Analysis and Documentation-Eyes and Ears/Nose/Throat

 

 

 

Eyes and Ears/Nose/Throat Documentation Statements such as “intact” and “within normal limits” are uninformative and will be treated as omissions. Organize your findings as they are listed in the attached documentation form. Describe the volunteer information, history, physical exam findings, and analysis.
Obtain the following information on an adult volunteer. For the history, ask about the items indicated. For the physical exam items; read the assigned chapters, review the course presentations/videos, and gather needed equipment before performing the exam. Use this guide when documenting the findings. Be sure to address all items in your documentation.
Volunteer Information
Gender, age, race/ethnicity
Health History Findings (address each item and list specific denials)
Eyes: Personal history of acute/chronic disease, surgery, injury, infection, and pain related to eyes; drainage, glasses/contacts and reason, color vision, blurring, double vision, light sensitivity, dryness, eye drops, redness, swelling, last eye exam and results. Family history of illnesses in this system.
Ears, nose, mouth/throat: Personal history of acute/chronic disease, surgery, injury, infection, and pain related to ENT; discharge, hearing loss, vertigo, tinnitus, sense of smell, nasal obstruction, bleeding, postnasal discharge, hoarseness, sore throat, lesions, bleeding or swelling of gums, difficulty chewing or swallowing, toothaches, natural teeth and/or dentures, dental caries, tooth abscess or extraction, last dental exam and results; frequency of brushing, flossing, use of mouthwash. Family history of illnesses in these systems.
Physical Exam Findings (address findings for each item)
Eyes
 Inspect – eyebrows, eyelids, eyelashes, lacrimal gland, sclera, cornea, iris, pupil, lower conjunctiva, etc. Palpate – periorbital area Assess vision (CN II-optic) – functional vision(Rosenbaum card), peripheral vision (confrontation test) Assess balance/alignment – corneal light reflex, cover/uncover Assess extraocular movements/coordination (CN III-oculomotor, IV–trochlear, VI-abducens) – cardinal fields of gaze, lid lag Assess pupil responses – direct light, consensual light, accommodation
Ears
 Inspect – position, symmetry, shape, lesions, drainage, etc. Palpate Assess hearing (CN VI-acoustic) – whisper test, Weber, Rinne
Nose Inspect – external (position, symmetry, ridges, etc.), nares (septal deviation, polyps, drainage, mucosa, etc.) Palpate
Mouth and Throat
 Inspect – lips, mucosa, tongue, floor, color, teeth, gums, tonsils for color, grade tonsils, base/sides tongue, etc. Assess hypoglossal nerve (CN XII) – tongue movement Assess glossopharyngeal and vagus nerve (CN IX, CN X) – uvula/soft palate rising
Analysis: Abnormalities and/or Health Risks
Provide your analysis of actual/potential risks based on the information from the history and physical exam.

 

 

 

 

 

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