Download History taking

Head and Neck
Head
Done
poor Not
perfectly
done
Head inspection
mark
1. Hair distribution, quantity
2. Skull size, contour
3. Face expressions, and
symmetry of structure
4. Skin color. Lesions
5. Hair distribution, lesions, hair
loss
6. facial asymmetry, involuntary
movements, or edema
Palpate the head
Done
poor Not
perfectly
done
mark
1. Hair texture
2. Skull for lumps and lesions
3. Skin temperature, Texture
Neck
Inspection and Palpation of the
neck
1. Skin color, integrity, shape
2. Symmetry
3. Masses, scars
4. Enlarged glands or lymph nodes
5. Trachea – position (should be
midline)
6. Thyroid gland enlargement,
consistency, masses, tenderness
Done
poor Not
perfectly
done
mark
Eyes
Done
poor Not
perfectly
done
Inspection of the eyes
mark
1. Symmetry
2. Position and alignment of eyes
3. Eyebrows- Quantity, distribution
4. Eyelids-Edema, color, lesions
5. Conjunctiva and sclera-color, vascular
pattern
6. Cornea and lens
7. Iris
8. Pupils
Pupils examination
Done
poor Not
perfectly
done
mark
1. Size
2. Shape
3. Reaction to light
4. Symmetry
Examination of the eyes
1. Visual acuity (Snellen eye chart)
2. Visual field by confrontation
3. Extraocular movements
4. Accommodation
5. Using the Ophthalmoscope
Done
poor Not
perfectly
done
mark
1-Visual acuity (Snellen eye chart)
Position patient 20 feet (6 meters) from
the chart
Patients should wear glasses if needed
Test one eye at a time
2-Visual field by confrontation
The client should be sitting 60-90 cm from you and at eye level
Test one eye at a time
The client’s peripheral visual fields are compared to that of the examiner.
This test assumes the examiner has normal peripheral vision
3- Extraocular movements
The client must keep the head still while following a pen that you will move in several
directions to form a star in front of the client’s eyes.
Always return the pen to the center before changing direction
4- Accommodation
An object held about 10 cm from the client’s nose
Ears
Inspect and palpate the ears
Done
poor Not
perfectly
done
mark
1. Auricle for redness, lesions,
symmetry
2. Ear canal for discharge, foreign
bodies, redness, swelling
3. Use otoscope to see the
tympanic membrane
4. Palpation Auricle for lumps,
tenderness
5. Palpate the mastoid process for
tenderness or deformity
Examine the hearing acuity Done
perfectly
poor Not
done
mark
1. Whisper test
2. Rinne test
3. Weber test
4. Romberg test
1- Whisper test
Ask the client to occlude the other ear or the ear may be occluded by the nurse.
Cover your mouth so the client cannot see your lips
Standing 30-60cm behind patient, softly say “nine-four,” “baseball”
Ask the client to repeat the phrase.
2- Rinne test
Compare time of air vs. bone conduction
Place the base of the tuning fork on the client’s mastoid process- and note the number of
seconds.
Then move the fork in front the external auditory meatus (1-2 cm)
If bone conduction is equal or greater than air conduction, then suspect conductive hearing loss
3- Weber test
Lateralization of sound to impaired
ear; suspect unilateral conductive
hearing loss
4- Romberg test
Ask the patient to remain still and close
their eyes (for about 20 seconds).
If the patient loses their balance, the test
is positive.