Joy N.

Bautista, RN, MPH, DRDM, MAN

EENT assessment

Health History: EYES

Corrective lenses for distance or for reading? Blurred vision, blind spots, floaters, double vision, discharge, or unusual sensitivity to light? Trouble seeing at night? Eye injury or eye surgery? Lazy eye? Allergies? Last eye examination? Complaints of eye pain or headaches? Squint to see objects at a distance? Hold objects close to his eyes to see them?

Health History: GENERAL EYE HEALTH

Family History
hypertension, diabetes, stroke, multiple sclerosis, syphilis, or HIV glaucoma, cataracts, vision loss, or retinitis. Digoxin overdose can cause a patient to see yellow halos around bright light Exposure to chemicals, fumes, flying debris, or infectious agents Wear eye protection Smoking increases the risk of vascular disease, which can lead to blindness and can damage vision.

Medication History Occupation

Smoking

Health History: PEDIATRIC EYE

Delivered vaginally or by cesarean birth? If delivered vaginally, mother have a vaginal infection at the time? (Inform the parents that infection such as chlamydia, gonorrhea, genital herpes, or candidiasis can cause eye problems in infant.) Erythromycin ointment instilled in his eyes at birth? Passed the normal developmental milestones? Know how to hold and care for sharp objects such as scissors?

Health History: ELDERLY EYE

Any difficulty climbing stairs or driving? Tested for glaucoma? When? Result? If with glaucoma, eye drops? What kind? How well can Px instill eye drops? Eyes feel dry? Burn? How treated?

Physical Exam: EYE TOOLS

a good light source a penlight one or two opaque cards an ophthalmoscope (DOCTORS NEED THIS!) vision-test cards gloves tissues cotton-tipped applicators

Physical Exam: GENERAL APPEARANCE

Observe the patients face. With the scalp line as the starting point check that his eyes are in normal position.
They should be about one-third of the way down the face and about one eyes width apart from each other.

Then assess the eyelid, conjunctiva, cornea, anterior chamber, iris, and pupil.

Physical Exam: EYELIDS

Upper eyelid cover top quarter of the iris so the eyes look alike. Check for an excessive amount of visible sclera above the limbus (corneo-scleral junction). Ask the patient to open and close his eyes to see of they close completely. If the downward movement of the upper eyelid in down gaze is delayed, the patient has a condition known as lid lag, which is a common sign of hyperthyroidism. Assess the lids for redness, edema, inflammation, or lesions. Check for a stye, or hordeolum, a common eyelid lesion.

Physical Exam: EYELIDS

Inspect the eyes for excessive tearing or dryness. The eyelid margins should be pink, and the eyelashes should turn outward. Observe whether the lower eyelids turn inward toward the eyeball, called entropion, or outward, called ectropion. Examine the eyelids for lumps. Note tenderness, swelling of the nasolacrimal duct or discharge through the lacrimal point, which could indicate blockage of the nasolacrimal duct.

Physical Exam: CONJUNCTIVA

Bulbar conjunctiva should be clear and shiny (Px looks up). Note excessive redness or exudate. Inspect the bulbar conjunctiva for color changes, foreign bodies, and edema. Observe the scleras color, which should be white to buff. Palpebral conjunctiva should be uniformly pink (Px looks down). Cobblestone appearance in Pxs with allergies.

Physical Exam: CORNEA

The cornea should be clear and without lesions. Test corneal sensitivity by lightly touching the cornea with a wisp of cotton.
The patient should blink. If he doesnt blink, he may have suffered damage to the sensory fibers of cranial nerve V to the motor fibers controlled by cranial nerve VI. Keep in mind that people who wear contact lenses may have reduced sensitivity because theyre accustomed to having foreign objects in their eyes.

Physical Exam: ANTERIOR CHAMBER & IRIS

The iris should appear flat, and the cornea should appear convex. Excess pressure on the eye such as that caused by acute angle-closure glaucoma may push the iris forward, making the anterior chamber appear very small. The irises should be the same size, color, and shape.

Physical Exam: PUPIL

Each pupil should be equal size, round, and about one-fourth the size of the iris in normal room light. Test the pupils for accommodation
Place your finger approximately 4 inches (10.2 cm) from the bridge of the patients nose. Ask the patient to look at a fixed object in the distance and then to look at your finger. His pupils should constrict and his eyes converge as he focuses on you finger.

Physical Exam: PUPILS

Test the pupil for direct and consensual response.
In a slightly darkened room, hold a penlight about 20 (50.8 cm) from the patients eyes Direct the light at the eye from the side Note the reaction of the pupil youre testing (direct response) and the opposite pupil (consensual response). They should both react the same way. Note sluggishness or inequality in the response. Repeat the test with other pupil.

Physical Exam: VISUAL ACUITY

Snellen chart and near-vision chart test for far and near vision Snellen E chart for pediatric patients E orientation Visual acuity is recorded as a fraction.
The top number (20) is the distance between the patient and the chart (20 ft) The bottom number is the distance from which a person with normal vision could read the line. The larger the bottom number, the poorer the patients vision.

Physical Exam: PERIPHERAL VISION

Confrontation - to test peripheral vision

Sit directly across the patient and have her focus her gaze on your eyes. Place your hands on either side of the patients head at the level of her ears so that theyre about 2 feet apart. Tell the patient to focus her gaze on you as you gradually bring your wiggling fingers into her visual field. Instruct the patient to tell you as soon as she can see your wiggling fingers; she should see them at the same time you do. Repeat the procedure while holding your hands at the superior and inferior positions.

Physical Exam: EYE MUSCLES

Corneal light reflex
Ask the patient to look straight ahead Shine a penlight on the bridge of his nose from about 12 inches to 15 inches (30.5 cm to 38 cm) away. The light should fall at the same spot on each cornea If it doesnt, the eyes arent being held in the same plane by the extraocular muscles This commonly occurs in a patient who lacks muscle coordination, a condition called strabismus.

Physical Exam: EYE MUSCLES

Cardinal position of gaze - evaluate the oculomotor, trigeminal and abducent nerves as well as the extraocular muscles
Ask the patient to remain still while you hold a pencil or other small objects directly in front of his nose at a distance of about 18 (45 cm) Ask him to follow the object with his eye, without moving his head Move the object to each of the six cardinal positions, returning to the midpoint after each movement The patients eyes should remain parallel as they move. Note abnormal findings such as nystagmus and ambylopia, the failure of one eye to follow an object.

Physical Exam: EYE MUSCLES

The cover-uncover test only done when there is an abnormality detected when assessing the corneal light reflex and cardinal positions of gaze
Have the patient stare at a wall on the other side of the room. Cover one eye and watch for movement in the uncovered eye. Remove the eye cover and watch for movement again. Repeat the test with other eye. Eye movement while covering or uncovering the eye is considered abnormal. It may result from weak or paralyzed extraocular muscles, which may be caused by cranial nerve impairment.

Health History: EARS

Hearing loss, tinnitus, pain, discharge, and dizziness. Discharge, history of head injury. Vertigo (spinning), nausea, vomiting, or tinnitus. Ear problem or injury Chronic disorders. Current treatments and medications Allergies.

Health History: NOSE

Nasal stuffiness, nasal discharge, and epistaxis, or nosebleed. Colds, hay fever, headaches, and sinus trouble. Nose or head trauma. Environmental allergies Color and consistency of the discharge.

Health History: MOUTH, THROAT, NECK

Bleeding or sore gums Mouth or tongue ulcers Bad taste in his mouth, bad breath Toothaches, loose teeth, frequent sore throat, hoarseness or facial swelling Smokes or uses other types of tobacco. Neck pain or tenderness, neck swelling, or trouble moving his neck.

Health History: GENERAL HEALTH

Changes in tolerating hot and cold weather? Weight changes? Breathing problems or feel as if heart skips beats? Changes in menstrual pattern? Tremors, agitation, or difficulty concentrating or sleeping?

Physical Exam: EARS

Assess the ears for position and symmetry.
The top of the ear should line up with the outer corner of the eye, Ears should look symmetrical, with an angle of attachment of no more than 10 degrees

The face and ears should be the same shade and color. Low-set ears - congenital disorders, including kidney problems. Inspect the auricle for lesions, drainage, nodules, or redness. Pull the helix back and note if its tender. If pulling the ear back hurts the patient, he may have otitis externa. Inspect and palpate the mastoid area behind each auricle, noting tenderness, redness, or warmth. Inspect the opening of the ear canal, noting discharge, redness, odor, or the presence of nodules or cysts.

Physical Exam: HEARING ACUITY

Webers test - when the patient reports diminished or lost hearing in one ear
Strike the tuning fork lightly against your hand, and then place the fork on the patients forehead at the midline or on the top of his head. Hears the tone equally well in both ears normal Hears the tone better in one ear right or left lateralization Hears the tone in impaired ear conductive hearing loss Hears the tone in unaffected ear sensorineural hearing loss

Physical Exam: HEARING ACUITY

Rinne test - after Webers test to compare air conduction of sound with bone conduction of sound

Strike the tuning fork against your hand, and then place it over the patients mastoid process. Ask him to tell you when the tone stops; note this time in seconds. Move the still-vibrating tuning fork to the ears opening without touching the ear. Ask him to tell you when the tone stops. Note the time in seconds. Air-conducted tone (ear) should be twice as long as the boneconducted tone (mastoid) Bone-conducted tone air-conducted tone conductive hearing loss Air-conducted tone bone-conducted tone sensorineural hearing loss

Physical Exam: NOSE

Observe patients nose for position, symmetry, and color. Note variations, such as discoloration, swelling, or deformity. Observe for nasal discharge of flaring.

To test nasal patency and olfactory nerve (cranial nerve I) function,

If discharge is present, note the color, quantity, and consistency. If you notice flaring, observe for other signs of respiratory distress.

Inspect the nasal cavity. Ask the patient to tilt his head back slightly, and then push the tip of his nose up.

Ask the patient to block one nostril and inhale a familiar aromatic substance through the other nostril. Ask him to identify the aroma. Repeat the process with the other nostril, using a different aroma. Check for severe deviation of perforation of the nasal septum. Examine the vestibule and turbinates for redness, softness, swelling, and discharge.

Physical Exam: NOSE

Examine the nostrils by direct inspection, using nasal speculum, a penlight or small flashlight, or an otoscope with a short, wide-tip attachment. Observe the color and patency of the nostril, and check for exudate. The mucosa should be moist, pink to light red, and free from lesions and polyps. Palpate the patients nose with your thumb and forefinger, assessing for pain, tenderness, swelling, and deformity.

Physical Exam: SINUSES

Check for swelling around the eyes, especially over the sinus area. Palpate the sinuses, checking for tenderness.

Transillumination if there is tenderness

Frontal sinuses place your thumbs above the patients eyes just under the bony ridges of the upper orbits, and place your fingertips on his forehead. Apply gentle pressure. Maxillary sinuses gently press your thumbs on each side of the nose just below the cheekbones Darken the room and have the patient close her eyes. Place the penlight on the supraorbital ring and direct the light upward to illuminate the frontal sinuses just above the eyebrows Place the penlight on the patients cheekbone just below her eye and ask her to open her mouth. The light should transilluminate easily and equally.

Physical Exam: MOUTH & THROAT

Inspect the patients lips
Pink, moist, symmetrical, and without lesions Bluish hue or flecked pigmentation is common in darkskinned patients

Put gloves and palpate the lips for lumps or surface abnormalities. Place a tongue blade on top of his tongue.
The oral mucosa should be pink, smooth, moist, and free from lesions and unusual odors. Increased pigmentation is seen in dark-skinned patients.

Physical Exam: MOUTH & THROAT

Observe the gingiva, or gums
Pink, moist, and have clearly defined margins at each tooth. Shouldnt be retracted

Inspect the teeth, noting their number, condition, and whether any are missing or crowded If the patient is wearing dentures, ask him to remove them so you can inspect the gums underneath. Inspect the tongue
Midline, moist, pink, and free from lesions. The posterior surface should be smooth, and the anterior surface should be slightly rough with shall fissures. The tongue should move easily in all directions, and it should lie straight to the front at rest. Inspect the ventral surface of the tongue and the floor of the mouth. Inspect the lateral borders smooth and even-textured

Physical Exam: MOUTH & THROAT

Inspect the patients oropharynx by asking him to open his mouth while you shine the penlight on the uvula and palate. You may need to insert a tongue blade into the mouth and depress the tongue. Place the tongue blade slightly off center to void eliciting the gag reflex. The uvula and oropharynx should be pink and moist, without inflammation or exudates. The tonsils should be pink and shouldnt be hypertrophied. Ask the patient to say Ahhh. Observe for movement of the soft palpate and uvula. Palpate the lips, tongue, and oropharynx. Note lumps, lesions, ulcers, or edema of the lips or tongue. Assess the patients gag reflex by gently touching the back of the pharynx with a cotton-tipped applicator or the tongue blade.

Physical Exam: NECK

Observe the patients neck
Symmetrical, and the skin should be intact. Note any scars. No visible pulsations, masses, swelling, venous distention, or thyroid or lymph node enlargement should be present.

Ask the patient to move his neck trough the entire range of motion and to shrug his shoulder. Ask him to swallow. Note rising of the larynx, trachea, or thyroid.

Physical Exam: NECK

Palpate the patients neck to gather data.
Using the finger pads of both hands, bilaterally palpate the chain of lymph nodes under the patients chin in the preauricular area Proceed to the area under and behind the ears. Assess the nodes for size, shape, mobility, consistency, temperature, and tenderness, comparing nodes on one side with those on the other.

Palpate the trachea, which is normally located midline in the neck.

Place your thumbs along each side of the trachea near the lower part of the neck. Assess whether the distance between the tracheas outer edge and the sternocleidomastoid muscle is equal on both sides.

Physical Exam: NECK

Palpate the thyroid, stand behind the patient and put your hands around his neck, with the fingers of both hands over the lower trachea. Ask him to swallow as you feel the thyroid isthmus. The isthmus should rise with swallowing because it lies across the trachea, just below the cricoid cartilage. Displace the thyroid to the right and then to the left, palpating both lobes for enlargement, nodules, tenderness, or a gritty sensation. Lowering the patients chin slightly and turning toward the side youre palpating helps relax the muscle and may facilitate assessment.

Physical Exam: NECK

Auscultate the neck.
Using light pressure on the bell of the stethoscope, listen over the carotid arteries. Ask the patient to hold his breath while you listen to prevent breath sounds from interfering with the sounds of circulation. Listen for bruits, which signal turbulent blood flow.

If you detect an enlarged thyroid gland, also auscultate the thyroid area with the bell.
Check for a bruit or a soft rushing sound, which indicates a hypermetabolic state.