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Assessing the Head

Assessing the Head

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Published by Dr Magda Bayoumi
Assessing the Head, Face, and Neck

Dr/ Magda Bayoumi Health assessment course

After you have successfully completed this chapter, you should be able to:
–  Identify pertinent head, face, and neck history questions.
–  Obtain a history specific for head, face, and neck.
–  Perform a physical assessment of the head, face, and neck.
–  Document head, face, and neck assessment findings.
–  Identify actual or potential health problem.
Assessing the Head, Face, and Neck

Dr/ Magda Bayoumi Health assessment course

After you have successfully completed this chapter, you should be able to:
–  Identify pertinent head, face, and neck history questions.
–  Obtain a history specific for head, face, and neck.
–  Perform a physical assessment of the head, face, and neck.
–  Document head, face, and neck assessment findings.
–  Identify actual or potential health problem.

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Assessing the Head, Face, and Neck

Dr/ Magda Bayoumi Health assessment course

Dr/Magda Bayoumi 1 http://faculty.ksu.edu.sa/73577/default.aspx

After you have successfully completed this chapter, you should be able to:
■ Identify pertinent head, face, and neck history questions ■ Obtain a history specific for head, face, and neck ■ Perform a physical assessment of the head, face, and neck ■ Document head, face, and neck assessment findings ■ Identify actual or potential health problems stated as a nursing diagnosis ■ Differentiate between normal and abnormal head, face, and neck assessment findings ■ Identify pertinent eye and ear history questions ■ Obtain an eye and an ear history ■ Perform an eye and an ear physical assessment ■ Document eye and ear assessment findings ■ Identify actual/potential health problems stated as nursing diagnoses ■ Differentiate between normal and abnormal eye and ear findings

Dr/Magda Bayoumi 2 http://faculty.ksu.edu.sa/73577/default.aspx

the head, face, and neck form a large portion of what is often referred to as the head, eyes, ears, nose, and throat (HEENT) system. This is actually a complex set of varied organs, combined during assessment because of their proximity to one another and the integration among the components of the system. The HEENT encompasses almost all of the systems: integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine, and lymphatic. The vascular, neurological, and musculoskeletal components of the HEENT, as well as the eyes and ears, are covered in separate chapters. The components addressed in this chapter include the head, face, nose, sinuses, neck,mouth,and pharynx. These components are complex in their actions and are involved in expression, communication, nourishment, respiration, and sensation, among other functions. Furthermore, disorders involving the head and face can be devastating to patients because they can greatly affect appearance. Even minor disorders involving the head, face, or neck can be perceived as disfiguring by patients.

Anatomy and Physiology Review

Dr/Magda Bayoumi 3 http://faculty.ksu.edu.sa/73577/default.aspx

aspx .ksu.edu.Dr/Magda Bayoumi 4 http://faculty.sa/73577/default.

edu.sa/73577/default.Dr/Magda Bayoumi 5 http://faculty.ksu.aspx .

Dr/Magda Bayoumi 6 http://faculty.aspx .edu.ksu.sa/73577/default.

jaundice) may indicate systemic problems.g. Neck and jaw pain may indicate cardiovascular disease. CARDIOVASCULAR Temporal and carotid arteries located in head and neck.aspx . MUSCULAR Facial muscles needed for expression.Interaction With Other Body Systems NEUROLOGICAL Cranial nerves located in head. RESPIRATORY Respiratory tract begins at nasal and oral cavities. Dr/Magda Bayoumi 7 http://faculty. DIGESTIVE Mouth is beginning of digestive tract. Cranial nerves influence ability to communicate both verbally and nonverbally and to eat. INTEGUMENTARY Skin-color changes on face (e. pallor. Respiratory infections often begin in upper airways of nose and throat..sa/73577/default. Injuries to head and face can affect breathing.ksu.edu. cyanosis. face and neck. communication and nutrition. ENDOCRINE Thyroid and parathyroid glands located in neck.

a major emphasis of the examination is on the head. For example. face. Also ask about your patient’s occupation. is required to have a physical examination before participating in a deep-sea diving course and receiving certification. children tend to have more upper respiratory problems and pharyngitis than older adults.g. Introducing the Case Study Mr ahmed. make sure to at least perform a focused health history of the head. REPRODUCTIVE Pregnancy can cause changes in facial color (chloasma).past health. and neck. a 17-year-old high school senior.URINARY Changes in face (e. If you don’t have the time to perform a complete health history. face. face. Biographical Data Review the patient’s biographical information.face. Dr/Magda Bayoumi 8 http://faculty. It also includes a review of systems (ROS). Performing the Head. and neck structures. and neck. As you perform the assessment. Your history will include obtaining biographical data and asking questions about the patient’s current health. Mast cells located in pharynx SKELETAL Skull protects brain. It must also detect any other disorders that may affect these structures. and Neck Assessment Assessment of the head. Tonsils located in pharynx. and neck. face. edema or uremic frost) may reflect renal problems.aspx .sa/73577/default. be alert for signs and symptoms of actual and potential problems of the various components of the head. and neck.ksu. Because of the requirement that Ahmed be able to tolerate use of the diving equipment. Health History The health history identifies any related symptoms or risk factors and the presence of diseases involving the head. LYMPHATIC Cervical lymph nodes located in neck. He is very excited about spending his spring vacation diving. face.and neck involves obtaining a complete health history and performing a physical examination.. Lips and mouth are erogenous areas. Note your patient’s age—certain diseases are more prevalent in specific age groups. Face. and family and psychosocial history. Does he or she have a job that puts him or her at risk for head injury? Does he or she spend long hours at a computer terminal (may result in tension headaches)? Questions like these will help to identify the potential for exposures to physical and environmental situations that could harm the head.You plan to complete both a health history and a physical examination.edu.

throat. nasal discharge. including migraines. or neck.Current Health Status Determine whether the patient has any specific presenting complaints related to the head. however. Symptom analysis can help identify any forgotten trauma or physical exertion that might explain the complaint. or neck? Some examples are head pain. but it could also be trauma or infection/inflammation in the structures near the jaw.and neck. if any. and the initial history and physical will have to be very focused. nasal congestion.edu. mouth. it might be a goiter of the thyroid gland or enlarged lymph nodes. and neck pain. it is important to determine the patient’s overall health status. face. health problems do you have? ■ What.aspx . postnasal drip. masses. If a detailed history is either not feasible or inappropriate. Jaw Tightness and Pain When a patient presents with jaw tightness and/or pain. and trauma. sore throat. Head Pain Head pain can be associated with a variety of problems. ■ Do you have problems or complaints related to your head. as well as others that you might identify later. jaw pain. Always ask patients if they have a personal or family history of heart disease. be sure to ask the following basic questions. OTC or prescribed medications do you take? ■ Is there anything specific that you think I should know related to your overall health or this specific complaint? Symptom Analysis Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book. mouth sores or pain. when the patient’s presenting problems are particularly acute or distressful.ksu. Because disorders of several systems can influence the head. mouth or dental pain. tension. face. the cause may be TMJ syndrome. sore throat. nosebleeds. foods. neck pain or stiffness. such as the PQRST format. Any such complaints. An important consideration for jaw discomfort is whether it might be caused by cardiovascular disease. nose. mouth lesions. Neck Mass When a patient complains of a neck mass. There will be times. ■ Do you have allergies to any medications. epistaxis. if any. nasal congestion. Neck Pain and Stiffness Neck pain and stiffness can stem from musculoskeletal problems as well as from infections. Remember that you must pursue a symptom analysis (PQRST) for any complaint identified during this focused history. Some common complaints include headaches. or environmental factors? ■ What. difficulty swallowing. systemic infections. should be explored and developed using an organized system of symptom analysis. and hoarseness.sa/73577/default. Dr/Magda Bayoumi 9 http://faculty. Enlarged nodes may signal either an infectious or a malignant disorder. face.

the nurse must ask about current drug Past Health History (continued) CATEGORY/QUESTIONS TO ASK RATIONALE/SIGNIFICANCE use. Nosebleed Epistaxis. exposures to infectious diseases. and Neck When obtaining a health history to assess a patient’s head and neck.aspx . and epistaxis (nosebleed). alopecia (hair loss). musculoskeletal disorders. Mouth Lesions A mouth lesion can be caused by a malignancy. foreign objects in the throat. However. trauma. or poorly fitted dentures or orthodontic appliances. for example. as well as an immunization and medication history. including thyroid hypertrophy or malignancies. Past Health History Once you have investigated the patient’s chief complaint. hospitalizations. or major injuries. Dr/Magda Bayoumi 10 http://faculty. However. explore the past health history. nutritional deficit. Many of the commonly used drugs listed below can produce adverse reactions in the head and neck. or trauma. malignancies. the most common cause is a bacterial or viral illness. hypertension. is usually self-limited and has relatively benign causes. or nosebleed.edu.major diagnostic procedures. Drugs That Adversely Affect the Head.This portion of the history includes childhood and adulthood illnesses. Mouth and Dental Pain Mouth pain can be caused by ischemic heart disease. neuromuscular disorders. including gingivitis (gum inflammation). or dental problems.ksu. It can also be an indication of gastroesophageal reflux.sa/73577/default. Face. throat discomfort can be associated with throat masses. and other causes. and allergies. Sore Throat When a patient complains of a sore throat. surgeries. prolonged periods of shouting or loud speech. or other health problems. Hoarseness Another common complaint is hoarseness. malignancies. Hoarseness may be caused by overuse of the voice. it can be caused by coagulopathies or other hematologic disturbances.Nasal Congestion Nasal congestion is usually caused by an upper respiratory infection or allergy.

aspx . and Neck Dr/Magda Bayoumi 11 http://faculty. Face.edu.sa/73577/default.Focused Health History for the Head.ksu.

and neck. Review of Systems The ROS allows you to explore each body system to determine whether the patient has a complaint that might affect the head.sa/73577/default.Family History The purpose of the family history is to identify health problems that are familial or genetic.ksu. The genogram described in earlier chapters is a helpful way to organize the information obtained through the family history. both living and dead. Dr/Magda Bayoumi 12 http://faculty.aspx . as well as all other systems. face. this review has the potential to trigger the patient to recall symptoms that she or he might otherwise have forgotten or to relate symptoms that she or he previously thought were unimportant. The focus should be on problems that either have a genetic component or are attributed to environmental/ living situations shared with the patient. The history should include information on close relatives. Ask the patient about problems that commonly affect the head.or neck.edu. Although exploring the patient’s presenting complaint will already have alerted you to the potential for many symptoms. face.

■ Immunizations up to date. tetanus updated last year when he stepped on a piece of glass while wading on a shoreline. but notes that he works in a busy restaurant and attends public school. ■ No current complaints. so could be exposed to “whatever’s going around. ■ Born in the United States.aspx . ■ Protestant religion. ■ Takes OTC antihistamines when he has no prescribed antihistamines on hand. ■ Seasonal hay fever since childhood. but has been told this is not available. after frequent bouts of ear infections. On rare occasions at times other than in the fall or spring. ■ Both adoptive parents are in good health. Antihistamines generally control the symptoms. reliable. and helps identify the patient’s ability to perform self-care activities and obtain and carry out recommended treatments. social involvement. face. It determines risks associated with exposure to hazards. Past health history: ■ Usual childhood illnesses. and daily activities and habits in order to identify factors that can influence the health of the head. and neck. itching eyes. ■ Tympanoplasty at age 3.ksu. Case Study: Reviewing Ahmeds' Biographical data: ■ 17-year-old unmarried male. Dr/Magda Bayoumi 13 http://faculty.” Family history: ■ Biological family history unknown. would like to know his family health history.sa/73577/default.without complications. ■ Works part-time in fast-food restaurant. ■ Father is computer salesman and mother is radiology technician. although he does have “hay fever” in spring and fall. he has symptoms Case Study Findings that last several hours. ■ Source: Self. but he is not sure what triggers them. Says he is “health directed”and wishes to maximize health. recreational interests. takes no other medications ■ No recent exposures to known infections. runny nose.Psychosocial Profile The psychosocial profile provides information about the patient’s occupation. Current health status: ■ Describes current health as excellent. and head congestion. after frequent throat infections. He is not currently experiencing any symptoms. has always taken one multivitamin daily. but usually takes Claritin during seasonal allergy attacks. ■ Tonsils and adenoids removed at age 4. provides information about the patient’s support system. was adopted immediately after birth. but generally has several weeks of sneezing.edu.

and this is well tolerated.Review of systems: ■ General Health Survey: States that health is usually good. Attends school from 8 A. on weekends. and juice. and nose. hair. No skin rashes. ■ Has many friends and enjoys spending time with groups. ■ Gastrointestinal: Appetite good. they make it difficult to sleep and he wakes frequently through the night. ■ Genitourinary: No history of renal disease. on Saturday. ■ Tolerates swimming well. ■ No medications other than seasonal use of antihistamines and daily vitamin. practices 1 to 2 hours a day.M. nasal congestion and clear drainage. until 3:15 P. ■ Endocrine: No changes in weight or shoe size (11).. ■ Not currently sexually active. ■ Exposed to second-hand smoke in the restaurant where he works. on school nights and 1 A. is aware of safe sex practices. During “allergy season”sometimes has sleep difficulty. Lunch is fast food.aspx . and works 5 P. sneezing. uses no cosmetics on face other than occasional OTC acne medication. obtained between classes. as he is concerned about the potential health hazards.sa/73577/default. wearing goggles. ■ Eats three meals plus one or two snacks daily. and nails. ■ HEENT: No swollen nodes or masses in head or neck. no bleeding disorders. dizziness.M.When he takes OTC antihistamines. otherwise not generally around smokers or exposed to any known chemicals. eyes. Does some amount of physical activity daily. shortness of breath (SOB). when his mother awakens him to get ready for school. If he takes no antihistamines or decongestants. ■ Lives in a single-family.M.M. No major yet chosen. Uses no recreational drugs. Wears protective gear while playing baseball. ■ Neurological: No headaches. postnasal drip.Admits to rare use of alcohol (beer).M. two-story home described as “more than adequate” for his family. shared with his parents. has daily bowel movement. Breakfast consists of cereal. tremors.edu. depending on time of year. Dr/Magda Bayoumi 14 http://faculty. Psychosocial profile: ■ Bathes daily. or wheezing. on Monday and Friday nights and noon until 6 P. ■ Normally sleeps well and awakens rested. but has no steady girlfriend. ■ Plays baseball and competes on swim team. ■ Lymphatic/Hematologic: Positive seasonal allergies. ■ Does well in school and has been accepted to the state university. or paresthesia. ■ Works part-time at restaurant. ■ Integumentary: No changes in skin. Goes to bed at 11:30 P. ■ Respiratory: No cough. No changes in weight or energy level.milk. ■ Cardiovascular: No chest pain or history of cardiovascular disease. ■ Musculoskeletal: No weakness reported. no dietary restrictions. ■ Reproductive: Heterosexual.Vision 20/20. ■ Typical day starts at 6:45 A. Dates.M. until 11 P. he often awakens with congestion and/or sinus pressure.“Allergy attack” causes ear fullness. and scratchy/itchy throat. sees doctor and dentist for checkup once a year. not currently sexually active. no nausea or vomiting.ksu. no problems reported. No specific dietary restrictions or food intolerances.M. Tries to avoid exposure to smoke. Dinner is usually a cooked meal.M. on weekdays.

CRITICALTHINKINGACTIVITY 1 Based on his history. you need to visualize the underlying structures and identify landmarks. Dr/Magda Bayoumi 15 http://faculty. Both triangles are helpful in locating the underlying structures of the neck. or neck? Anatomical Landmarks Before you begin your physical assessment of the head.edu. The sternocleidomastoid and trapezius muscles form the triangles.aspx .ksu. or neck? CRITICALTHINKINGACTIVITY 2 What strengths can you identify that will help Ahmed prevent or adapt to any problems of the head. face. This is the facial crease that is often seen when someone smiles. face. face. face.The palpebral fissure is the distance between the upper and the lower eyelid.Case Study Evaluation Before you proceed with the physical examination of the head. is Ahmed at risk for any problems of the head. The nasolabial fold is the distance from the corner of the nose to the edge of the lip.sa/73577/default. and neck. Two landmarks on the face that are useful in determining symmetry of facial features are the palpebral fissures and the nasolabial folds . and neck history. The information from your patient history will be important to consider before and during your physical examination. The anterior and posterior triangles are important landmarks of the neck. and neck. document the key history information you have learned from John’s health history and his related head. face.

face. Physical Assessment During the history. and neck are a penlight or otoscope for focused light. like the throat and internal nose. if it is enlarged. Approach All four techniques of physical assessment—inspection.They are actually performed almost in concert. and auscultation—are used in the examination of the head. cup of water. face. they are not distinct. face. facial expressions. Lighting is very important. Although you inspect an area or structure before touching or moving it. and neck. The only areas to be auscultated are the carotids and jugulars and. you probably developed a sense of the patient’s concerns and may have begun to cluster the data obtained to help guide your physical examination. face. One common sequence is the head-to-toe approach that begins with inspection of the shape and general placement of the head and facial structures. as you approach the physical examination. palpation. mouth. Face. The assessment of the arteries and veins is also incorporated into the examination of the neck and face. can only be inspected. you observed the patient’s body posture. You should have an awareness of any physical limitations or discomfort that will influence the physical examination. and adhere to a set routine in order to avoid omitting a test. and neck.whereas others do this only after they have completed the examination of the neck. this takes only a moment and is usually followed immediately by touching or palpating the area.mouth. and throat.Now. nose. transilluminator. followed by a thorough inspection of the facial muscles and then the neck. perform a physical examination that focuses on the head. face. tongue blades.and this generally occurs after you have applied pressure over the sites during palpation. Dr/Magda Bayoumi 16 http://faculty.Focused Health History for the Head. and speech—all of which are important observations for the head. you will want a widetipped speculum. and neck to be percussed is the sinus area.ksu. Some structures. you must be very objective in your observations as you inspect the internal structures of the nose. and neck. If you are using an otoscope as a light source.The only area of the head. and neck. Face. generally only the sinuses are percussed. and gloves. No matter what sequence you use. throat.always take into consideration the structures’symmetry during your examination. you should develop.aspx . and only the vessels of the neck and thyroid are auscultated. stethoscope. practice. gauze.sa/73577/default. TOOLBOX The tools that will be necessary to examine the head. and Neck After the general survey and head-to-toe assessment. Although inspection and palpation are discussed separately below. A nasal speculum is another useful piece of equipment. sequential activities. the thyroid. and some examiners prefer also using a gooseneck lamp or headlamp when examining the mouth and throat. Some examiners prefer to examine the nose. mouth. and throat along with the face. mouth. Performing the Physical Assessment for the Head. Although there is no “right” sequence to follow for the examination of these structures and organs. fluidity of movements.edu. The cranial nerve (CN) assessment is generally incorporated in the examination of the face. Throughout the history. throat.nose. percussion.

Put on gloves in case there are open lesions under the hair. or congenital deformity. and occiput.Assessing the Head and Face Examination of the head and face involves inspection and palpation. Inspecting head size and shape and symmetry of facial features ABNORMALFINDINGS/R AT I O N A L E ■Abnormal increase in head size in young child: May indicate hydrocephalus. cheeks. Dr/Magda Bayoumi 17 http://faculty. ■ Variation is wide. A B N O R M A L F I N D I N G S / R AT I O N A L E Asymmetry of shape and contour: Previous trauma. 2. wigs. Inspection Have patients remove hats.sa/73577/default. Head Shape: Variation is wide.ksu. surgery. mastoids.aspx . Identify the prominences of the brows. although shape should be symmetrical and contour rounded. INSPECTION OF THE HEAD AND FACE: 1. Begin with inspection. between and within gender and racial/ethnic group. or hair ornaments if present.edu. ■ Inconsistently large head size in adolescent or adult: May indicate acromegaly. Head Size: ■ Inspect head size and shape and symmetry of facial features.

Asymmetry is also seen with Bell’s palsy and stroke.aspx . usually occur in the head and face. or Dr/Magda Bayoumi 18 http://faculty. A B N O R M A L F I N D I N G S / R AT I O N A L E ■Facial appearance inconsistent with gender.3.edu. Head Contour/Facial Structures ■ Use light palpation to note head size. age. including bulges or projections: Previous trauma. hypothyroidism with myxedema. However. symmetrical motion. masses or areas of tenderness.sa/73577/default. ■Asymmetry of movement: Suggests neuromuscular disorder or paralysis. ■ Smooth. ■ Tenderness: Trauma. shape. there should be symmetry of features and movement. crepitus. or racial/ethnic group: May indicate an inherited or chronic disorder with typical facies. Cushing’s syndrome. HELPFULHINT Two good places to inspect for symmetry of facial features are the palpebral fissures and the nasolabial folds. TMJ syndrome. PALPATION OF THE HEAD AND FACE 1. TMJ (Temporomandibular Joint Syndrome) Palpate the TMJ by placing fingers over the TMJ and palpating the joint as the patient opens and closes his or her mouth. or congenital deformity. ■ Relatively smooth with no unexpected contours or bulges. symmetry. such as Graves’ disease.ksu. or acromegaly. congenital deformity. temporal arteritis. ■ No tenderness or lesions. ■ Asymmetry of features: Previous trauma. with no pain. or inflammatory process. surgery. 2. paralysis. or edema. age. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Contour abnormalities. and racial/ethnic group. or spastic muscular contractions. Facial Appearance: Facial appearance varies by gender. Tics. surgical alterations. ■ Use light palpation to palpate the scalp for mobility and tenderness.

ksu. however. Transillumination requires a darkened room.Only the frontal and maxillary sinuses are readily accessible for assessment. Assessing the Sinuses Assessment of the sinuses includes inspection (with transillumination). Any glow noted with transillumination of either the frontal or the maxillary sinus should be symmetrical. A transilluminator should be used. palpation.and percussion. ■ Transilluminate maxillary sinuses by shining light below eyes while Dr/Magda Bayoumi 19 http://faculty. Absence of transillumination suggests sinus fullness or thickening. have the patient open her or his mouth and position her or his head so that you can observe the roof of the mouth. and look for a glow on the roof of the mouth. Inspection The sinus areas are inspected for edema and discoloration. A B N O R M A L F I N D I N G S / R AT I O N A L E 2. absence of transillumination may not always indicate pathology. with the patient’s mouth opened. Frontal and Maxillary Sinuses Inspect frontal sinuses above the eyes and maxillary sinuses below the eyes.clicking. palpation.To transilluminate the maxillary sinuses. However.you can also transilluminate the sinuses. Remember. INSPECTION OF THE SINUSES 1.and percussion.edu. or crepitus/popping: TMJ syndrome. Frontal and Maxillary Sinuses by Transillumination A S S E S S M E N T T E C H N I Q U E S / N O R M A L VA R I AT I O N S ■ Transilluminate frontal sinuses by shining light upward under eyebrow.To transilluminate the frontal sinuses.sa/73577/default. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Irregular or uneven movement. either a penlight or an otoscope with a speculum attached are good alternatives. the frontal sinuses are located above the eyebrows and the maxillary sinuses are located below the eyes. It may simply be a normal variant caused by the thickness of the bones overlying the sinuses or underdevelopment of the sinuses. ■ No periorbital edema or discoloration. hold the light source so that the light is directed upward from just below the brows. Envision the areas of the face that overlay the sinuses. Place the light source below the eyes and above the cheek. ■ Periorbital edema and dark undereye circles: Sinusitis.A glow of light may be detected over the brow. If you suspect a sinus problem after regular inspection. pain with motion.aspx .

■ Palpate maxillary sinuses by pressing below eyes. Percuss maxillary sinuses with direct or immediate percussion below eyes.sa/73577/default. ■ Dull tone: Indicates thickening or fullness of sinus cavity or cavities. PALPATION OF THE SINUSES: 1. ■ No tenderness. A B N O R M A L F I N D I N G S / R AT I O N A L E Absence of transillumination over one sinus when opposite structure transilluminates: Mucosal thickening or sinus fullness with sinusitis.ksu. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Tenderness: May indicate infectious or allergic sinusitis. ■ Expected variations include absence of transillumination because the ability to transilluminate is dependent on the thickness of the bones overlying the structure examined. red glow noted above eyebrow. associated with chronic or acute sinusitis.aspx . Frontal and Maxillary Sinuses Palpate frontal sinuses by pressing upward just below eyebrows. Dr/Magda Bayoumi 20 http://faculty. Resonant tone.looking for a red glow on the roof (palate) of the mouth. red glow noted on roof of mouth. No tenderness. note tenderness. ■ Absence of transillumination must be considered with other findings. note tenderness. A B N O R M A L F I N D I N G S / R AT I O N A L E ■Tenderness: Suggests sinusitis. ■ Maxillary sinus: Normally. Frontal sinus: Normally.edu. PERCUSSION OF THE SINUSES Percuss frontal sinuses with direct or immediate percussion above eyebrows.

head or nose trauma. especially in infants. ■ Clear. epistaxis. variations consistent with ethnic group/race and with oral mucosa. ■ Intact. scant mucus present. or mass. surgical alteration.ksu. including acromegaly or Down syndrome. A B N O R M A L F I N D I N G S / R AT I O N A L E ■Bright red mucosa: Inflammation from rhinitis or sinusitis. Abnormal shape also associated with typical facies. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Misalignment of nose or shape inconsistent with patient’s biographical information: Previous trauma. ■ Midline placement. ■ Deviated septum: Normal variant or following trauma. ■ Yellow or green drainage: Upper respiratory infection. ■ Moist. Dr/Magda Bayoumi 21 http://faculty. hypertension. and race/ethnic group. and symmetry. ■ No nasal flaring. gender. irritation or chronic infections. ALERT A deviated septum is cause for concern if breathing is obstructed. ■ Septum located midline.sa/73577/default. External Nose ■ Note size. unilateral drainage: May be spinal fluid as a result of head trauma or fracture. also suggests cocaine abuse. or bleeding disorders 2.edu. Shape symmetrical and consistent with age. Internal Nasal Mucosa: Tilt head back and use nasoscope or penlight to inspect nasal mucosa. ■ Pale or gray mucosa: Allergic rhinitis. or cocaine use. ■ Clustered vesicles: Herpes infection. ■ Clear. bilateral drainage: Allergic rhinitis. ■ Dried crusted blood: Previous epistaxis. ■ Bloody drainage: Trauma. with only clear. congenital deformity. shape.INSPECTION OF THE NOSE: 1. rounded projections): Allergies. mucoid drainage: Viral rhinitis. ■ Copious or colored discharge: Allergic or infectious disorder. ■ Clear. ■ Ulcers or perforations: Chronic infection.aspx . ■ No crusting or polyps. ■ Pink. ■ No drainage. ■ Polyps (elongated. trauma. ■ Nasal flaring: Suggests respiratory distress. with no lesions or perforations. who are obligatory nose breathers.

aspx . The middle turbinate is located more medially. ■ Redness: Inflammatory or infectious disorder. pink. ■ Pallor: Anemia. allergy. ■ No unusual odors A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Asymmetry of placement: Congenital deformity.edu. ■ Cyanosis: Vasoconstriction or hypoxia. symmetrical and shape/size consistent with general features of patient. ■ Lesions: Infectious or inflammatory disorder. ■ Cheilitis (inflammation of lips). ■ Pale or gray mucosa overlying turbinates: Allergic disorder. ■ Cartilaginous portion is slightly mobile. boggy turbinates: Allergic disorder. ■ Cheilosis (fissures at corners of lips): Deficiency of B vitamins or maceration related to overclosure. then ulceration): Herpes viral infection. or surgical alteration. Turbinates Inspect the turbinates. Therefore any persistent lesion requires medical attention. INSPECTION OF THE MOUTH AND THROAT 1. ■ Coloring consistent with ethnic group/race. drying.3. the inferior turbinate is more lateral. mouth lesions tend to heal quickly with treatment. and the superior is not visible. lesions. painless ulcer of primary syphilis. PALPATION OF THE NOSE 1. Nontender. ■ Angioedema: Allergic response. R AT I O N A L E / S I G N I F I C A N C E ■ Enlarged. Chancre: Single. paralysis. skin intact. and cracking: Dehydration.ksu. Overlying mucosa coloring consistent with other mucous membranes. Be aware of the possibility of oral cancer.sa/73577/default. Dr/Magda Bayoumi 22 http://faculty. and moist. External Nose Occlude each nostril and note patency. lip licking. odor. ■ Medial and inferior turbinates visible. HELPFULHINT Because the mucous membranes reproduce cells rapidly. Lips: ■Inspect color. no masses. condition. symmetrical. ■ Herpes simplex (clustered area of fullness/nodularity that forms vesicles. ■ Midline. trauma. Nares patent A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Deviations or masses: Previous trauma or infection.

A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Various abnormalities include loose. they are usually impacted or extracted. condition of teeth. ■ Mottled enamel: Fluorosis (excessive fluoride).ksu. Teeth and Bite: Have patient open and close mouth. Discoloration of teeth: Chemicals or medications (tetracycline may discolor teeth gray if administered before puberty). color. malalignment. poorly anchored teeth. or 32 if the four third molars. Note occlusion and number.aspx . and in good repair.edu.) ■ Teeth should be white. 2.sa/73577/default. (However. with good occlusion.■Halitosis: Infections or gastrointestinal problems. not loose. ■ Most adults have 28 teeth. dental caries. or wisdom teeth. are erupted. 1234Dental caries Malocclusion Fluorosis Tetracycline staining Dr/Magda Bayoumi 23 http://faculty.

bleeding gingivae may also be seen with leukemia and human immunodeficiency virus (HIV).edu. bleeding. moist. ■ Note condition of gingiva. such as dilantin or calcium channel blockers. ■ Gums consistent in color with other mucosa and intact. Inflamed. Color variants acceptable if consistent with patient’s ethnic group/race for instance.3.sa/73577/default. erosion of underlying mucosa: In denture wearers. lesions of mucosa.ksu. dark stippling in dark-skinned patients.aspx . condition. Gum hyperplasia ■ Gum recession or inflammatory gum changes (gingivitis/ periodontal disease): Poor dental hygiene or vitamin deficiency. Oral Mucosa and Gums: A S S E S S M E N T T E C H N I Q U E S / N O R M A L VA R I AT I O N S ■ Inspect color. intact mucosa. poorly fitted dentures. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Gum hyperplasia: Side effect of medications. retraction. Dr/Magda Bayoumi 24 http://faculty. ■ Pink. or hypertrophy. with no bleeding.Gingival recession Chronic gingivitis Leukemia ■ Pale or gray gingivae: Chronic Gingivitis ■ Abrasions.

Stensen’s duct intact at buccal mucosa at level of second molars. Cocaine use.edu. mucosa-covered projection on the hard palate (torus palatinus) or on floor of mouth (torus mandible) are normal variations.4. ■ Bony. HIV palatal candidiasis 5. Salivary Ducts: A S S E S S M E N T T E C H N I Q U E S / N O R M A L VA R I AT I O N S ■ Stensen’s duct: Inspect inner aspect of cheek (buccal mucosa) opposite the second upper molar. ■ Wharton’s duct: Have patient lift tongue and inspect the floor of mouth. pink.sa/73577/default. Palate intact. no lesions. or nodules. smooth. Dr/Magda Bayoumi 25 http://faculty. swelling.aspx . ■ Wharton’s duct intact at either side of frenulum. Hard and Soft Palate: Inspect color and condition of hard and soft palate. ■ Both ducts with moist and pink mucosa.ksu. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Perforation: Congenital or from trauma or drug use.

A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Fullness or inflammatory changes of glands: Blockage of duct by calculi, infection, malignancy. Parotitis is inflammation of parotid glands, (Parotitis; 6. Tongue: Inspect color, texture, moisture, and mobilityPink and moist. ■ Coloring may vary consistent with ethnic group/race. ■ Mucosa intact with no lesions or discolorations. ■ Papillae intact. Tongue is freely and symmetrically mobile (CN XII intact). ■ Geographic tongue is a normal variation.

A B N O R M A L F I N D I N G S / R AT I O N A L E Absence of papillae, reddened mucosa, ulcerations: Allergic, inflammatory, or infectious cause. ■ Color changes: May indicate underlying problems; for example, red “beefy” tongue is seen with pernicious anemia. Black, hairy tongue: Fungal infections. Hypertrophy and discoloration of papillae: Antibiotic use. ■ Reddened, smooth, painful tongue, with or without ulcerations (glossitis): Anemia, chemical irritants, medications. ■ Cancers may form on the tongue and on other oral mucosa.

7. Oropharynx: Inspect oropharynx for color, lesions, and drainage. Mucosa is pink, moist, intact. The lymphoid-rich posterior wall may have a slightly irregular surface. ■ No lesions, erythema, swellings, exudate, or discharge.

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A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Yellowish or green streaks of drainage on the posterior wall: Postnasal drainage. ■ Gray membrane/adherent material: Diphtheria. ■ White or pale patches of exudates with erythemic mucosa: Infection, including streptococcal bacterial infection or mononucleosis viral infection. Gonorrhea and chlamydia are also associated with exudative pharyngitis. ■ Erythema: Inflammatory response, typically associated with infectious pharyngitis; also common in smokers. ■ Scattered vesicles/ulcerations: Herpangioma. 8. Tonsils: Locate tonsils posterior to arches on sides of throat. ■ Note color, size, and exudate. ■ Symmetrical, pink, clean crypts. Crypts may have normal variation of small food particles (tonsilar pearls) orscant amounts of white cellular debris. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Bulges adjacent to the tonsilar pillars: Potential peritonsillar abscess. ■ Reddened, hypertrophic tonsil, with or without exudates: Acute infection or tonsillitis. ■ Lymphoid cobblestoning. ■ Enlarged tonsils with exudates. See Next: Tonsil Grading Scale

9. Uvula: ■ Have patient say “AH!” and note symmetrical rise of the uvula. ■ Midline, pink, moist, without lesions. ■ Symmetrical rise of the uvula A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Erythema, exudate, lesions: Infectious process. ■ Asymmetrical rise of the uvula: Problem with CN IX and CN X.

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PALPATION OF THE MOUTH AND THROAT 1. Lips: Lightly palpate lips for consistency and tenderness. ■ Soft, nontender, no masses. ■Areas of induration, thickening, nodularity, or masses: Neoplasm. ■ Tender induration that soon develops vesicles: Herpes simplex. 2. Tongue: Lightly palpate tongue for consistency and tenderness. ■ Tissue is soft, without masses, nodules, thickenings, or tenderness. ■ Tissue is soft, supple, without nodules, thickenings, masses, or tenderness. Sublingual glands may be palpable under the tongue but should be nontender, soft, and supple. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Areas of induration, thickening, nodularity: Potential malignancy. ■ Areas of unexpected induration, thickening, nodularity or other mass: Malignancy
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blocked ducts. or masses. or hypertrophy in mid to lower half of anterior neck. Submandibular and sublingual: Palpate under the mandible. supple. a. Neck erect. A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Enlarged.Inspecting the neck from the neutral position b. or malignancy. infection. No masses. and Sublingual): Parotid: Palpate in front of ears. Glands (Parotid. ■ Thyroid not visible. Submandibular and sublingual glands may be palpable but should be nontender.Inspecting the neck when the client swallows water A B N O R M A L F I N D I N G S / R AT I O N A L E Dr/Magda Bayoumi 29 http://faculty. bulges.3. tender parotid glands: Parotitis. swelling. no lumps. INSPECTION OF THE NECK Inspect neck in neutral and hyperextended positions and as patient swallows.ksu. and soft.edu. Parotid glands are nonpalpable and nontender. Submandibular.aspx . midline.Inspecting the neck when hyperextended c.sa/73577/default.

lymphoma. adenitis. glandular. Normal palpable nodes are more likely to be found in children than in adults. round.sa/73577/default. ■ Supple. nontender. and not freely movable.aspx . A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Masses: Lymphadenopathy.ksu. To distinguish between salivary glands and lymph nodes. movable. cerebellar tumor.  Patients who present with a sore throat often complain about “swollen glands. visible thyroid: Goiter or malignant mass. enlarged cervical glands. no masses. ■ Torticollis (deviation of neck to one side caused by spasmodic contraction of neck muscles): Scars. tonsillitis. Deep cervical nodes are normally nonpalpable. remember: A normal lymph node is either small (_1 cm). ■ Enlarged. rheumatism retropharyngeal abscess.  A palpable normal node is more likely to be a superficial node than a deep cervical one. and nontender or tender and enlarged with infection.” They are actually feeling their submandibular salivary glands. or other malignancy.edu. soft.■Enlargements: Lymphadenopathy. disease of cervical vertebrae. PALPATION OF THE NECK 1. HELPFULHINTS  Lymphatic tissue is largest in childhood and decreases in size with age. Neck: ■ Use light palpation and check for masses or areas of tenderness. maligna Dr/Magda Bayoumi 30 http://faculty. soft to rubbery. Submandibular glands are larger.

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symmetrical. ■ Provides history with ease.aspx . ■ Head and Face ■ Head is normocephalic.supple. ■ Lips are pink. ■ Cervical nodes are nonpalpable. Dr/Magda Bayoumi 35 http://faculty. ■ Stensen’s and Wharton’s ducts with mucosa intact. with no exudates or lesions. no induration or swelling. ■ Projects a confident and comfortable affect. ■ Height 5'10". and neck problems. ■ Nose and Sinuses ■ Sinuses are nontender.neck is supple. face. resonant to percussion. ■ Head-to-toe scan reveals no signs of head. no lesions or exudates. with no lesions or polyps. nontender. ■ Trachea is midline and mobile.with no drainage or lesion. no lesions. healthy appearance consistent with stated age.ksu. ■ Scant clear. ■ Pharynx ■ Tonsils are symmetrical. External nose is midline. ■ Head-to-toe scan reveals no signs of problems in other systems/areas that would affect head. ■ Thyroid is nonpalpable. ■ Vital Signs ■ Temperature 97. ■ Oral mucosa is uniformly deep pink. mucosa intact and pink.sa/73577/default. small. freely mobile. ■ Nasal mucosa is intact. no nasal flaring. ■ Pulse 62. symmetrical. slightly paler than oral mucosa. ■ Tanned skin. good occlusion. or tenderness.with full range of motion. bulges. ■ Face is symmetrical at rest and at motion. ■ Uvula is midline with symmetrical rise and pink mucosa. ■ Septum is midline. pink. ■ Blood pressure (BP) 100/72. left arm. smooth.Case Study Findings Your general health survey and head-to-toe assessment of M r Ahmed have concluded.8_F. with no deviation or perforation. glistening. pink mucosa with papillae intact. ■ Turbinates are symmetrical. slightly enlarged. with no lesions. and maxillary/frontal sinuses transilluminate bilaterally. lesions. ■ Weight 160 lb. and neck. ■ Mouth and Teeth ■ Lips are midline. ■ No apparent distress. ■ Posterior wall is moist. moist.edu. The following are your findings: ■ General Health Survey ■ Well-developed 17-year-old male. ■ Tongue is supple. ■ Nares are patent. with clean crypts. ■ Respirations 14. no bulges or masses. close easily. ■ 28 white teeth in good repair. ■ Neck ■ Head and neck are erect. pink.mucoid secretions.with no abnormal contour. face. no lesions or indurations.with no lesions or indurations.

Use this information to identify a list of nursing diagnoses.sa/73577/default. teenage driving.edu. 3. CRITICALTHINKINGACTIVITY 4 Now that you have identified appropriate nursing diagnoses for Me Ahmed. Risk for Trauma. Dr/Magda Bayoumi 36 http://faculty. Health-Seeking Behaviors.document the key history and physical examination findings that will help you formulate your nursing diagnoses. including learning outcomes and teaching strategies. related to the desire to participate in recreational activities and to maintain overall health.Now that your examination of Mr AHMED is complete.ksu. 2. Disturbed Sleep Pattern. Cluster the supporting data. design a nursing care plan and a brief teaching plan for one of the diagnoses identified above. occasional alcohol intake. related to adverse reaction to medication and/or sinus/nasal discomfort and congestion. Some possible nursing diagnoses are provided below.aspx . Identify any additional nursing diagnoses. Case Study Analysis and Plan CRITICALTHINKINGACTIVITY 3 What strengths and areas of concern have you identified related to Mr Ahmed’s current health status? Nursing Diagnoses Consider all of the data you have collected during your assessment of Mr Ahmed. 1. related to frequent athletic activities.

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aspx .ksu. Dr/Magda Bayoumi 38 http://faculty. and differentiation of colors. Visual difficulties can result from disease or injury to any of the structures involved in the visual pathway.edu. including central and peripheral vision. the external and internal structures of the eye work together to receive and transmit images to the occipital lobe of the brain for interpretation. near and distance vision.sa/73577/default.To accomplish these tasks.Assessing the Eye and the Ear Anatomy and Physiology Review: The Eye The primary function of the eye is vision.

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edu. motor.and to the maintenance of those skills in adulthood. to the development of psychosocial. ■ Information from both the history and the physical examination is then analyzed to determine appropriate nursing diagnoses.aspx .SUMMARY ■ The eyes are complex sensory organs that provide specialized functions crucial to neurosensory development in infancy. Dr/Magda Bayoumi 56 http://faculty.ksu. ■ A comprehensive history and physical examination enable early detection and treatment of sight problems. including exploration of factors that may be related to eye health. ■ A thorough health history provides direction for the physical examination.sa/73577/default.and cognitive skills in childhood.

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and stapes (stirrup) bones to move. middle and inner ear.edu. Understanding Sounds and Sound Waves Hearing occurs by air conduction and bone conduction of sound waves. Intensity or loudness is determined by the size ofthe sound waves. the number of sound waves per second.Anatomy and Physiology Review: The Ear The main functions of the ears are hearing and equilibrium. middle.aspx . Structures and Functions of the Ear The three parts of the ear—external. and inner— contain anatomical structures that work together to allow us to hear. Sound waves are characterized by differences in pitch and loudness. Frequency.it involves carrying sound waves through the external auditory canal to the tympanic membrane (TM).sa/73577/default.There.where they stimulate the vestibulocochlear nerve and transmit the impulses to the temporal lobe for interpretation. vestibulocochlear nerve (CN VIII). How We Hear Air conduction is the primary mechanism of hearing. then on to the cranial nerve and the temporal lobe Dr/Magda Bayoumi 59 http://faculty. and inner ear. and temporal lobe .ksu. Bone conduction provides an additional pathway whereby sound waves vibrate the skull bones and transmit the vibrations to the inner ear structures. Both air and bone conduction use a common final pathway involving transmission of the vibrations to the inner ear structures. middle. thus transmitting the vibrations to the inner ear structures. Sound waves can be classified on a traffic or machinery noise or exposure to rock music concerts at 120 dB or more can cause damage to the hearing structures and result in permanent hearing loss. incus (anvil). Maintaining normal equilibrium requires proper functioning of the structures in the inner ear. Hearing requires an intact and unobstructed external canal. Sound waves move through the external. the sound vibrations cause the TM and the malleus (hammer). determines the pitch of the sound.

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palpate the tragus.aspx . Otherwise.ALERT  Before inserting the otoscope.edu. and helix. The inner two-thirds of the ear canal are over the temporal bone and are very sensitive. insert the scope very carefully.  Insert the otoscope only in the outer third of the canal. If any of these are tender.ksu. mastoid.sa/73577/default.  Dr/Magda Bayoumi 66 http://faculty. you may inadvertently push an object farther up the canal.  Always inspect the external canal for foreign objects before inserting the otoscope.

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motor. Information from both the history and the physical examination is then analyzed to determine appropriate nursing diagnoses.aspx .SUMMARY ■ A thorough health history provides direction for the physical examination to include exploration of factors that may be related to ear health. ■ The ears are complex sensory organs that provide specialized functions crucial to neurosensory development in infancy and to the development of psychosocial.ksu.edu. Dr/Magda Bayoumi 68 http://faculty. ■ A comprehensive history and physical examination enables early detection and treatment of hearing problems. and cognitive skills in childhood and the maintenance of those skills in adulthood.sa/73577/default.

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does not have coverage for dental or vision examinations. ■ No family history of glaucoma or vision loss. age 78.however. Biographical data: ■ 55-year-old Caucasian widow and mother of one child. Glucatrol 5 mg bid.Case study Mrs Heas. She admits to having difficulty sticking to a diabetic. ■ Mother. Past health history: ■ History of HTN for past 10 years and poorly controlled adult-onset diabetes diagnosed 3 years ago Denies trauma or surgery affecting the eyes or hospitalizations except for childbirth. age 30. Captopril 25 mg bid.No history of Dr/Magda Bayoumi 70 http://faculty. Review of systems: ■ General Health Survey: States that she is usually in good health. eye pain. Current health status: ■ Complains of blurred vision that has increased over the past month. drainage. She takes the oral hypoglycemic agent Glucatrol as well as Lasix and Captopril for HTN. is a 55-year-old secretary whom you are seeing in the clinic for the first time. no abortions. ■ Has medical insurance coverage through her employer. last eye examination 5 years ago. Ears. ■ Denies allergies to foods. Family history: ■ One child. She has a history of hypertension (HTN) for 10 years and was diagnosed with type 2 (non– insulin-dependent) diabetes mellitus (NIDDM) 3 years ago. ■ Blurred vision has not prevented her from caring for herself at home. double vision. low-sodium diet and taking her medications regularly.One child. ■ Head. or changes in the appearance of the eyes. or environment.edu. ■ Works full-time as a secretary at a large law firm. and Throat (HEENT): No eye tearing or drainage. ■ Father deceased. it is difficult to read the material she is typing on the computer screen. which has gradually worsened over the past several months.multiple sclerosis (MS). Blurred vision is constant and worsened by fatigue. sensitivity to light. ■ Last physical examination 10 months ago. Eyes.aspx . ■ Integumentary: No skin lesions or allergies. and 400 to 600 mg of ibuprofen as needed for joint pain nearly every day. ■ Catholic religion.Wonders if she needs new glasses. ■ One brother. history of colon cancer. and stroke 4 years ago. age 30. deceased 2 years ago at age 50 from a myocardial infarction. She has experienced blurred vision. lives in nursing home and has history of NIDDM. Nose. and died of heart attack at age 56. States that nothing seems to cause the problem or has helped relieve it.sa/73577/default. Case Study Findings ■ Typically works at a computer for at least 4 hours each day.ksu. ■ Mammogram and Pap smear negative. Currently takes Lasix 20 mg bid. ■ Denies tearing. alive and well. drugs. of Irish/Italian descent.even with reading glasses.

■ Admits difficulty following prescribed diabetic and low-sodium diets. last eye exam 5 years ago. document the key information you have learned from Mrs. or myasthenia gravis. Gets yearly mammograms and Pap tests. Commutes 30 minutes to and from work. and dresses. how might her visual problem affect her? CRITICALTHINKINGACTIVITY What special needs might Mrs.edu. but returned to workforce after husband died of a heart attack 2 years ago. doing housework.M. has tried to become more involved in her favorite hobbies: reading. positive history of HTN. no history of thyroid disease. when she rises. ■ Stress and coping mechanisms include gardening and talking over problems with son and longtime friends fromneighborhood. Psychosocial profile: ■ Last physical 10 months ago. ■ Typical day starts at 6:30 A. ■ Endocrine: Positive history for type 2 diabetes. ■ Is Catholic. Eats lunch (sandwich) at diner most days.Monday through Friday.watching TV. ■ Main social supports are friends from neighborhood and son and daughter-in-law. to 5 P. Heas’s health history.sa/73577/default. ■ Generally sleeps 8 hours a day without napping. chemotherapy. Goes to movies with friends occasionally. with occasional overtime. ■ Main source of exercise is gardening and yard work.. and gardening. visiting son.M. and has breakfast (bagel and coffee). ■ Drinks socially three to four times a year. paresthesia. unless she runs errands or shops for groceries. or immunotherapy.Visits mother in nursing home once a week.M. Hesa have because of the problems with her eyes? Dr/Magda Bayoumi 71 http://faculty. but is not currently active in church. Hesa’s health history. Usually returns home by 6 P.M. Leaves for work at 8 A. ■ Lives in a rural community just outside of town.Tries to eat regularly but has a limited appetite and finds it difficult to cook balanced meals for one person. ■ Neurological: No muscle weakness. CRITICALTHINKINGACTIVITY Considering Mrs. ■ Musculoskeletal: No joint pain or deformity or rheumatoid arthritis. Denies any specific ethnic or cultural practices.M. Goes to bed at 11 P. Rarely cooks a full dinner unless her son visits. ■ Sees son once a week (lives in a neighboring town). Case Study Evaluation Before you proceed with the physical examination of the eye and the ear. ■ Respiratory: No history of respiratory. MS.aspx . Spends weekends gardening in warm weather. Now works full-time as a secretary. showers.Works 8:30 A. Smoked 1 pack of cigarettes a day since age 18 until 10 years ago when diagnosed with high blood pressure (BP). ■ Since loss of her husband. in her own home.M. visiting mother in nursing home. ■ Cardiovascular: No history of cardiac symptoms.ksu. running errands.headache or head injury. ■ Lymphatic: No history of human immunodeficiency virus (HIV).No symptoms of upper respiratory infection.Watches TV or reads after dinner. ■ Gastrointestinal: No history of liver or renal disease. Reports using computers for an average of 4 hours a day. ■ Was a full-time homemaker during her 22-year marriage.

■ Native American and Spanish descent. Family’s main source of financial support. Current health status: ■ Chief complaint is intermittent fullness and pressure in both ears for past 2 weeks. ■ Gastrointestinal: Denies nausea. ■ Patient has two teen-aged girls. diarrhea. ■ Current medications include an over-thecounter (OTC) allergy medication. tetanus. ■ Received polio. ■ Hospitalized once at age 3 with pneumonia and concurrent bilateral otitis media. tinnitus. ■ Full-time construction supervisor with bachelor’s degree. and diphtheria vaccinations. Environmental allergy to dust and pollen. dust. ■ One brother. He is the sole support of his two teenaged children (ages 14 and 16) and his physically disabled wife. diagnosed with neurofibromatosis including acoustic neuroma. Health is usually good. has controlled HTN.measles/mumps/rubella. ■ Mother. or HTN. vomiting.sa/73577/default. Family history: ■ Father. or recent trauma to the ears. age 70. ages 14 and 16. age 40. ■ One sister. ■ Denies precipitating factors such as recent upper respiratory infection or recent altitude changes. occurring yearly or less. ■ Allergic to sulfa. or ear trauma. drainage.who appears reliable. Review of systems: ■ General Health Survey: Denies fatigue or recent weight loss. wife is disabled. Source of biographical data is patient. Past health history: ■ History of frequent ear infections as an infant and young child. and pollen. penicillin. Dr/Magda Bayoumi 72 http://faculty. Biographical data: ■ Married. ■ Denies asthma. ■ Integumentary: Denies rashes. He has a clinic appointment to discuss “problems with my ears” that make it increasingly difficult for him to function in the work environment.Treated with antibiotics.edu. ■ Rates severity of his ear fullness and pressure as 7 on a 10-point scale. age 36. recently diagnosed with HTN. both alive and well. ■ Carries HMO insurance through his employer that covers entire family.CRITICALTHINKINGACTIVITY What factors from her health history might affect her eyes? Case study II: Mr Hassan is a 50-year-old construction supervisor. diabetes. currently in remission. He has worked in construction for 15 years.ksu. resolved with antibiotics. ■ HEENT: Denies ear pain. or slow wound healing. History of frequent childhood ear infections and occasional ear infections as an adult. age 78. ■ Related symptoms include intermittent. practicing Catholic.aspx . or recent changes in bowel habits. lesions. drainage. Reports recent upper respiratory infection 4 weeks ago with earache. bilateral hearing loss described as “like hearing in a tunnel” and intermittent dizziness.50-year-old father of two (ages 14 and 16). diagnosed with MS at age 45. ■ Denies ear pain.

Psychosocial profile: ■ Last physical examination was 6 months ago. Cooks dinner for wife and two daughters. ■ Denies chronic or recent exposure to loud noise at home or at work. Leaves for work by 6:15 A. Returns home by 4 P.ksu. how might this hearing problem affect him? C R I T I C A L T H I N K I N G A C T I V I T Y III What strengths does Mr. Rarely exercises because of lack of time.(Wife cannot drive because of disability. Usually gets 7 hours of sleep a night. ■ Typical day starts at 5:30 A.■ Genitourinary: Denies changes in bladder habits.most days unless he has errands to run.Hassan’s health history and his related ear history. ■ Neurological/Musculoskeletal: Intermittent problem with balance since onset of ear pressure. or paresthesia. Hassan possess that will help him cope with and manage his health problems? Dr/Magda Bayoumi 73 http://faculty.M. running errands. document the key information you have learned from Mr. Last ear exam was 4 weeks ago during recent ear infection. Goes to bed by 10 P.M.edu. chauffeuring daughters. CRITICALTHINKINGACTIVITY I What factors in Mr. fatigue. Hassan’s history may explain his hearing problem? C R I T I C A L T H I N K I N G A C T I V I T Y II Considering Mr.Monday through Friday. on workdays. muscle weakness. ■ Has a hectic life with major family responsibilities and many stressors. and has breakfast (cereal and coffee). especially brother and father. to 3 P. Denies vertigo.Works 7 A. ■ Main social supports are family. Denies ever having a hearing test. Case Study Evaluation Before you proceed with the physical examination.sa/73577/default. and intermittent balance problems.Talking with friends and family is main coping mechanism.M.M. when he rises.aspx .by turning up sound on TV and phone handset). ■ Ear pressure and fullness have caused intermittent problems in managing his household and socializing. States that he can usually compensate for the hearing loss at home (e. showers. ■ States that hearing loss causes safety issues at work. although lunch at work is rushed. then often drives daughters to various school or social activities. Spends weekends attending sporting events. and a few close friends at work. Eats quick lunch from sidewalk vendor.) ■ Generally eats a well-balanced diet.M. Spends evenings watching TV. ■ Ear problems have not caused sleep difficulties.. Hassan’s history.g.M.

fatigue.(Wife cannot drive because of disability. ■ Typical day starts at 5:30 A. ■ Denies chronic or recent exposure to loud noise at home or at work. showers.M. Case Study Evaluation Before you proceed with the physical examination. and intermittent balance problems. how might this hearing problem affect him? C R I T I C A L T H I N K I N G A C T I V I T Y III What strengths does Mr. ■ Neurological/Musculoskeletal: Intermittent problem with balance since onset of ear pressure. muscle weakness.Hassan’s health history and his related ear history.M. although lunch at work is rushed.edu. then often drives daughters to various school or social activities. Leaves for work by 6:15 A. Hassan possess that will help him cope with and manage his health problems? Dr/Magda Bayoumi 74 http://faculty.g. Denies ever having a hearing test.M. ■ Main social supports are family. Usually gets 7 hours of sleep a night. Cooks dinner for wife and two daughters. Spends weekends attending sporting events. ■ States that hearing loss causes safety issues at work. Spends evenings watching TV. Psychosocial profile: ■ Last physical examination was 6 months ago. on workdays. ■ Ear problems have not caused sleep difficulties. especially brother and father. and a few close friends at work.■ Genitourinary: Denies changes in bladder habits. Eats quick lunch from sidewalk vendor.) ■ Generally eats a well-balanced diet.by turning up sound on TV and phone handset).sa/73577/default.M. CRITICALTHINKINGACTIVITY I What factors in Mr. document the key information you have learned from Mr. Hassan’s history. chauffeuring daughters. Denies vertigo. when he rises. or paresthesia. Returns home by 4 P.most days unless he has errands to run. running errands.Monday through Friday.aspx .Works 7 A. to 3 P.Talking with friends and family is main coping mechanism.M.ksu. Goes to bed by 10 P. States that he can usually compensate for the hearing loss at home (e. ■ Has a hectic life with major family responsibilities and many stressors.M. Rarely exercises because of lack of time.. Hassan’s history may explain his hearing problem? C R I T I C A L T H I N K I N G A C T I V I T Y II Considering Mr. and has breakfast (cereal and coffee). Last ear exam was 4 weeks ago during recent ear infection. ■ Ear pressure and fullness have caused intermittent problems in managing his household and socializing.

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