow-brown crusts as
Grave's DZ-hyperthyroidism) healing ensues

Pupil
Angioedema: Diffuse, non-pitting, tense
swelling of the skin and subcutaneous tissue.
Anisocoria - unequal pupils (benign Rapid with allergy / hives
if <0.4mm)

Peutz-Jeghers Syndrome: small brown

Argyll Roberton (AR) Pupils
Bilateral small pupils that constrict when
patient focuses on near object but DO NOT
constrict when exposed to bright light
Accommodate but do not React to light
Tonic Pupil
Dilated pupil constricts SLOWLY with
convergence, NOT light response
Compare to Horner Syndrome
Marcus Gunn Pupil pigmented spots in dermal layer of lips,
buccal mucosa, and perioral area (also hands/
feet). Autosomal dominant syndrome,
intestinal polyps, risk of GI cancer.
Relative Afferent Pupillary Defect (RAPD)
Chancre of Primary Syphilis: ulcerated papule
Swinging flashlight test: pupils appear to
with indurated edge appears after 3-6 weeks
dilate when bright light is swung from
of incubating infection from Treponema
unaffected eye to affected eye.
Pallidum. Lesions resemble carcinoma or
crusted cold sore,

Dorsal midbrain damage (Edinger Westphal Most Common cause: lesion of the Optic
Nucleus) Neurosyphilis Nerve (proximal to Optic Chiasm) Optic
Carcinoma of the Lip: like actinic cheilitis,
Neuritis
SCC usually effects lower lip, may appear as
scaly plaque, ulcer w/ or w/o crust or as
Vision Loss
nodular lesion. (fair skin and sun exposure)

Oral Mucosa:
Gradual Bilateral One sided

Fordyce Spots: normal sebaceous glands that

Cataracts Macular Degeneration Glaucoma Painless - vascular etiologies Hemianopsia Quadrantic Defects
appear small yellowish spots in buccal
mucosa ro lips

Clouding (opacity) of the lens
Slow central loss in Nuclear Cataract and
Macular Degeneration
Dry Atrophic
Most common-drusen accumulate beneath
macula causing it to deteriorate or
degenerate over time
Cause of poor CENTRAL vision in older adults
Wet Exudative
Neovascular membranes develop under the
Retina, can leak fluid and blood and if
untreated cause centrally blinding.
Subretinal hemorrhage or exudates
Drusen - Cellular debri, may be hard and
sharply defined or soft and confluent with
altered pigmentation
New vessels that grow and tend to be poor
quality, leak and rupture, causing BLINDNESS
Neovascularization
Proliferative Retinopathy
Change in color and size of optic disc
Narrow-Angle Glaucoma
Sudden increase in IOP when drainage of
aqueous humor is blocked
Iris bows forward from lens pressure,
Crescent Shadow!
Primary Open-angle Glaucoma (POAG) -
most common
loss of vision in peripheral fields
Retinal exam reveals pallor and increasing
size of optic CUP
Risk Factors: >65 y/o, African American,
diabetes, myopia, ocular HTN, Intra-ocular
pressure (IOP) >21mmHg
Giant-cell arteries or nonphysiologic cuases
Unilateral
Painless - vitreous hemorrhage from diabetes Painful - cornea or anterior chamber
or trauma
Corneal ulcer, uveitis, traumatic hyphema,
Macular degeneration, retinal detachment, acute angle glaucoma
retinal vain occlusion, or central retinal artery
occlusion
Optic neuritis from Multiple Sclerosis (
immediate referral)
Left Hemianopia - Left optic nerve lesion= NO
vision in Left eye
Bitemporal Hemianopia: Optic chiasm lesion,
Pituitary Tumor= Bilateral Temporal NO vision
Right Nasal Hemianopia: Outer optic tract
lesion, Internal carotid artery thrombus= Left
Eye nasal 1/2 NO vision
Right Homonymous Hemianopia: Optic Tract
lesion= Bilateral Right 1/2 NO vision (L nasal /
R temporal)
Right Hemianopia w/ Macular Sparing: PCA
infarct= Bilat Right 1/2 no vision with good
central vision
Right Superior Quadrantanopia: Meyers Loop
lesion, Left temporal Lesion = Left eye RUQ,
Koplik's Spots: Earl sign of Measles (Rubeola)
Right eye RUQ
small white specks that resemble grains of
salt on a red background, near first or second
molar
Right Inferior Quadrantanopia: Dorsal Optic
Radiation Lesion, Left Parietal Lesion = Left
RLQ, Right RLQ
Petechiae: small red spots that result when
blood escapes from capillaries into tissue,
biting of cheek
Oral Candidiasis (thrush): yeast infection,
thick white plaques, prolonged Antibiotics
use or corticoid steroid use and AIDS
Leukoplakia: Thickened white patch on oral
mucosa that cannot be scraped off. Causes:
frequent chewing of tobacco, leads to
CANCER

Red eye
Chronic cheek chewer: thickened ragged
appearing white patch of buccal mucosa
Painless - Subconjunctival Hemorrhage

Gritty - Viral conjunctivitis

Painful - hyphema, episcleritis, acute angle Injection: dilation of conjunctival vessels

closure Glaucoma, herpes keratitis, Foreign
body, fungal keratitis, sarcoid uveitis
Diffuse: Conjunctivitis - Localized: Episcleritis

Hyposphagma (Subconjunctival hemorrhage)

bleeding underneath conjunctiva Icterus: yellow eye - bilirubin retenion

Chemosis: Edema of conjunctiva Cyanotic Sclera (blue eye) children w/

osteogenesis imperfecta

Diplopia = double vision

Horizontal Diplopia: Palsy of CN III or CN VI

Vertical Diplopia: Palsy of CN III or CN IV

Dysfunction of Superior Oblique

Lesions in brainstem or cerebellum, weakness

or paralysis of one or more extraocular
muscles

Diplopia in one eye with other closed

suggests problem with cornea or lens

FUNDUS - Retina

Papilledema Spontaneous Venous Pulsations (SVP) Enlarged CUP suggests Chronic open-angle
glaucoma

Swelling of the Optic disc and Anterior Rhythmic variations in caliber of retinal veins
bulging of the CUP as they cross the fundus

Associated with increased Intracranial Narrow in Systole

pressure (ICP)

Signals Meningitis, subarachnoid
hemorrhage, trauma, mass lesions
Wider in Diastole
Blurred margins of disc and loss of cup
Loss of SVPs occurs with high ICP (above
190mmhg) that change pressure gradient
between cerebral spinal fluid pressure and
intraocular pulse pressure in optic disc

Other causes include glaucoma and retinal

vein occlusion

Position & Alignment

Convergence: toward bridge of nose, within

5-8 cm of nose, POOR in Hyperthyroidism

Accommodation: pupil constricts when

focusing on near objects

Strabismus: CROSS EYED, binocular fixation

is NOT present. one or both eyes, cover test
or corneal light reflex, correctable w/ surgery

Amblyopia: LAZY EYE, reduced Visual Acuity

NOT correctable, caused by strabismus,
uremia, toxins

Tropia: misalignment that is always there,
cover-uncover test
Esotropia (inward deviations)
Phoria: misalignment that only occurs some
of the time, such as when synchronization is
broken between eyes by covering one, Cross-
cover test.

Exotropia (outward deviation)

Hypertropia (upward deviation)

Hypotropia (downward deviation)

Hirschberg's Test: (penlight) reflection on

cornea, if not symmetric possible tropia.

Ophthalmoscope:

Diopter to 0

Nearsighted (Myopic) RED numbers

Farsighted (Hyperoptic) BLACK or GREEN

numbers

Red Reflex: if absent could indicate tumor in

infants, congenital cataract, Central Artery
occlusion, or retinal detachment

Clarity: Cornea, Ant. Chamber, Lens, Vitreous

Humor

Optic Disc: Color-Margins-Size of Cup/disc

Ratio (1:2)

Retina: inspect vessels- AV ratio (2:3)

Arteries lighter red, smaller, brighter - Veins Retinal Lesions (Hemorrhages)

dark red, larger, no light reflex, Follow
vessels in 4 directions noting 'nicking' from
Hypertensive Retinopathy
Fovea & Macula: measured by 'disc diameters'
from optic disc
Soft Exudates (Cotton-wool spots): white/
yellow ovoid lesions with soft borders. Most
common cause DM and HTN
Hard Exudates: white creamy yellow with
hard borders. Accumulation of lipids and
proteins, increased risk of Retinal Edema,
causes DM and HTN

Drusen: yellow round spots with soft or hard

borders-normal with aging and also in
Macular Degeneration

Subtopic 1