Head, Ears, Eyes, Nose, Throat Physical Assessment

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  • Topic: Thorax, Lymphatic system, Upper respiratory tract infection
  • Pages : 4 (863 words )
  • Download(s) : 840
  • Published : February 8, 2013
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HEENT/Respiratory Examination

22-year-old female presents for physical with no chief complaint or concerns.

Subjective:

HEAD, FACE, NECK: Patient denies any headaches, head injury, dizziness, neck pain, lumps or swelling. No history of head or neck injury or surgery.

EYES: Patient denies any problems associated with vision, does not wear any form of corrective lenses but does not remember her last vision test. Patient denies any pain, redness/swelling, watering/discharge, or allergies that affect her eyes. No history of trauma or surgery associated with eyes, no history of glaucoma. Patient is a student nurse and uses protective eyewear when suspecting possible contact with human secretions, with no episodes of exposure while working.

EARS: Patient denies earache, infections, discharge, hearing loss, tinnitus or vertigo. Patient reports daily use of Q-tip, cotton swabs to clean ears. Does not remember last hearing examination.

NOSE: Patient denies any discharge or congestion in the nose. Denies any allergies, frequent upper respiratory infections, sinus pain, nosebleeds, changes in sense of smell, and no trauma to nose.

MOUTH AND THROAT: Patient denies sores, lesions, gum bleeding, toothaches, loose teeth, difficulty swallowing, changes in sense of taste, hoarseness, or sore throat. Patient denies use of any tobacco products and reports drinking about 3 drinks/week in a social setting. Reports twice daily teeth brushing; sees dentist twice a year for cleaning. No dentures or dental appliances.

AXILLA: Patient denies tenderness, lumps, rashes, irritation, or pain.

THORAX, LUNGS: Patient denies cough, dyspnea, or chest pain while breathing. No history of respiratory infections. Denies use of any tobacco products and no smoking. Last TB test in May 2012, seasonal flu/H1N1 shot in October 2012, and no pneumonia immunization. Patient is a nursing student and takes necessary precautions (fitted-mask, PPE, masking patient, patient in private...
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