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376 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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UNIT 2
A. Fever blister (herpes simplex virus)
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF D ENTIST RY,
MEDIC AL COLL EGE OF GEORG IA
Vesicles on erythematous bases with serous fluid are found on the lips, gums or
A
hard palate, either singly or in clusters. They later rupture, crust over and
become painful (
These are herpes simplex lesions, which are commonly called cold sores or fever
P
Figure 11.39A).
blisters. This common viral infection may be precipitated by febrile illness,
sunlight, stress or allergies.
A round, painless lesion with central ulceration (
A
Figure 11.39B) is noted. This
lesion may become crusted.
This is a chancre, the primary lesion of syphilis.
P
A plaque, wart, nodule or ulcer is noted, usually on the lower lip.
A
This may be squamous cell carcinoma, the most common form of oral cancer,
P
which is more frequent in males (
Basal cell carcinoma lesions can have pearly borders, crusting, and central
P
Figure 11.39C).
ulcerations (Figure 11.39D).
Persistent, painless, white, painted-looking patches are noted on the lips
A
(
Figure 11.39E). They are associated with heavy smoking and the use of
chewing tobacco.
These patches are leukoplakia and are considered premalignant lesions. They
P
often occur at sites of chronic irritation from dentures, tobacco or excessive
alcohol intake.
B. Chancre from primary syphilis
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
C. Squamous cell carcinoma
SCIEN CE PHOTO L IBRARY/ DR P MARA ZZI
D. Basal cell carcinoma
Palpation
E
1. Don nonsterile gloves.
2. Gently pull down the consumer’s lower lip with the thumb and index finger
of one hand and pull up the consumer’s upper lip with the thumb and index
finger of the other hand.
3. Note the tone of the lips as they are manipulated.
4. If lesions are present, palpate them for consistency and tenderness.
Lips should not be flaccid and lesions should not be present.
N
A P
See inspection of the lips for pathologies.
Examination of the tongue
E
1. Ask the consumer to stick out the tongue (CN XII assesses tongue movement).
2. Observe the dorsal surface for colour, hydration, texture, symmetry,
fasciculations, atrophy, position in the mouth and the presence of lesions.
3. Ask the consumer to move the tongue from side to side and up and down.
4. With the consumer’s tongue back in the mouth, ask the consumer to
press it against the cheek. Provide resistance with your finger pads held
on the outside of the cheek. Note the strength of the tongue and compare
bilaterally.
5. Ask the consumer to touch the tip of the tongue to the roof of the mouth.
You may also grasp the tip of the tongue with a gauze square held between
the thumb and the index finger of the gloved hand (Figure 11.40).
6. Inspect the ventral surface of the tongue, the fraenulum and Wharton’s ducts
for colour, hydration, lesions, inflammation and vasculature.
7. With the gauze square, pull the tongue to the left and inspect and palpate
the tongue using the finger pads.
8. Repeat with the tongue held to the right side.
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
E. Leukoplakia
FIGURE 11.39 Lip abnormalities
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 377
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The tongue is in the midline of the mouth. The dorsum of the tongue should be
N
pink, moist, rough (from the taste buds), and without lesions. The tongue is
symmetrical and moves freely. The strength of the tongue is symmetrical and
strong. The ventral surface of the tongue has prominent blood vessels and
should be moist and without lesions. Wharton’s ducts are patent and without
inflammation or lesions. The lateral aspects of the tongue should be pink,
smooth and lesion free.
The tongue is enlarged.
A
An enlarged tongue may be associated with myxoedema, acromegaly, Down
P
syndrome or amyloidosis. Transient enlargement may be associated with
glossitis, stomatitis, cellulitis of the neck, angioneurotic oedema, haematoma
or abscess.
The tongue is red and smooth with absent papillae.
A
This indicates glossitis caused by a vitamin B
P
, iron or niacin deficiency. It may
12
FIGURE 11.40 Tongue assessment
also be a side effect of chemotherapy.
There is a thick, white, curd-like coating on the tongue that leaves a raw, red
A
surface when it is scraped off (Figure 11.41A).
This is candidiasis, or thrush, which may also be red in the absence of the
P
coating. Thrush can result from changes in the normal oral flora due to
chemotherapy, radiation therapy, disorders of the immune system such as AIDS,
antibiotic therapy, or excessive use of alcohol, tobacco or cocaine.
Thin, pearly white lesions that coalesce and become thick and palpable are
A
noted on the sides of the tongue. These white lesions are firmly attached to the
underlying tissue and will not scrape off.
This is leukoplakia. It is considered a premalignant lesion. Some leukoplakia
P
progresses from dysplasia to a malignancy.
A painful, small, round, white ulcerated lesion with erythematous borders is
A
abnormal (Figure 11.41B).
This is an aphthous ulcer (canker sore), which can be associated with stress,
P
A. Candidiasis (thrush)
extreme fatigue, food allergies and oral trauma.
CHAPTER 11
HEALTH EDUCATION
Making connections – oral cancer
Oral cancer risk factors are important to consider for long-term health promotion and harm
minimisation, especially for factors that are modiable by a change in lifestyle choices.
Consider which of these factors are modiable and would inuence your opportunistic
education approaches.
> Male sex
• Aboriginal and Torres Strait Islander peoples are 1.4 times more likely to die from
cancer and have a lower ve-year relative survival rate compared to non-Aboriginal
and Torres Strait Islander peoples (AIHW, 2018).
> Age > 40 years
> Tobacco use (pipes, cigars, cigarettes)
> Excessive alcohol use
> Sun exposure (lips)
> History of leukoplakia
> History of erythroplasia
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
COUR TESY OF DR DA NIEL D. RONE Y
B. Aphthous ulcer (canker sore)
FIGURE 11.41 Tongue conditions
378 PHYSICAL EXAMINATION
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UNIT 2
C. Ankyloglossia
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF D ENTIST RY,
MEDIC AL COLL EGE OF GEORG IA
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
D. Oral hairy leukoplakia
COUR TESY OF DR DA NIEL D. RONE Y
E. Carcinoma of the tongue
A short lingual fraenulum is observed (Figure 11.41C).
A
Ankyloglossia is a congenital abnormality (also known as tongue-tie).
P
The tongue has a hairy appearance and is yellow, black or brown (
A
This is oral hairy leukoplakia, or hairy tongue, a benign condition that can result
P
Figure 11.41D).
from antibiotic therapy. The hairy appearance is caused by elongated papillae.
Lesions are noted on the ventral surface of the tongue.
A
The ventral surface of the tongue is an area where malignancies are likely
P
to develop, especially in consumers who drink alcohol and smoke or use
smokeless tobacco.
Indurations, or ulcerations (
A
Figure 11.41E), are present on the lateral surfaces of
the tongue.
Most lingual cancers are located in this area and are associated with use of
P
alcohol and tobacco.
Patches of red denuded areas on the lingual surface of the tongue, frequently
A
at the papillae, surrounded by ridges of pale yellow epithelium are
abnormal (
This harmless condition, geographic tongue, has no known cause. Its name is
P
Figure 11.41F).
derived from the patterns of regular and irregular surfaces on the tongue that
resemble a map.
Numerous furrows or grooves are observed, often radiating horizontally from the
A
midline of the dorsal surface of the tongue (Figure 11.41G).
This harmless and often inherited condition is fissured or scrotal tongue. It is
P
different from syphilitic glossitis, which is characterised by longitudinal furrows.
Engorged blood vessels of the tongue are abnormal (see
A
A haemangioma of the tongue is a benign overgrowth of vascular tissue.
P
Deviation of the tongue toward one side (see
A
Figure 11.41I), atrophy and
Figure 11.41H).
asymmetrical shape of the tongue are abnormal.
Unilateral paralysis of the tongue muscles will cause the tongue to deviate
P
towards the affected side because the muscles on the paralysed side are unable to
oppose the strong muscles of the unaffected side. The consumer is unable to
push the tongue towards the nonparalysed side. Lesions of the hypoglossal
nucleus or nerve fibre cause these unilateral symptoms.
Atrophy of the tongue and the inability to protrude the tongue are abnormal.
A
Bilateral paralysis of the tongue muscles will prevent the consumer from
P
protruding the tongue. Syringobulbia or trauma to CN XII may cause
hypoglossal nerve paralysis.
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF D ENTIST RY, MEDICA L
COLLEGE OF GEORGIA
F. Geographic tongue
FIGURE 11.41 continued Tongue conditions
Examination of buccal mucosa
E
1. Ask the consumer to open their mouth as wide as possible.
2. Use a tongue depressor and a penlight to assess the inner cheeks and the
openings of Stensen’s ducts (Figure 11.42).
3. Observe for colour, inflammation, hydration and lesions.
The colour of the oral mucosa on the inside of the cheek may vary according to
N
race. Dark skinned people have a bluish hue; light-skinned people have pink
mucosa. Freckle-like macules may appear on the inside of the buccal mucosa.
The buccal mucosa should be moist, smooth, and free of inflammation and
lesions. Some consumers may have torus mandibularis (see Figure 11.43A), which
are bony nodules in the mandibular region.
Leathery, painless, white, painted-looking patches are noted.
A
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 379
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MEDIC AL COLL EGE OF GEORG IA
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF D ENTIST RY,
I. Cranial nerve XII (hypoglossal) palsy
G. Fissured tongue (scrotal tongue)
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF D ENTIST RY,
MEDIC AL COLL EGE OF GEORG IA
H. Haemangioma
FIGURE 11.41 continued Tongue conditions
Leukoplakia may be found in the buccal mucosa.
P
Yellow patches on the buccal mucosa are present.
A
Fordyce spots are small sebaceous glands (see
P
The orifice of Stensen’s duct is erythematous and oedematous. It may be tender
A
Figure 11.43B).
to palpation.
This is seen in parotitis, an inflammation of the parotid gland. The area
P
between the ear lobule and angle of the mandible may not be visible due to
the swelling of the parotid gland (see
Figure 11.43C). Acute unilateral swelling
may be seen in mumps.
The mucosa is pale.
A
This can be caused by anaemia or vasoconstriction that may occur when the
P
sympathetic nervous system is stimulated, such as in shock.
The mucosa is cyanotic.
A
Cyanosis can indicate systemic hypoxaemia. See Chapters 8 and 14.
P
The mucosa is erythematous.
A
Erythema can be associated with stomatitis.
P
There is excessive dryness of the mucosa.
A
This is xerostomia, which occurs when salivary gland activity is decreased, when
P
FIGURE 11.42 Assessment of the
buccal mucosa
the consumer is hypovolaemic, or with mouth breathing, Sjögren’s syndrome or
salivary gland obstruction.
Excessive moisture is noted in the mouth.
A
This condition may be noted in the early stages of inflammation or when the
P
consumer is hypervolaemic.
CHAPTER 11
A. Torus mandibularis
FIGURE 11.43 Buccal mucosa
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
B. Fordyce spots
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
C. Left parotitis
SCIEN CE PHOTO L IBRARY/ DR P MARA ZZI
380 PHYSICAL EXAMINATION
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UNIT 2
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
FIGURE 11.44 Gingivitis with herpes simplex
COUR TESY OF GA RY SHELL ERUD, DDS
FIGURE 11.45 Gingival recession
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
FIGURE 11.46 Gingival hyperplasia
Examination of the gums
E
1. Instruct the consumer to open the mouth.
2. Observe dentures or orthodontics for fit.
3. Remove any dentures or removable orthodontia.
4. Shine the penlight in the mouth.
5. Use the tongue depressor to move the tongue to visualise the gums.
6. Observe for redness, swelling, bleeding, retraction from the teeth
or discolouration.
In light-skinned individuals, the gums have a pale red, stippled surface. Patchy
N
brown pigmentation may be present in dark-skinned consumers. The gum
margins should be well defined with no pockets existing between the gums and
the teeth and no swelling or bleeding.
The gingiva are red, tender and swollen, and bleed easily (
A
This describes gingivitis, which may be caused by poor dental hygiene,
P
Figure 11.44).
improperly fitted dentures, and scurvy. Gingivitis can also occur with stomatitis
that occurs in mouth infections and upper respiratory tract infections.
Gingival borders are red and there is infection of the pockets formed between
A
receding gums and teeth. Purulent drainage may be present.
This is periodontitis, which is an inflammation of the periodontium due to
P
chronic gingivitis. This condition is caused by infrequent brushing of the teeth
and poor oral hygiene.
Blue lines are noted approximately 1mm from the gingival margin.
A
These are lead lines or bismuth lines caused by chronic exposure to lead or bismuth.
P
The gums are brownish.
A
This occurs in association with Addison’s disease.
P
A nontender, immobile tumour lighter than the gums is noted on the gum.
A
This lesion is epulis, a fibrous tumour of the gums.
P
The gums are retracted from the teeth (Figure 11.45), sometimes exposing the
A
roots of the teeth.
This recession of the gums often occurs in older individuals due to poor oral hygiene.
P
Hypertrophy of gum tissue is abnormal (
A
This is gingival hyperplasia and is usually painless; it occurs in pregnancy, in
P
Figure 11.46).
wearers of orthodontic braces, by dental plaque, or with the use of some
medications such as phenytoin.
Small ulcers or folds of excess tissue are noted on the gums under an ill-fitting
A
denture. Inflamed and swollen nodules may be seen in the area of the palate.
Continued irritation of the gums by ill-fitting dentures results in hyperplasia.
P
REFLECTION IN PRACTICE
The consumer with poor oral hygiene
Mary is a 78-year-old widow who lives alone. She attends the clinic for a blood pressure
check-up, but you notice that she has left her dentures out. When you ask her where her
teeth are she states they are hurting her. On inspection you note multiple ulcers in her
gums, remains of food particles in her gum and cheek margins and a foul smell. On further
investigation you nd out that she brushes her dentures every few days but does not have a
cleaning regimen for her gums and mucous membranes.
> What type of education would you recommend and why?
> Would you refer Mary to anyone?
> What type of treatment may she require and why?
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 381
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Examination of the teeth
E
1. Instruct the consumer to open the mouth.
2. Count the upper and lower teeth.
3. Observe the teeth for discolouration, loose or missing teeth, caries,
malocclusion and malformation.
The adult normally has 32 teeth, which should be white with smooth edges,
N
inproper alignment, and without caries.
Teeth are absent.
A
This problem may be due to loss or failure of development. The consumer’s
P
nutritional status may be seriously impaired when the teeth are insufficient.
There are white or black patches on the surface of a tooth. These patches may
A
become eroded as damage progresses.
These are dental caries, or cavities, resulting from poor oral hygiene.
P
The teeth are worn at an angle.
A
Biting surfaces of the teeth may become worn down by repetitive biting on hard
P
substances or objects or grinding of teeth (bruxism), especially at night.
A tooth is dark in colour and the consumer reports insensitivity to cold.
A
This is usually a dead tooth, which results in a darkening of the enamel.
P
Teeth that have serrated edges (Figure 11.47) are abnormal.
A
These are called Hutchinson’s incisors. Pregnant women with syphilis can
P
have infants with abnormal dentition because of the effects of the disease on
tooth development.
CHAPTER 11
Examination of the palate
E
1. Ask the consumer to tilt the head back and open the mouth as wide
as possible.
2. Shine the penlight in the consumer’s mouth.
3. Observe both the hard and the soft palates.
4. Note their shape and colour, and the presence of any lesions or
malformations.
The hard and soft palates are concave and pink. The hard palate has many
N
ridges; the soft palate is smooth. No lesions or malformations are noted.
The palates are red, swollen, tender, or with lesions.
A
These findings are symptoms of infection.
P
A fibrous, encapsulated tissue growth on the palate is abnormal (Figure 11.48).
A
A fibroma may be idiopathic or neoplastic in origin. Chronic trauma can also
P
lead to fibroma formation.
A lesion that has become eroded is noted on the palate.
A
This may be a cancerous lesion in the epithelium of the hard palate.
P
There is a hole in the hard palate.
A
Palatine perforation is related to syphilis or radiation therapy.
P
FIGURE 11.47 Hutchinson’s incisors
FIGURE 11.48 Fibroma
COUR TESY OF DA LE RUEMP ING, DDS, MSD
COUR TESY OF DR JO SEPH KONZ ELMAN , SCHOOL OF
DENT ISTRY, MEDI CAL COLL EGE OF GEOR GIA
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
382 PHYSICAL EXAMINATION
4+3+2+1+
Tonsil
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UNIT 2
CLINICAL REASONING
Practice tip: Maintaining dignity during physical examination
Examining the mouth, gums and teeth of a client is important; however, please ensure you
are managing this examination with dignity. This means allowing the client to remove teeth
if they can, and ensure they are rinsed before being offered to place back in the mouth.
Donot ask questions while teeth are removed as this can be difcult and embarrassing for
the client to try and speak clearly while they have no teeth in. Handle false teeth and dental
plates gently and ensure they are not dropped.
While people of any age may have false teeth and dental plates, this is seen in higher
percentages in elderly consumers. Revisit the aged care standards (hint Standard 1)
to review examples of this. Resource link: https://www.agedcarequality.gov.au/
providers/standards
Examination of the throat
Inspection
E
1. Ask the consumer to tilt the head back and to open the mouth wide. The
consumer can either stick out the tongue or leave it resting on the floor
ofthe mouth.
2. With the right hand, place the tongue blade on the middle third of
the tongue.
3. With the left hand, shine a light at the back of the consumer’s throat.
4. Ask the consumer to say ‘ah’.
5. Observe the position, size, colour and general appearance of the tonsils
and uvula.
6. Touch the posterior third of the tongue with the tongue blade.
7. Note movement of the palate and the presence of the gag reflex.
8. Assess the colour of the oropharynx. Note the presence of swelling,
exudate or lesions.
When the consumer says ‘ah’, the soft palate and the uvula should rise
N
symmetrically (CN IX and X). The uvula is midline. The throat is normally pink
and vascular and without swelling, exudate or lesions. Normal tonsillar size is
evaluated as 1+ to 2+. (See
tonsils are behind the pillars. The consumer’s gag reflex should be present but is
congenitally absent in some consumers (CN IX and X).
Figure 11.49 for grading scale.) This indicates that both
FIGURE 11.49 Grading of tonsils: 1+ tonsils are visible, 2+ tonsils are between the pillars and uvula, 3+ tonsils
are touching the uvula, 4+ tonsils extend to the midline of the oropharynx
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 383
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The posterior pharynx is red with white patches. The tonsils are large and red
A
with white patches, and the uvula is red and swollen.
Viral pharyngitis and tonsillitis are common illnesses with these findings.
P
Tonsils, pillars and uvula are very red and swollen, with patches of white or
A
yellow exudate on the tonsils (
Figure 11.50). The posterior pharynx is bright red.
The consumer reports soreness of the throat with swallowing.
These findings are typical of streptococcal pharyngitis and tonsillitis and are
P
usually associated with significant lymphadenopathy. However, diagnosis
requires throat culture.
There is a greyish membrane covering the tonsils, uvula and soft palate.
A
These findings are typical of diphtheria, acute tonsillitis or
P
FIGURE 11.50 Streptococcal pharyngitis
infectious mononucleosis.
The consumer speaks with a hoarse voice and the oropharynx is red.
A
Causes of hoarseness are varied and may include overuse of the voice,
P
inflammation due to viral or bacterial infection, lesions of the larynx,
foreign bodies, and pressure on the larynx from masses or an enlarged
thyroid gland.
The consumer has difficulty opening the mouth (trismus) and is noted to have
A
unilateral tonsillar swelling. Unusual phonation is also observed.
These findings are associated with peritonsillar abscess, which is most
P
commonly seen in older children and young adults with a history of
FIGURE 11.51 Left tonsil is 4+ and right
tonsil is 3+
frequent tonsillitis.
Chronic 3+ or 4+ tonsils (
A
Large tonsils frequently lead to loud snoring and obstructive sleep apnoea.
P
The consumer has a small oropharynx and history of snoring.
A
Obstructive sleep apnoea occurs when muscles in the nasopharynx and
P
Figure 11.51) are abnormal.
pharynx relax during sleep, resulting in pauses in breathing. Typically,
consumers are overweight, middle-aged men who complain of excessive
daytime sleepiness.
CHAPTER 11
EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION FINDINGS
In the evaluation phase of a health assessment, the focus is on ensuring the data
gathered is complete, accurate and documented appropriately (see case study as
an example of the focused assessment; see Chapter 22 for a comprehensive health
assessment). In evaluating the data you should:
> draw on your critical thinking and problem-solving skills to make sound
clinical decisions
> act on abnormal data (include communicating findings to other
health professionals)
> ensure documentation reflects the outcomes of the clinical decisions/actions
taken (refer to Chapter 3, which discusses in detail why documentation is so
important and how this may be undertaken in different health settings).
The case study that follows steps you through this process.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
384 PHYSICAL EXAMINATION
UNIT 2
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THE CONSUMER WITH ACUTE RHINOSINUSITIS
This case study illustrates the application and the objective
documentation of the ears, nose, mouth and throat assessment.
Lianna Potter is a 61-year-old nurse who presents to the health
clinic complaining of facial pain and frontal headache.
HEALTH HISTORY
CONSUMER PROFILE 61-year-old Caucasian female
CHIEF COMPLAINT ‘I have had a headache and facial pressure for over 10 days.’
HISTORY OF THE PRESENT
ILLNESS
CASE STUDY
PAST HEALTH HISTORY MEDICAL HISTORY Hypertension since age 40
Consumer was in her usual state of health until 10 days ago, when she developed an upper respiratory infection
that seems to have become worse. Her symptoms started with nasal congestion, purulent nasal discharge
and mild facial pressure. After 5 days, she developed thick, green, purulent nasal discharge, bilateral frontal
headache (4/10 intensity), maxillary facial pain (6/10 intensity), and bilateral maxillary toothache. She has had a
low-grade fever (37.4°C) without chills, sweats, ear pain, sore throat, chest congestion, wheezing or dyspnoea.
The symptoms seem to get worse when she leans over. She has been taking decongestants every 6 hours and
ibuprofen 400mg at bedtime without relief for 3 days. Consumer has been renovating downstairs bathroom and
guest bedroom for the past two weeks.
SURGICAL HISTORY Hysterectomy, age 54
ALLERGIES Bees – anaphylaxis
MEDICATIONS > Hydrochlorothiazide 25mg every morning
> Ibuprofen for headaches 200–600mg BD PRN
> Demazin Cold and Flu – paracetamol (500mg) and phenylephrine PRN for
nasal congestion (5mg)
COMMUNICABLE DISEASES Has had COVID-19 in past three months
INJURIES AND ACCIDENTS Denies
SPECIAL NEEDS Denies
BLOOD TRANSFUSIONS Denies
CHILDHOOD ILLNESSES Chickenpox, age 5, without sequelae
IMMUNISATIONS All up to date as per employment requirements
FAMILY HEALTH HISTORY
SOCIAL HISTORY ALCOHOL USE 1–2 glasses of wine per week
TOBACCO USE Never smoked
DRUG USE Denies
DOMESTIC AND INTIMATE
PARTNER VIOLENCE
SEXUAL PRACTICE Monogamous relationship with husband
TRAVEL HISTORY Denies recent travel more than 100km from home in past month
WORK ENVIRONMENT Is a nurse manager at local health service
HOME ENVIRONMENT Lives with husband and adult daughter and grandchild in a single-
Denies
family home. Recent renovation of downstairs area to allow for Airbnb
rental to supplement income, as getting ready for retirement
HOBBIES AND LEISURE
ACTIVITIES
Music, playing golf, caravanning
>>
EARS, NOSE, MOUTH AND THROAT 385
CHAPTER 11
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>>
HEALTH HISTORY
STRESS New home arrangement with daughter and grandchild returning home
after marriage breakdown, home renovation, recent pandemic was
stressful for healthcare workers
EDUCATION Postgraduate qualication in nursing
ECONOMIC STATUS Professional – middle class; husband retired
MILITARY SERVICE None
RELIGION Christian
CULTURAL BACKGROUND Dutch ancestors; would like to visit European cousins some day
ROLES AND RELATIONSHIPS Very close to her husband and children; several close friends from her
social book club and neighbourhood
HEALTH MAINTENANCE
ACTIVITIES
CHARACTERISTIC PATTERNS OF
DAILY LIVING
SLEEP 7–8 hours of sleep during the week; 8–9 hours on the weekends; does not
DIET Gluten free
EXERCISE Walks on treadmill three times weekly for 45 minutes followed by
STRESS MANAGEMENT Talks openly with her friends and exercises regularly
USE OF SAFETY DEVICES Uses seat belt in car; not taking any health precautions with home
HEALTH CHECK-UPS Annual well-woman examination; sees primary care provider every
Wakes at 5 a.m., skips breakfast, drives 45 minutes to get to work;
usually buys lunch at hospital café, often works over hours, especially
during staff shortages and during the recent pandemic; goes to the gym
2–3 times a week; arrives home around 6.30 p.m., prepares dinner for
family; watches TV and goes to bed around 10 p.m.
feel well rested last 10 days and states ‘just perpetually tired since COVID
started with workload’. At times is woken by grandchild during night.
stretching; occasional spin/aerobics class
remodelling equipment/masks
4 months for hypertension; up to date in all other areas of preventive
health (mammogram and pap smear)
PHYSICAL EXAMINATION
EXAMINATION OF THE EAR AUDITORY SCREENING VOICE-WHISPER TEST Intact
TUNING FORK TESTS > Weber test – midline without
lateralisation
> Rinne test – ⊕
EXAMINATION OF
THE NOSE
INSPECTION AND PALPATION EXTERNAL EAR Nontender, external auditory canal
clear without inammation, no mastoid
tenderness
OTOSCOPIC ASSESSMENT Both tympanic membranes are shiny pink
and mobile with visible light reexes;
without bulging or perforation
INSPECTION EXTERNAL NOSE Midline without swelling, bleeding,
lesions or masses
PATENCY Each nare is patent
INTERNAL NOSE Mucosa is red and swollen with purulent
nasal discharge bilaterally; septum
deviated to the left
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