Lucinda Hirahoka FNP, PA-C, MPH September , 2004 HEENT History Lucinda Hirahoka FNP, PA-C, MPH September , 2004

HEENT History Descriptors Mode of onset a. describe events coincident with onset b. onset gradual or sudden? c. total duration of the symptom Location of the symptom Character of the symptom Radiation of the symptom Frequency of the symptom Precipitating factors Aggravating factors

HEENT History 8. Relieving or ameliorating factors 9. Associated symptoms 10. Course of symptoms (getting worse, better, etc) 11. Effect of symptoms on daily life 12. Past treatment or evaluation of the symptom a. when, where, by whom? b. what studies were done and what were the results? c. results of past treatment d. past diagnosis 13. Patients concerns

HEENT History Review of Systems General State of health Body weight Fatigue Weakness Fever

HEENT History Skin Areas of increased redness/heat, rashes, growths, sun sensitivity, itching, changes in texture, pigment or color, excessive dryness or sweating

HEENT History Head Headaches Sinus problem

Headache Muscle Tension Headache: Constant band like pressure lasting days to weeks; usually worse at the end of the day; often occipital location Migraine Headache: Throbbing, often unilateral frontal headache; usually visual prodromata, nausea and vomiting precede the attack. Positive family history of migraine

Headache Sinus Headache: Facial pain often associated with nasal stuffiness and discharge; increased when head is flex forward Nonspecific Febrile Headache: Muscle aches and pains

Headache Cervical Arthritis: Occipital and neck ache worse with neck movement; patient usually over 40 years old Trigeminal Neuralgia: Brief jabs of facial pain caused by touching a trigger point. Frequently seen after shingles of the trigeminal nerve

Headache Serious Cases of Headaches Meningitis: Recent development of fever, headache, nausea, and vomiting Subarachnoid bleeding: Very rapid onset of unilateral headache often with change in consciousness or neurologic function; vomiting is common

Headache Temporal arteritis: Temporal headache with body aches, often in patients over 40 years old; transient decrease in vision may progress to blindness Hypertensive Crisis: Blurring vision; a history of HTN is common

History Intracranial Mass: No characteristic history; most suspect is recent headache that doesn’t fit the above patterns Subdural Hematoma: Headache and level of consciousness may wax and wane over months, usually in the very old or alcoholics with history of head injury

HEENT History Eyes Diplopia: Double vision Eye muscle dysfunction due to tumor, trauma, pressure of exophtalmic thyroid diseases, strabismus, intracraneal aneurysm, diabetes, brain stem disease, myasthenia gravis.

Eyes Changes in acuity: Decrease or loss of vision. Important to know whether it happened suddenly or gradually. Sudden visual loss suggest retinal detachment, vitreous hemorrhage, or occlusion of the central artery Blurring: Is commonly caused by refractive errors; high blood sugar also causes blurred vision.

Eyes Lacrimation Pain Itching Photophobia Infection Discharge Erythema

HEENT History

HEENT History Ears Hearing Conductive hearing loss: Loss of hearing for all frequencies Otoesclerosis: Old age Ear wax or foreign body Chronic otitis externa or serious otitis

Ears Nerve deficit-Type Hearing Loss High frequency hearing loss is often noted. The patient may note difficulty when listening on the telephone or in groups. Prebyscus: Old age Loss secondary to chronic noise, severe head trauma, mumps, acoustic neuroma, use of ototoxic medications (aminoglycosides, aspirin, quinine, furosemide); or congenital.

Ear Ear Pain: Unilateral or bilateral. History of upper respiratory infection with nasal congestion. Ear pulling or tagging increases pain, inability to “pop” ears. Tinnitus: Ringing or buzzing in ears. It increases with age. Sometimes associated with hearing loss and vertigo (Meniere’s), or high dose ASA use.

Ears Discharge Color of discharge: bloody, yellow, white, CSF (after trauma), brownish (wax) Associated with ear pain and upper respiratory infection

HEENT History Nose Discharge: Common complaint is rinorrhea or nasal discharge, which is often associated with nasal stuffiness. Important to find out color of discharge: clear, whitish, yellow, greenish, bloody. Acute runny, stuffy nose is due to viral URI; a chronic runny stuffy nose is usually related to excessive decongestant use, vasomotor rhinitis, or allergic rhinitis.

Nose Epistaxis: Bleeding from the nose. The Kiesselback plexus is the most common site associated with anterior septum bleeding. The most common cause of nose bleeding in children is trauma “nose picking”. Other causes are inflammation, drying and crusting of the mucosa, tumors, foreign bodies, and bleeding disorders.

Nose Sense of smell changes: Alterations may be noted following infection, trauma, allergic rhinitis; rarely noted in neurologic disease. Obstruction: Due to congestion, foreign object or polyps which are often associated with history of asthma.

HEENT History Mouth/Throat Primary Gum Disease: Gingival hyperthrophy usually seen in patients taking Dilantyn. Periodontal disease: Bleeding or sore gums, poor dental hygiene

Mouth Primary Lip Disease: Herpes simplex: Painful lesions on lips or in mouth Cheilosis: Cracking and inflammation of the corners of the mouth; often the patients are edentulous

Mouth Growths and Tumors Leukoplakia: Painless persistent white plaques; history heavy smoker, HIV + immuno-compromised patients. Neoplasia: Persistent lumps, sores.

Mouth Infections Candida: Common in diabetics, infants, HIV+, antibiotic and adrenal steroids use. Canker sore: Painful recurrent ulcers in the mouth and lips Vitamin deficiency: Gingival bleeding, cheilosis, oral ulcers, hyperthrophic tongue. Usually seen in the alcoholic and or malnourish patient. Dental caries: gum soreness, abcess.

Throat Sore throat: Frequent complaint, usually associated with URI. Infections of the throat: Pharyngitis Mononucleosis Herpangina Peritonsillar abscess Epiglottitis

Throat Hoarseness: Refers to an altered quality of the voice, allergy, smoking or inhaled irritants. Hoarseness lasting more than two weeks needs to be refer for visualization of the larynx. Dysphagia: Difficulty swallowing, feeling of obstruction, “lump in my throat” Odynophagia: Pain with swallowing

HEENT History PMH/Chronic Illness Medications Allergies Habits Family History Social History HCM