History taking : Head & neck

THE HEAD

Symptom : Headache Change in vision: hyperopia, presbyopia, myopia, scotomas Double vision, or diplopia Hearing loss, earache, tinnitus Vertigo Nosebleed, or epistaxis Sore throat, hoarseness Swollen glands Goiter

Headache Change in vision: hyperopia, presbyopia, myopia, scotomas Double vision, or diplopia Hearing loss, earache, tinnitus Vertigo Nosebleed, or epistaxis Sore throat, hoarseness Swollen glands Goiter

Is the headache one-sided or bilateral? Severe with sudden onset? Steady or throbbing? Continuous or intermittent (comes and goes)?

life-threatening causes such as meningitis, subdural or intracranial hemorrhage, or mass lesion.

Primary headaches have no identifiable underlying cause. Secondary headaches arise from other conditions—some of these may endanger the patient's life.

Look for “red flags” that raise suspicion of worrisome secondary causes : recent onset (less than 6 months); onset after 50 years; acute onset like a “thunderclap,” or “the worst headache of my life”; markedly elevated blood pressure; presence of rash or signs of infection; presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; or persisting neurologic deficits.

The most important attributes of headache are its severity and chronologic pattern. Is the headache severe and of sudden onset? Does it intensify over several hours? Is it episodic? Chronic and recurring? Is there a recent change in pattern? Does the headache recur at the same time every day?

If headache is severe and of sudden onset, consider subarachnoid hemorrhage or meningitis. Migraine and tension headaches are episodic and tend to peak over several hours. New and persisting, progressively severe headaches raise concerns of tumor, abscess, or mass lesion.

Unilateral headache in migraine and cluster headaches. Tension headaches often arise in the temporal areas; cluster headaches may be retro-orbital.

Nausea and vomiting are common with migraine but also occur with brain tumors and subarachnoid hemorrhage.

Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Does the patient report an aura with neurologic symptoms, such as change in vision or numbness or weakness in an arm or leg ?

THE EYES

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

Difficulty with close work suggests hyperopia (farsightedness) or presbyopia (aging vision); with distances, myopia (nearsightedness).

Is there blurred vision? If yes, is the onset sudden or gradual? If sudden and unilateral, is the visual loss painless or painful?

If sudden unilateral visual loss is painless, consider vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion. If painful, :causes are cornea and anterior chamber as in corneal ulcer, uveitis, traumatic hyphema, and acute glaucoma. Optic neuritis from multiple sclerosis may also be painful.

bilateral and painless:medications that change refraction such as cholinergics, anticholinergics, and steroids may contribute.bilateral and painful: consider chemical or radiation exposures

bilateral visual loss gradual: cataracts or macular degeneratio

If the visual field defect is partial, is it central, peripheral, or on only 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?

Does the patient wear glasses? Ask about pain in or around the eyes, redness, and excessive tearing or watering Check for 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 ?

THE EARS

Opening questions 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?

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.

Medications that affect hearing include aminoglycosides, aspirin, NSAIDs, quinine, furosemide

Complaints of earache, or pain in the ear, are especially common. Ask about associated fever, sore throat, cough, and concurrent upper respiratory infection.

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.

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.

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. 11

Causes include viral infections, allergic rhinitis (“hay fever”), and vasomotor rhinitis. Itching favors an allergic cause.

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 ?

Did symptoms appear after a URI? Is there pain on bending forward or maxillary toothache? Fever or local headache? Tenderness over the sinuses?

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 have bleeding that 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. Carefully differentiate epistaxis from hemoptysis or hematemesis, because each has different causes. 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 associated with acute upper respiratory symptoms A sore tongue may result from local lesions as well as 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. EXAMPLES OF ABNORMALITIES Bleeding gums are most often caused by gingivitis

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?.

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.

Ask “Have you noticed any swollen glands or lumps in your neck?” EXAMPLES OF ABNORMALITIES Enlarged tender lymph nodes commonly accompany pharyngitis.

. 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?”.

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