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History Pe Ent

The document provides an overview of how to conduct a history and physical examination. It discusses obtaining the patient's history, including their chief complaint, past medical history, review of systems, and risk factors. It then outlines how to perform a physical examination, including examinations of the head, eyes, ears, nose, mouth, neck, and skin. The physical examination section provides detailed steps for specific examinations such as otoscopy, laryngoscopy, and neurological assessment.

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69 views44 pages

History Pe Ent

The document provides an overview of how to conduct a history and physical examination. It discusses obtaining the patient's history, including their chief complaint, past medical history, review of systems, and risk factors. It then outlines how to perform a physical examination, including examinations of the head, eyes, ears, nose, mouth, neck, and skin. The physical examination section provides detailed steps for specific examinations such as otoscopy, laryngoscopy, and neurological assessment.

Uploaded by

Falling Hate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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History taking &

Physical Examination
Presented by: Group 1C - LNU Clerks

Table of contents

01 History Taking

02 Physical Examination

Members
➔ Guerrero, Annaliza C 

➔ Assmaa, Mahagoub Dafa Alla Hamid

➔ Parsapally, Joy Emmanuel

➔ Vankuri , Toman Krishna Reddy

➔ Shanika Barnes

01
History Taking
Review

Chief Complaint

Patient History

Review of Systems

Obtaining the History
Obtaining the patient records
➔ Electronic health ➔ Interview. / Biodata

records (EHRs).

● Name

● Referent notes
 ● Age

● Radiographic images 
 ● Sex

● Laboratory values 
 ● Religion

● Pathology specimens
 ● Education 

● Occupation

● Address 

Chief Complaint
“OPQRST”


Onset 
 Paliating / provoking 


Quality
 Radiation


Severity 
 Temporal

Past Medical History
➔ Medical history 

➔ Surgical history

➔ Allergies 

➔ Medications

➔ Social history

➔ Living situation

➔ Family history 





Risk Factors
Tobacco and alcohol use: 


● First and second hand exposure to tobacco is important to note.



● Ask about cigarette, and chewing tobacco consumption, either
current or past use.

● Alcohol consumption can be difficult to quantify


Drug use : 

● Recreational and Intravenous (IV) drug use should be addressed


Sexual practices:


● Increasing recognition of the role that human papillomavirus plays in


some head and neck cancers and assessment for sexually transmitted
diseases.

Review of Systems
GENERAL
 body weakness, weight loss, Chills


INTEGUMENTARY
 urticaria, pigmentation, rash


HEAD and NECK
 dizziness, Pain, Stiffness, headache, 


EYES
 Blurry Vision, itchiness, Discharges, Periorbital pressure


EARS
 Hearing Loss, Discharges, Pain


NOSE
 Epistaxis, Obstruction, Discharge 


MOUTH AND THROAT
 Soreness, Odynophagia, Dysphagia, Gum bleeding


RESPIRATORY
 Cough, difficulty of breathing, Tachypnea


CARDIOVASCULAR
 Palpitation, Cyanosis, chest pain



Review of Systems
GASTROINTESTINAL
 Diarrhea, Constipation, Nausea, Melena, Abdominal Pain


RENAL or URINARY
 Dysuria, Polyuria, Nocturia, Incontinence, Anuria, Oliguria


GENITALIA
 Irritation, Discharge, Itching


MUSCULOSKELETAL
 Joint Pain, Muscle Pain, Numbness, Weakness, Limitation of motion


ENDOCRINE
 Heat or Cold Intolerance


NERVOUS
 Seizures, Tremors, headache, Syncope, Dizziness


HEMATOPOIETIC
 Easy Bruisability



Overview

Physical
02 Examination
Physical Examination

Step 1 Step 3
Establish Rapport
 Use of Gloves, Protective
Step 2 Eye/ Face Covering, and
Hand Washing before and facemask

after every examination

General Appearance
Assessment of vital signs

Level of alertness and orientation

Patient’s affect

Evidence intoxication

Personal Hygiene

Gait and Ability to navigate

Head and Facies
Examine the shape, symmetry, and signs of trauma


Inspect Facial skin - sun damage, lesions, rhytids


Note presence of dysmorphic features


Palpate the facial skeleton dor deformities, irregularities, and step-offs


Personal Hygiene


Inspect the Parotid gland - enlargement or masses


Bimanual examination of the oral cavity


Assessment of the Preauricular and Retroauricular lymph nodes



Facial Nerve Grading
System
Eyes
Note the shape of Palpebral fissures

Inspect for conjunctive and sclera - Infection,
Swelling, or Discoloration

Presence if spontaneous nystagmus & extraocular
movements

Fundus Examination

Ears
AURICLES


Inspection the Postauricular region


Note for clinical signs of mastoiditis


Note for the position and shape of the pinna


Examine the overlying skin


Inspection of the areas of the anterior root of the


helix and tragus

Tympanic
Membrane
TYMPANIC MEMBRANE


Assess for areas of myringosclerosis


Note for perforations


Perform pneumatic otoscopy 


Assess the middle ear



Tuning fork tests, usually done
Hearing Assessment with a 512-Hz fork

● Compares bone conduction of the patient with the
examiner. 


Schwabach test ●
●
Multiple tuning forks are used - 256 Hz to 2048 Hz,

This test assumes that the examiner has normal
hearing.

Nose
Equipment:

● Nasal speculum

● Penlight

● Tongue blade





Examination of the Nose
The nose can be examined in three parts:

● Examination of the external nose

● Anterior Rhinoscopy

● Posterior Rhinoscopy

Inspection:

● Congenital deformities (Clefts)

● Acquired Deformities

● Shape

● Swelling ( Inflammatory, cysts, tumors)

● Ulceration ( Trauma, neoplastic, infective)


Palpation:

● Tenderness

● Crepitus

● Deformities

Anterior Rhinoscopy Examination of the
Vestibule Look for:

● Boil or Abscess

● Ulcerations and abrasions

● Excoriation because of discharge.



ANTERIOR RHINOSCOPY

● Examination of the nasal cavity using a
nasal speculum:





POSTERIOR RHINOSCOPY Post Nasal Mirror:

● It consists of a handle on which a small mirror is attached to shaft at an
angle of 110.


POSTERIOR RHINOSCOPY Technique



1. Hold the mirror like a pen in the right hand.

2. Warm the mirror

3. Ask the patient to open the mouth.

4. Depress the anterior 2/3rds of the tongue

5. Feel the warmth of the mirror on the back of the wrist. It should not be hot.

6. Introduce the mirror from the angle of the mouth over the tongue depressor
and slide it behind the uvula. Avoid touching the posterior wall of the
pharynx as it may trigger gagging.

7. Instruct the patient to breath through the nose.

8. Tilt the mirror in different direction to see various structures of the
nasopharynx.

TRANSILLUMINATION TEST

● Dim the room light



● Place the lighted otoscope directly on the
infraorbital rim (bone just below the eye).

● Ask the patient to open their mouth and
look for light glowing through the mucosa
of the upper mouth.

● Principle: In the setting of inflammation,
the maxillary sinus becomes fluid filled
and will not allow this transillumination.

ORAL CAVITY

● Tongue: Check for Common and taste sensations



● Size: Macroglossia in acromegaly, Down's syndrome

● Ulcers

● Movements: Restricted in hypoglossal palsies, tumor infiltration

● Fasciculation: Motor neuron disease

● Depapillation: Vitamin deficiencies

● Furrowing , as in geographic tongue

● Coating: Thrush, black hairy tongue

● Buccal Mucosa: Parotid duct opening Opposite upper 2nd
molar), red or white patches, ulcers, moisture

● Hard Palate: Swelling, ulcer, perforations, clefts etc.

● Uvula: Position, deviations (Towards the normal side in ulcers

● Floor of mouth: Wharton duct openings, ulcers, and bimanual
palpation

● Teeth and occlusion

OROPHARYNX

● Soft Palate: Swelling, ulcer, movement,


perforations, clefts etc.

● Uvula: Position, deviations (Towards the
normal side in palsies), ulcers

● Tonsillar pillars: congestion, ulcers,
patches.

● Tonsils: Presence, size, crypts, ulcers

● Posterior pharyngeal wall: Lymphoid
follicles, ulcers.

LARYNGOSCOPY:

● Visual exam of the voice box (larynx) and the vocal cords.

● Laryngoscopy is also done to remove foreign objects stuck
in the throat.

There are two main kinds:

1.Indirect laryngoscopy - uses mirrors to examine the
larynx and hypopharynx

2.Direct laryngoscopy - uses a special instrument (flexible
or rigid scope)

INDIRECT LARYNGOSCOPY
Technique

● Mirror is held like a pen in the right hand with the glass
pointing downwards.

● Warm the mirror and test the temperature on the back of the
hand.

● The patient is asked to stick out the tongue which is held with a
piece of gauze.

● The patient is asked to breath through the mouth.

● The mirror is introduced into the mouth to the uvula which is
gently pushed back to get a view of the larynx and the pyriform
fossae.

● The patient is asked to say 'Aaa' and 'Eee'.

Neck
Triangles of the Neck
Lymph Node Regions
Thyroid Gland
Skin
● The external auricles receive a significant amount of sunlight
and are at risk of developing malignancies such as basal cell
and squamous cell carcinoma of the skin

● The scalp should also be examined for lesions such as
melanoma, basal cell carcinoma and squamous cell carcinoma.

● The inspection should include assessing if irregular borders,
heterogenous colour and and ulceration sand satellite lesions.

Neurologic Examination
Thank you!






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