ROS
Health History
General Objective
Eye
Ear
100
Respiratory
What is difficulty breathing, cough
100
Frequent headaches Head Injuries Seasonal allergies/ Sinusitis/ Sinus problems Otitis media/externa Frequent colds Epistaxis Other issues?
What issues are included in past medical history specific to HEENT?
100
Gather Equipment Provide privacy Wash hands - never too much -Scrubbing (friction) with antibacterial soap while washing hands makes it more effective than hand sanitizer Explain procedure to patient
what should you do to prepare for examination?
100
red prominence
What is caruncle
100
wax -redness/swelling -drainage -swimmer's ear -tympanic membrane (pearly gray
what do you inspect the internal ear for?
200
ENT/Mouth
What is changes/difficulty in hearing, ear pain or discharge, change/difficulty smelling, runny nose, sore throat, problem swallowing, difficulty eating/chewing foods, sores or lesions in the mouth, and last dental exam
200
HEENT overlaps w/ which systems?
What is neuro & musculoskeletal systems
200
skull temporal artery Temperomandibular joint Face
what should you inspect/palpate when assessing the head,
200
Palpebral fissure
What is distance between the lid margin
200
Parts of Ear Exam
What isInspect (external ears) first Palpate -pinna -Tragus -Mastoid Process
300
Cardiovascular
What is Chest pain, abnormal heart beats, skipped beats, fluttering, shortness of breath with/without exertion
300
allergies: -food -medications -contact -other agents
what information is included in the allergies sections?
300
As you are evaluating hair and scalp you are noting the skull- there are many normal variants most of us have some bumps & craters Assess for lesions, moles, levi, displaced hair, hair breakage
What is skull
300
white area
What is sclera
300
The affected part of the ear
what is ear treatment based on?
400
Endocrine
What is hot or cold, sweaty, hair, weight loss or gain
400
prescription OTC herbal alternative
what form of meds are documented?
400
tenderness
What is temporal artery
400
covers sclera Palpebral conjunctiva lines the lids Bulbar conjunctiva lies over the sclera
What is conjunctiva
400
Cartilage -usually one inch long sensitive to: -otoscope -wind -foreign bodies -bobby pins
What is ear canal
500
Musculoskeletal
What is painful joints or muscles, problems with range of motion
500
TMJ tenderness crepitation (cracking/rattling sound)
What is temporomandibular joint
500
over iris and pupil
What is cornea
500
acoustic nerve
What is cranial nerve VIII