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Physical Assessment

Head, Nose, Mouth, Throat-Upper Respiratory

Head & Neck Review of Systems Trouble with headaches? any asssoc nausea, vomiting or vision change Changes in scalp/hair? loss or growth, distrib, texture, color Swollen glands/lumps in your neck?D Neck pain/stiffnesss? Thyroid problems?
Nose & Sinuses Review of Systems Do you have problems with runny nose, stuffy nose or allergies (hay fever)? Do you have any sinus or facial pain? Have you ever had any nasal injuries or nose bleeds?
Mouth & throat Review of Systems Do you have any sores in your mouth, tongue or on your gums? Do you have bleeding gums, tooth pain or any loose teeth? Do you wear dentures or have partials? Have you noticed frequent sore throats, hoarseness or changes in your voice?
Head Inspection a.Head position: “Head is midline and upright” b.Size & shape of skull: “normocephallic, atraumatic” c.Hair distrib & texture d.Abnormal head or facial movements:“I note no abnormal movemements"
Head Palpation a.Deformities, lumps or lesions: “there are no deformities, lumps or lesions” b.Tenderness, swelling, depressions: “I note no tenderness, swelling or depressions”
Noe & Sinuses ID Landmarks Bridge Tip Ala Nasi Vestibule Anterior Nares Maxillary Sinus Frontal Sinus
Test for Nasal Obstruction occlude one side at a time and have pt breathe use mirror to detect signs of breathing
Inspect/Report on nasal septum/mucosa/turbinates Use speculum with patient's head hyperextended -otoscope to side at angle. 1.Bleeding,2.Deviation,3.Inflammation,4.Perforation: “ I see no bleeding, deviation,inflammation or perforation” 1.Color,2.Exudates,3.Swelling,4.Bleeding.5.Growths:"Mucosa & turbinate are pink,no exudtaes, swelling, bleedding/growths"
Palpate Frontal/Maxillary sinuses Transilluminate "No tenderness/swelling to the frontal and maxillary sinuses bilaterally" Transillumniate sinuses and report findings
Lips 1.Color,2.Moisture,3.Ulcers,4.Cracking: "Lips are pink, moisture is intact, there are no ulcers or cracking" Lift upper and lower lips use gloves/tongue blade
Oral Mucosa Use tongue blade/gloves Buccal mucosa 1.Color,2.Nodules,3.White patches: "Color is pink (intact) ther are no nodules or white patches"
Gums/Teeth Use tongue blade/gloves 1.Color,2.Swelling,3.Ulceration,4.Missing teeth: "I am examining the gums and teeth. There is no swelling, ulcerations or missing teeth"
Roof of mouth 1. Color 2. Hard palate
Tongue 1.Color,2.Moisture,3.Ventral Surface Texture,4.Dorsal Surface Texture 5.Symmetry On Protrusion: "The tongue is pink, moist, ventral and Dorsal surface texture is intact, there is symmetry on protrusion"
Pharynx ID/Report ID/RPs on tonsils (if present)& ID: a)anterior pillars b)rise of soft palate and uvula (CN10) c)posterior pharyngeal wall - avoiding gag reflex d)RPs on posterior pharyngeal wall for: 1.Color,2.Exudates,3.Lesions: "Color intact, no exudates/lesions"
Temporal Mandibular Joint Checks active opening and closing of jaw for: 1. Clicks, 2. Misalignment: "None noted"
Neck Inspects and reports condition of neck: 1.Symmetry,2.Masses,3.Scars: "The neck is symmetrical w/o masses or scars"
Lymph Nodes ID/Palpate using gentle, circular motion with finger tips 1.Pre-auricular,2.Post-auricular,3.Occipital, 4.Tonsilar,5.Submandibular,6.Submental,7.Sup cervical,8.Postr cervical,9.Deep cervical chain 10.Supraclavicular nodes: "The pt has no palpable nodes, however, they would be recorded by sz.cm/moblty/tnderns/sh
Trachea and Thyroid ID Identifies and inspects trachea: 1.Palpates for tracheal deviation,2.States that trachea is midline or deviated,3.Identifies cricoid cartilage,4.Identifies thyroid isthmus: "Trachea is midline, I appreciate no tracheal deviation"
Thyroid Palpation Ppt thyroid gland by displacement frm postr positn, pt’s neck flexed away from displcn hand, Displcn fingers above isthmus, Ppting fingers are below isthmus Insp thyroid gland w/ light as pt swallows & RP on cdtn of thyroid:1.sz,2.shp,3.Nodules,4.Consistency, 5.Tenderness:"The pt thyroid galnd cosistency is firm, w/o nodules/tndrns, sz & shp intact" Auscultates thyroid for bruits w/ bell bilat “no brew-ees"
Created by: teyonka