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Physical Assessment
Jennylyn C. Guadalupe, RN
Health History provides the examiner with
complete health profile that guides all aspects
of the physical examination. It begins with
questions that focus on problems a symptom
of concern to the patient.

Chief Complaint - reason for seeking care
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Purposes of Physical Examination
The nurse uses physical assessment for the following
reasons:
To gather baseline data about the clients health
To supplement, confirm or refute data obtained in the
nursing history
To confirm and identify nursing diagnoses
To make clinical judgments about a clients changing
health status and management
Physical examination usually performed after the
health history is taken.

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Preparation of Examination

Environment

Equipment

Psychological Preparation


Physical Preparation


Positioning



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ORGANIZED & SYSTEMATIC EXAMINATION
key to appropriate Data in a least possible amount
of time
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Order of Examination


General Survey includes observation of general
appearance and behavior, vital signs, height and
weight measurement
Review of systems
Head to toe examination

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INSTRUMENTS


senses of vision, hearing, touch, and smell. Those
human senses may be augmented by special
instruments or tools e.g. Stethoscope,
OPTHALMOSCOPE)

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EXAMINATION TECHNIQUE

Patients Positioning and Prepping
SEATED: when seated, the drape should cover the patients lap and
legs. It can be moved to uncover parts of the body as they
examined.

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Patients Positioning and Prepping

SUPINE: the patient lies on his or her back, with arms
at the sides and legs extended. The drape should cover
the patient from chest and knees or toes. Again, you can
move or reposition the drape to give appropriate
exposure.
PRONE: the patient lies on his or her stomach. This
position may be used for special maneuvers as part of
the musculoskeletal examination. Drape the patient to
cover the torso.

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Patients Positioning and Prepping
DORSAL RECUMBENT: use for genital or rectal areas.
The patient lies supine with knees bent and feet on the
table. Place the drape in a diamond position from chest
to toes. Wrap each leg with the corresponding lateral
corner of the diamond. Turn back the distal corner of
the drape to perform the examination.
LATERAL RECUMBENT: This is a side lying position,
with legs extended or flexed. The left lateral recumbent
position (patients left side is down) may be used in
listening to heart sounds.



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LITHOTOMY: generally used for pelvic examination.



SIMS: of the rectum or obtaining rectal temperature.

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Assessment techniques

Inspection
Palpation
Percussion
Auscultation

Skills in Physical Examination & The Process of Physical examination

Inspection to detect normal characteristics or significant physical signs.
To inspect body parts accurately the nurse observes the following
principles:
Make sure good lighting is available
Position and expose body parts so that all surface can be viewed
Inspect each areas from size, shape, color, symmetry, position and
abnormalities
If possible, compare each area inspected with the same area of the
opposite side of the body
Use additional light (for example, a penlight) to inspect body cavities
Inspection- the first fundamental process is inspection or observation.
General inspection begins at the first moment of contact with the patient.
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Inspection
a. Posture and stature
Ex. Person who have breathing difficulties ( Dyspnea) secondary to cardiac disease
prefer to sit and may complain of feeling Smothered, if forced to lie flat for even brief
periods of time.
b. Body Movements
Generalized disruption of voluntary or involuntary movement and asymmetry of
movement.
Ex. Convulsive movements of epilepsy or tetanus or movements of patients with
rheumatic fever.
- Nutrition
Ex. Obesity maybe generalized as a function of excessive intake of calories or may
be specifically localized to the trunk in those with endocrine disorders ( Cushing
disease).
c. Speech pattern
Slurred coz of CNS disease or damage to cranial nerves, laryngeal nerve will produce
hoarseness.

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Skills in Physical Examination & The Process of Physical examination
Palpation
Palpation assessed through touch.
Ex. Superficial blood vessels, lympnodes, the thyroid, the
organs of the abdomen and pelvis, and the rectum. It should be
noted that when the abdomen is examined, auscultation is
performed before palpation and percussion to avoid altering bowel
sounds.

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Palpation
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Light palpation
Deep palpation
Skills in Physical Examination & The Process of Physical examination
Percussion examination by striking the bodys surface with a finger,
vibration and sound are produced. This vibration is transmitted
through the body tissues and the character of the sound depends on
the density of the underlying tissue
Sounds: Tympany is the drumlike sound produced by percussing
the air-filled stomach.
Resonance- is the sound elicited over air-filled lungs.
Hyperresonance- is audible when one percusses over
inflated lung tissue in someone with emphysema.
Dull sound- percussion of liver.
Flatness- percussion of the thigh.

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Skills in Physical Examination & The Process of Physical examination
Percussion
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Direct percussion
Indirect percussion
Skills in Physical Examination & The Process of Physical examination
Auscultation is listening to sound created in body organs to detect variations from
normal. Some sounds can be heard with the unassisted ear, although most sounds
can be heard only through a stethoscope.
Ex. Breath sound- movement of air through the trachea and bronchi, Vesicular,
Brochovesicular, Bronchial
Spoken voice- movement of air past functioning vocal cords
Bowel sounds- movement of air through the intestine.
Murmur- movement of blood through vascular structures that provide critical
resistance to flow
Heart sounds
Examples of Adventitious Breath Sounds
Crackles (previously called rales)
Rhonchi
Wheeze
Friction rub
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Physical assessment

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Assessment Sequencing
Head to - Toe Assessment


Body Systems Assessment
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EYES - Review of anatomy
conjunctiva - mucous
membrane of the eye.
cornea - protective part of
the eye.
iris - regulates quantity of
light into the eye.
lens - expands/contracts
in order to focus light.
pupil - circular area that
allows for the passage of
light.


retina - receives images from light and converts
them into electrical impulses sent to the brain.
vitreous humor - transparent liquid that gives the
eye its shape.
aqueous humor - fluid anterior to the lens that is
used in the support of the iris and refraction of the
light
EYE ASSESSMENT
SUBJECTIVE DATA
Vision difficulty(decrease
acuity, blurring, blind
sports.
Pain
Strabismus, diplopia
Redness, swelling
Watering, discharge
History of ocular
problems
Uses of glasses/contact
lenses
Self care behavior.
STRUCTURE - EYE
OBJECTIVE DATA
Preparation
Equipments needed
Snellens eye chart
Opaque card
/occluder
Penlight
Applicator stick
Ophthalmoscope
E Chart also known Tumbling E Chart

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OPTHALMOSCOPE
OBJECTIVE DATA
Facial and ocular
expression
Eye lids & Conjunctiva



Lacrimal system
Sclera
Cornea


----Prominence of eyes:
alert or dull expression.
__Symmetry, presence of
edema, ptosis, itching,
redness, discharges,
blinking, equality,
growth.
___Tears, swelling,
growth
___Color
___Clarity
Contd objective data
Anterior chamber

Iris & pupils

Pupillary reflex light
__Depth, presence of
blood/pus
__Irregularities in color,
shape , size
__Constriction of pupil in
response to light in that
eye (direct light
reaction);equal amount
of constriction in the
other eye (consensual
light reaction)
contd objective data
Accommodation


Lens

Peripheral vision



Acuity with or without
glasses
Supportive aids
__Convergence of eyes and
constriction of pupils as
gaze shifts from far to near
object
__Transparent or opaque

__Ability to see movements &
objects well on both sides of
field of vision

Ability to read newsprint,
clocks on wall, & recognize
faces-b/side/door
Glasses, contact lenses,
prosthesis.
Types of refractive errors
hyperopia - image is focused behind the retina,
(farsightedness): Inability to see near objects
clearly. The eye is too short for the lens, or
certain eye muscles have weakened with age.



Myopia - image focused anterior to the retina,
is also known as short sightedness, near
sightedness, and short sight. It is a refractive
error and it makes it difficult to see objects from
afar.

Presbyopia
- accommodation muscles are unable to focus,
People who have this condition will have a hard
time focusing, will experience blurry vision, and
will have tired eyes more often. People with
presbyopia will have trouble reading in poor light
conditions, they will have trouble changing their
focus from near to far, and they will keep
repositioning reading material in order to see
things properly.
Astigmatism
- uneven focusing / displaced lens,
characterized by abnormalities in the curvature
of your eyes. This can cause your vision to blur
at any angle.

Inflammation and infection of the eye

conjunctivitis is an inflammation of the mucous
membrane of the eye.
a. bacterial conjunctivitis
1. signs/symptoms
purulent discharge with edema
conjunctiva will appear red and inflamed
exudates
generally unilateral

Viral conjunctivitis (pink eye)
signs/symptoms
Eyelids may appear reddened.
Copious amounts of watery discharge with
scanty exudates.
Often bilateral
Usually a week in duration

Treatment
Pt should abstain from rubbing eyes
Warm water compresses, no contacts.
Sodium sulfacetamide 10% 1-2 qtts q6h X10day
Frequent hand washing to prevent spread

Allergic conjunctivitis
signs and symptoms
Eyes may appear reddened
May have itching and tearing
Minimal discharge
May appear chronic or reoccurring
Generally bilateral
diagnosis and treatment
Treatment is symptomatic
Normally associated with hay fever, seasonal changes
Vasocon-A can be used

Blepharitis
- an inflammation of the eyelids.
signs/symptoms
Tenderness, reddening,
sore sticky exudates
Eyelids may become inverted & eyelashes fall out
treatment
Antibiotics applied to eyelids
oral antibiotics like tetracycline or doxycycline
Artificial tears
Keep scalp and eyelids clean
Scales must be removed daily with moist applicator or warm,
moist wash cloth

Hordeolum (stye)
signs/symptoms
a. Localized pain, swelling to eye lid
b. Often purulent discharge
Treatment - Hot compresses, scrub with neutral soap, topical
antibiotic eye drops q3h, and if not resolved in 2-3 days,
refer to ophthalmology for I&D

4. Trauma-


A. Black eye: Swelling and discoloration around
the eye as a result of injury to the face.

Hyphema
: Bleeding into the front of the eye, behind the cornea.
a. Cause:
1. is usually caused by trauma.
2. It may be the result of an
athletic injury from a flying object, a stick, a ball, or another player's elbow.
3. Other causes include industrial accidents, falls, and fights.



Blow out fracture
When force is applied to the orbit causing contents to spill either medially
or inferiorly. If inferiorly, will end up in maxillary sinus.
signs/symptoms
epistaxis
enophthalmus
entrapment
dypesthesia
diplopia
fracture over infraorbital rim
X-rays needed; CT scan is definitive.
If there is entrapment of EOM, need surgery soon otherwise must wait5-
7 days
Must R/O ocular injury ; refer to ENT

5. Age-related Vision disorder
a. Macular degeneration - is the leading cause
of severe vision loss in people over age 60. It
occurs when the small central portion of the
retina, known as the macula, deteriorates. The
retina is the light-sensing nerve tissue at the
back of the eye. Because the disease develops
as a person ages, it is often referred to as age-
related macular degeneration (AMD).
two main types
Dry form. The "dry" form of macular
degeneration is characterized by the
presence of yellow deposits, called
drusen, in the macula.

Wet form. The "wet" form of macular degeneration is
characterized by the growth of abnormal blood vessels
from the choroid underneath the macula. This is called
choroidal neovascularization. These blood vessels
leak blood and fluid into the retina, causing distortion
of vision that makes straight lines look wavy, as well
as blind spots and loss of central vision. These
abnormal blood vessels eventually scar, leading to
permanent loss of central vision.

Treatments Macular Degeneration

There is currently no cure for macular degeneration, but
treatments may prevent severe vision loss or slow the
progression of the disease considerably. Several options
are available, including:
Vitamins. A large study performed by the National
Eye Institute of the National Institutes of Health, called
AREDS (Age-Related Eye Disease Study), showed
that for certain individuals, vitamins C, E, beta
carotene, zinc and copper can decrease the risk of
vision loss in patients with intermediate to advanced
dry macular degeneration.

Glaucoma
is an eye condition that develops when too much
fluid pressure builds up inside of the eye. It tends
to be inherited and may not show up until later in
life.
The increased pressure, called intraocular
pressure, can damage the optic nerve, which
transmits images to the brain. If damage to the
optic nerve from high eye pressure continues,
glaucoma will cause loss of vision. Without
treatment, glaucoma can cause total permanent
blindness within a few years.

Glaucoma
Symptoms Glaucoma
If intra ocular pressure is increased
Seeing halos around lights
Vision loss
Redness in the eye
Eye that looks hazy (particularly in infants)
Nausea or vomiting
Pain in the eye
Narrowing of vision (tunnel vision)

Cataract-
a clouding of the eye's natural lens, which lies
behind the iris and the pupil

Symptoms of Cataract
Cloudy or blurry vision.
Colors seem faded.
Glare. Headlights, lamps, or sunlight may
appear too bright.
A halo may appear around lights.
Poor night vision.
Double vision or multiple images in one
eye. (This symptom may clear as the
cataract gets larger.)
Frequent prescription changes in your
eyeglasses or contact lenses

Ear Anatomy
History
always ask the following
hearing loss
tinnitus - ringing in the ear
vertigo - sense of motion
otalgia - ear pain
otorrhea - drainage from the ear

ASSESSMENT
SUBJECTIVE DATA
Ear aches
Infections
Discharges
Hearing loss
Environmental noise
Tinnitus
Self care behavior

INSPECTION- OTOSCOPE

Contd subjective data
Inspect & Palpate the
External ear
Size & shape
Skin condition
Tenderness
External auditory
meatus
Inspect -otoscope

Inspect otoscope
Pull the pinna up &
back(straightens S
shape-canal)
Hold the otoscope &
inspect
Note any redness,
swelling,lesions, f/b,
discharge.

WEBER TEST


RINNE TEST

Hearing loss - 2 types
A. Conductive - seen in people with external or middle ear problem.
Occurs when auditory stimuli are not adequately transmitted through
the auditory canal, tympanic membrane, middle ear, or ossicles to the
inner ear.
History - Have perceived hearing loss & need things repeated
Physical exam
Weber - in conductive hearing loss, sound lateralizes to the affected
ear.
Rinne - in conductive hearing loss, bone conduction (BC) > air
conduction (AC)
Tests
audiogram: normal 0-25 db.

Causes
Cerumen impaction- usually occurs in persons who naturally
produce large amounts of cerumen.
External otitis media- (bacterial and fungal), excessive
moisture in the auditory canal (swimmers ear), and trauma
Serous otitis media- result from Eustachian-tube obstruction,
sudden changes in atmospheric pressure, allergy and viral
disease
Suppurative otitis media- may follow viral disease, tympanic
membrane perforation or prolonged forceful nose blowing.
> Common in infants and young children because of their
immature and relatively poorly draining Eustachian tubes.
Otosclerosis- a hereditary condition; it affects women twice as
often as men and typically develops between ages 15 and 30.
Trauma / tumors

B. Sensorineural - When the eighth cranial nerve or
cochlea are damage Involves the inner ear. Hearing
loss resulting from damage to the inner ear or to the
neural pathways from the inner ear to the brain
History - similar to conductive hearing loss.
PE: Weber - lateralizes to good ear
Rinne - AC>BC
Test: Audiogram - both BC and AC below 25db in
affected frequencies

Causes
noise induced - most common - occupationally involved
trauma - skull fractures (basilar)
Tumors

Treatment
Hearing conservation; may require baseline adjustment.
Hearing aides
Other Aids : Alert and signal devices, assisted listening devices from
telephone companies
Surgery : implantable cochlear prosthesis ( direct stimulation of the auditory
nerve)

Otitis Externa

Infection of external ear
Caused by bacteria, fungi, or may be a
dermatitis

Otitis Media (OM)
infection of middle ear caused by a build up of
fluid (mucus) which then becomes infected by
bacteria.
OTITIS MEDIA


Contact sports such as boxing can cause ear
injuries such as cauliflower ear and bruising and
swelling in general. But you can prevent this from
happening by wearing a head guard. Motor sports
are another potential cause of head and ear injuries
although a well fitting helmet can help reduce the
risk of that happening.

A pressure sore is the result of trauma to the
tissues. They tend to start as a small patch of red
skin which has been exposed to constant pressure.
This patch gradually worsens until the skin cracks
which damages lower layers of tissues.


NOSE
NOSE
SUBJECTIVE DATA
Discharge
Frequent colds(upper
respiratory infections)
Sinus pain
Trauma
Epistaxis
Allergies
Altered smell



OBJECTIVE DATA
Equipment Needed
Otoscope-short wide tip
nasal attachment
Penlight
2 tongue blades
Gloves
Cotton gauze pad

Inspect and palpate
:symmetric ,midline in
proportion to other
facial features
Inspect for any
deformity, asymmetry,
inflammation, or skin
lesions
Palpate for any
pain/break in contour.
Palpate the sinus
areas-Tenderness


Figure 14-2. p. 379.
Structures of the Nasal Cavity


Figure 14-8. p. 388.
Inspect Nasal Cavity

Middle turbinate
Inferior turbinate

Table 14-1. p. 405.
Abnormalities of Nose

Choanal Atresia
Foreign Body
Perforated Septum Epistaxis
Epistaxis (nose bleed)
Kiesselbachs plexus - located
anterior septum, supplied by
four arteries
Usually bleed from one nostril
Most nose bleeds are anterior
Causes
trauma, foreign body, dry air,
sinusitis, allergies, colds, foreign
objects in the nose, picking the
nose, and irritants among
others.


Figure 14-3. p. 379.
Paranasal Sinuses, Adult and Child

Figure 14-11. p. 390.
Palpate Sinuses
Palpate Sinuses
Sinusitis
- is an inflammation of the mucous membranes
of one or more paranasal sinuses.
a.Acute sinusitis
Inflammation of paranasal sinuses by
bacteria, viruses, or fungi
Accompanied by or follows colds
signs/symptoms
pain over affected sinus
headache
purulent rhinorrhea
fever and other systemic disease
anosmia( Lack of smell)

Physical exam Sinusitis
Acute Sinusitis
Mucosa is hyperemic and edematous
Turbinates are enlarged and often about the septum
Purulent drainage
Pain elicited from pressure over involved sinuses
Transillumination may reveal air-fluid level.
sinus X-rays
Four views - Caldwells, Waters, lateral & base.
See air-fluid level in involved sinus or may just be clouded.
Not required for diagnosis; more useful in chronic cases.
b.Chronic Sinusitis
Irreversible tissue changes have occurred in lining membrane of one or
more of the paranasal sinuses, mucosal thickening becomes apparent.
Causes repeated/persistent bacterial sinusitis
signs/symptoms
Purulent material in nose. Enlarged turbinates.
Similar to acute sinusitis.
Persistent nasal obstructions; chronic nasal discharge, clear or purulent
when infected
Cough-produced by constant dripping of discharge back into
nasopharynx
Feeling of facial fullness/pressure
Headache-may be vague or in same pattern as
acute sinusitis, more noticeable in the morning;
fatigue

Physical exam Chronic Sinusitis
Purulent material in nose. Enlarged turbinates.
May notice nasal polyps
X-rays
Sinus series and CT Scan show air-fluid level in acute sinusitis;
thickening of sinus mucous membranes, opacification, and anatomic
obstruction patterns in chronic sinusitis
Antral puncture and lavage-provides culture material to identify infectious
organism; also a therapeutic modality to clear of bacteria, fluid, and
inflammatory cells.
Nasal and sinus endoscopy (the sinuses can be easily accessed after the
patient has had an antrostomy).


Table 14-1. p. 406.
Abnormalities of Nose

Acute Rhinitis
Allergic Rhinitis
Sinusitis Rhinitis Polyps
Rhinitis
- is a disorder of the nose that interrupts its
normal functions of olfaction, and warming,
filtering, and humidifying inspired air.

Allergic (hay fever) Rhinitis
seasonal or perennial
Sneezing, lacrimation, itching, nasal
discharge etc.
Must obtain good history; key to diagnosis.
Caused by pollen, grasses, dust/house
mites etc.
frontal headache
trouble breathing through nose
Allergic rhinitis-IgE-
mediated response
causing release of
vasoactive substances
from mast cells

Physical exam Hay fever
pale mucosa
turbinates (inferior) enlarged
clear/thin secretions
possible deviated septum
nasal polyps
Hypersecretion-wet, running/dripping nose or post-nasal drip
Nasal obstruction symptoms-nasal congestion, pressure, or stuffiness
Headache
labs/allergy testing (in severe cases)
intradermal allergy testing
rast test (blood test)

b. Acute Rhinitis
common cold
cause - rhinovirus
signs/symptoms - fatigue, sore
throat, nasal discharge, headache,
fever, nasal obstruction, sneezing
physical exam
nasal mucosa red
inferior turbinates enlarged and
erythematous
clear watery discharge

Foreign body (Nose)
is the blockage of the nasal passages due to
foreign objects
common in younger children
difficulty in breathing
foul smelling, bloody, unilateral discharge
consult ENT for removal
4. Trauma
Nasal fracture
result of blunt trauma
signs/symptoms
epistaxis
nasal dyspnea
edema
pain
ecchymosis


Physical exam - crepitus, mobile nose, deviation, edema, ecchymosis.
Must look into nose to R/O septal hematoma. If found, refer to ENT.
Look for and rule out other facial fractures.
X-rays of little valve


Table 14-1. p. 407.
Abnormalities of Nose

Furuncle Carcinoma
Throat

Anatomy
The throat (pharynx) is located behind the mouth,
below the nasal cavity, and above the esophagus
and windpipe (trachea). It consists of an upper part
(nasopharynx), a middle part (oropharynx), and a
lower part (hypopharynx).
The throat is a muscular passageway through
which food is carried to the esophagus and air is
carried to the lungs.
The tonsils are located on both sides of the back
of the mouth, and the adenoids are located at the
back of the nasal cavity.


Figure 14-4. p. 380.
Oral Cavity Structures

Figure 14-5. p. 381.
Salivary Glands


Figure 14-14. p. 391.
Inspect Mouth


Figure 14-20. p. 396.
Inspect Throat

TONSILITIS

Pharyngitis
- inflammation of pharynx
causes -viral - Epstein-Barr virus (mono),
adenovirus, etc.
bacterial - group A & B strep
signs/symptoms
odynophagia
sore throat
dysphagia
fever, fatigue, otalgia

Physical exam (Pharyngitis)
tender anterior cervical adenopathy
erythmatous posterior pharynx
exudates
palatal petechiae
differentiation
throat C&S
severe symptoms suggest bacterial etiology
Often have concurrent tonsillitis

Treatment ( Pharyngitis)
throat C&S
Pen V-K 500 mg QID x 10 days
increase/force fluids, analgesics

Tonsillitis
- inflammation of tonsils.
causes - similar to pharyngitis -
viral - Epstein-Barr virus (mono), adenovirus, etc.
bacterial - group A & B strep
Signs/symptoms - more odynophagia and dysphagia due to increase of
tonsil size.
Physical exam - similar to pharyngitis.
tonsils enlarged, red, and exudate (white patchy)
palatal erythema and edema
cervical nodes may be tender, usually palpable
treatment - similar to pharyngitis if severe and persistent surgery is
recommended tonsillectomy- removal of the tonsils
tonsillitis rare without pharyngitis but can have vice-versa

Peritonsillar abcess
abcess of peritonsillar region, pus within surrounding tissues
signs/symptoms
hot potato voice
trismus - inability to open mouth fully
increased odynophagia
foul odor from mouth
unilateral pain
physical exam
uvular deviation
tender over anterior fauces arch
tonsils red, swollen
protuding and flunctuant on one side

Epiglottis
- inflammation of epiglottis.
causes - Haemophilus influenzae type B
Signs/symptoms
severe throat pain
difficulty swallowing
fever
drooling
muffled voice. Because the infection is in the epiglottis, the back of
the throat often does not appear infected. As swelling of the epiglottis
starts to narrow the airway, the person first begins to make a
squeaking noise when breathing in (stridor) and then has
progressively worse trouble breathing.

References:
Brunner & Suddarths, Medical-Surgical
Nursing, 8
th
edition
Henry M. Seidel, Mosbys Guide to
Physical Examination, 7
th
edition
Barbara Kozier, Fundamental of Nursing,
4
th
edition

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