Question

I am working in a homework for my nursing class

Topic: HEENT Assessment

Health history:

physical Assessment   

: normal finding:

abnormal finding:

related laboratory finding:

Answer 1

Ans) A HEENT examination is a portion of a physical examination that principally concerns the head, eyes, ears, nose, and throat.

Normal findings:

HEENT
 Head:  Configuration- normocephalic
 Hair- normal texture
 Scalp-  lesions, tenderness
 Eyes:  Sclera- white
 Conjunctiva- pink
 Fundoscopy-
o Red Reflex: present
o Disc: round, sharp margins, nl color
o Vessels: nl caliber, A/V ratio ~ ½
o Background:  abn pigmentation, hemorrhages or exudates
o Macula: visualized
 Ears:  External Ear- lesions, masses, tenderness
 Auditory Canal- normal
 Eardrum- TM’s gray, translucent, with nl light reflex
 Nose:  Color- pink  discharge
 Septum- midline
 Inferior and Middle Turbinates – normal
 Throat and
Mouth:
 Teeth: Present and in good dentition
 Tongue:  lesions
 Gums and Mucosa:  swelling, bleeding, infection
 Pharynx and Tonsillar Fossa: normal
 Openings of Stensen's and Wharton's Ducts: identified

Abnormal findings:

Eyes
Lids and conjunctivae (discharge, icterus, ptosis, edema)
Pupils and irises (reaction to light and accommodation, size, symmetry, extraocular movements, visual fields, visual acuity) Vision corrected to normal with bifocal lenses.

Optic discs and posterior segments (size, Cup to disc ratio, appearance, vessel changes, exudates, hemorrhages)

Ears/Nose/Throat
External ears, nose (scars, lesions, masses, foreign body)
Otoscopic exam (external auditory canals, tympanic membranes/mobility)
Hearing (whispered voice, Rinne and Webber test) Significant amount of cerumen
Nose (Nasal Mucosa, septum, turbinates)

Mouth / Dental
Inspection of lips, teeth and gums Missing several teeth; dentures were broken.
Oropharynx (oral mucosa, tonsils, tongue, palate, salivary glands, posterior pharynx)

Lab findings:

Decreased vision and permanent loss of vision are common complications of endophthalmitis. Patients may require enucleation to eliminate a blind and painful eye. The most important laboratory studies are Gram stain and culture of the aqueous and vitreous humor.
Diagnostic testing for orbital cellulitis starts with contrast-enhanced CT imaging of the orbits. Findings on CT indicating orbital cellulitis include any of the following: proptosis, inflam-
mation of the ocular muscles, subperiosteal abscess or frank orbital abscess.

Other diagnostic test for ear- audiometry.