Retinoblastoma physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [3] Sahar Memar Montazerin, M.D.[4]
Overview
Common physical examination findings of retinoblastoma include leukocoria, strabismus, proptosis, anisocoria, orbital cellulitis, hyphema, heterochromia iridis, poor vision, unilateral mydriasis, rubeosis iridis, vitreous hemorrhage, and findings of a chalky white-gray retinal mass on fundoscopic examination.
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Physical Examination
Physical examination of patients with [disease name] is usually normal.
OR
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
General Appearance
- Children with retinoblastoma are generally well-appearing.
- Children may appear cachectic in advanced cases.
Vital Signs
- High-grade / low-grade fever
- Hypothermia / hyperthermia may be present
- Tachycardia with regular pulse or (ir)regularly irregular pulse
- Bradycardia with regular pulse or (ir)regularly irregular pulse
- Tachypnea / bradypnea
- Kussmal respirations may be present in _____ (advanced disease state)
- Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
- High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure
Skin
- Skin examination of patients with [disease name] is usually normal.
OR
HEENT
- Nystagmus
- Strabismus
- Anisocoria
- Proptosis
- Poor vision
- Orbital cellulitis
- Hyphema
- Heterochromia iridis
- Unilateral mydriasis
- Rubeosis iridis
- Red, painful eye with glaucoma
- Vitreous hemorrhage
- Leukocoria (white reflex or cat's eye reflex)
- Low-set ears may be present in 13q deletion syndrome
- Telecanthus may be present in 13q deletion syndrome
- Ophthalmoscopic exam may be abnormal with findings of chalky white-gray retinal mass
- The red reflex: checking for a normal reddish-orange reflection from the eye's retina with an ophthalmoscope or retinoscope from approximately 30 cm / 1 foot, usually done in a dimly lit or dark room. Bryan Shaw helped develop a smart-phone app that can detect leukocoria in photos.
- The corneal light reflex / Hirschberg test: checking for symmetrical reflection of beam of light in the same spot on each eye when a light is shined into each cornea, to help determine whether the eyes are crossed.
- Ocular examination can be easily performed using a surgical or binocular handheld slit lamp microscope, and includes anterior segment evaluation (cornea, anterior chamber and iris).[1] Ocular examination is followed by indirect ophthalmoscopy with indentation under full mydriasis to examine the entire retina. In over 90% of cases, direct visualization of the tumor by an indirect ophthalmoscope is diagnostic for retinoblastoma.[2] The diagnosis of retinoblastoma is usually made during a dilated indirect ophthalmoscopic examination, performed under anesthesia. The characteristic finding is a chalky, white-gray retinal mass with a soft, friable consistency.[3]
- The fundoscopic examination may show retinal detachment with retinal vessels visible behind the lens and may show vitreous and/or subretinal seeding. Intrinsic tumor calcification, tumor microvasculature, may also be seen. This examination permits complete visualization of the retina, identification of multifocal tumors and/or vitreous or subretinal seeding.
- HEENT examination of patients with [disease name] is usually normal.
OR
- Abnormalities of the head/hair may include ___
- Evidence of trauma
- Icteric sclera
- Nystagmus
- Extra-ocular movements may be abnormal
- Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
- Ophthalmoscopic exam may be abnormal with findings of ___
- Hearing acuity may be reduced
- Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
- Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
- Exudate from the ear canal
- Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
- Inflamed nares / congested nares
- Purulent exudate from the nares
- Facial tenderness
- Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
Neck
- Neck examination of patients with [disease name] is usually normal.
Lungs
- Pulmonary examination of patients with [disease name] is usually normal.
Heart
- Cardiovascular examination of patients with [disease name] is usually normal.
Abdomen
- Abdominal examination of patients with [disease name] is usually normal.
Back
- Back examination of patients with [disease name] is usually normal.
Genitourinary
- Genitourinary examination of patients with [disease name] is usually normal.
Neuromuscular
- Neuromuscular examination of patients with [disease name] is usually normal.
OR
- Patient is usually oriented to persons, place, and time
- Altered mental status
- Glasgow coma scale is ___ / 15
- Clonus may be present
- Hyperreflexia / hyporeflexia / areflexia
- Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
- Muscle rigidity
- Proximal/distal muscle weakness unilaterally/bilaterally
- ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Positive straight leg raise test
- Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
- Positive/negative Trendelenburg sign
- Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
- Normal finger-to-nose test / Dysmetria
- Absent/present dysdiadochokinesia (palm tapping test)
Extremities
- Simian crease in the palms and broad thumb may be present in 13q deletion syndrome.
- A thorough systemic examination is important as a pre-requisite for general anaesthesia, as well as to rule out 13q deletion syndrome.
- Extremities examination of patients with [disease name] is usually normal.
OR
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Mehta M, Sethi S, Pushker N, Kashyap S, Sen S, Bajaj MS; et al. (2012). "Retinoblastoma". Singapore Med J. 53 (2): 128–35, quiz 136. PMID 22337189.
- ↑ Pandey AN (2014). "Retinoblastoma: An overview". Saudi J Ophthalmol. 28 (4): 310–5. doi:10.1016/j.sjopt.2013.11.001. PMC 4250503. PMID 25473349.
- ↑ Abramson DH (1990). "Retinoblastoma 1990: diagnosis, treatment, and implications". Pediatr Ann. 19 (6): 387–95. PMID 2201000.
- ↑ Image courtesy of Dr. Frank Gaillard Radiopaedia (original file [1]).[http://radiopaedia.org/licence Creative Commons BY-SA-NC