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    Ent Assessment PDF

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    vijayalakshmi
    This document contains a patient assessment report for Mrs. Rajeshwari, a 27-year-old female admitted to the ENT ward with complaints of sore throat, dry cough, nose block, and difficulty swallowing for 4 weeks. After examination, she was diagnosed with laryngitis. The report includes her medical history, physical examination findings, and a systemic assessment of her ears, nose, mouth, throat, and neck. It finds red and inflamed nasal mucosa, an obstructed nose, tender sinuses, and a deviated septum.

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    Ent Assessment PDF

    Uploaded by

    vijayalakshmi
    1K views10 pages
    This document contains a patient assessment report for Mrs. Rajeshwari, a 27-year-old female admitted to the ENT ward with complaints of sore throat, dry cough, nose block, and difficulty swallowing for 4 weeks. After examination, she was diagnosed with laryngitis. The report includes her medical history, physical examination findings, and a systemic assessment of her ears, nose, mouth, throat, and neck. It finds red and inflamed nasal mucosa, an obstructed nose, tender sinuses, and a deviated septum.

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    ENT ASSESSMENT.pdf

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    This document contains a patient assessment report for Mrs. Rajeshwari, a 27-year-old female admitted to the ENT ward with complaints of sore throat, dry cough, nose block, and difficulty swallowing for 4 weeks. After examination, she was diagnosed with laryngitis. The report includes her medical history, physical examination findings, and a systemic assessment of her ears, nose, mouth, throat, and neck. It finds red and inflamed nasal mucosa, an obstructed nose, tender sinuses, and a deviated septum.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views10 pages

    Ent Assessment PDF

    Uploaded by

    vijayalakshmi
    This document contains a patient assessment report for Mrs. Rajeshwari, a 27-year-old female admitted to the ENT ward with complaints of sore throat, dry cough, nose block, and difficulty swallowing for 4 weeks. After examination, she was diagnosed with laryngitis. The report includes her medical history, physical examination findings, and a systemic assessment of her ears, nose, mouth, throat, and neck. It finds red and inflamed nasal mucosa, an obstructed nose, tender sinuses, and a deviated septum.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The patient, Mrs. Rajeshwari, was admitted to the hospital with complaints of sore throat, dry cough, nose block and difficulty swallowing. After investigations, she was diagnosed with laryngitis.

    The patient's diagnosis is laryngitis.

    The patient's chief complaints are sore throat, dry cough, nose block and difficulty swallowing for the past 4 weeks.

    ENT ASSESSEMENT

    PATIENT PROFILE:

    Name : Mrs. Rajeshwari

    Age/Sex : 27y/F

    IP.No : 2015033338

    OP. No : 2015032104

    Ward : Female ENT ward

    Religion : Hindu

    Nationality : Indian

    Education : B.A

    Occupation : Manager

    Marital status : Married

    Address : 365, Villianur Main Road, Kombakkam,

    Puducherry.

    Date Of Admission : 07/5/14

    Final Diagnosis : “LARINGITIS”

    Dr.Name : Dr. Prabu

    Source of information : patient, cash sheet and relatives


    HISTORY COLLECTION:

    Chief complaints:

    The patient complaints of sore throat, dry cough, nose block and difficulty to swallow for
    past 4 weeks.

    Present medical history:

    Mrs. Rajeshwari was admitted in SVMCH & RC, in female ENT ward with the
    complaints of sore throat, dry cough, nose block and difficulty to swallow for past 4 weeks. After
    thorough investigation the doctor was diagnosed “laryngitis”. Now the patient taking treatment
    such as inj. Taxim 1gm. Od. Inj.Rantac od, inj. Amoxy 500 mg od.

    Past medical history:

    There is no significant past medical history.

    Present surgical history:

    There is no significant history of present surgical history.

    Past surgical history:

    There is no significant history of past surgical history.

    Family medical history:

    There is no history of communicable and non- communicable history such as DM,


    Hypertension, Leprosy, Asthma and HIV etc.

    Family history:

    SI.NO FAMILY AGE/ EDUCATION OCCUPATION RELATIONSHIP HEALTH


    MEMBERS SEX STATUS
    1. Mr.Gopi 62y/M - Farmer Father in law Healthy
    2. Mrs. Ranjitha 58y/F - Housewife Mother in law Healthy
    3. Mr. Rangarajan 29y/M ITI welder Husband Healthy
    4. Mrs.Rajeshwari 27y/F B.A Manager Wife Laryngitis
    Socio economic history:

    Mr. Rangarajan is the bread winner of the family and his working as welder and he earn
    Rs. 9000/ month. They belongs to middle class family. There is availability of closed drainage
    system and electricity facility available.

    Personal history:

    Elimination:

    Bowel: patient defecated 2 times/ day.

    Bladder: patient void urine 6-9 times / day.

    Dietary pattern:

    Patient take both vegetarian and non- vegetarian diet.

    Rest and Sleep:

    Sleep disturbance due to throat pain.

    Bad habits:

    There is no history of bad habits like tobacco chewing.

    Allergic reactions:

    There is no history of allergic reactions such as pollen, dust and drugs.


    PHYSICAL EXAMINATION
    GENERAL APPEARANCE:
    Consciousness : conscious

    Orientation : well oriented to time, place and person

    Body built : thin

    Posture and Gait : normal

    Body movements : movable

    Hygiene, grooming and dress : neat

    Mood and affect : depressed due to pain

    Facial expression : dull

    Speech : slow

    Vital signs
    Temperature : 99 degree F

    Pulse : 78 bts/min

    Respiration : 24breaths/min

    Blood pressure : 120/70 mm Hg

    Measurements:
    Height : 159 cm

    Weight : 40 kg

    Skin
    Color and Vascularity : brown and no hypo/hyperpigmentation
    Moisture : dry
    Temperature : warm
    Texture : smooth
    Turgour : normal
    Head and scalp:
    Skull : round shape

    Scalp : dandruff and pediculus present

    Hair : black and thick

    Face : round

    Eyes
    Eyebrows : symmetry and curved

    Eye lids : no swollen and infected

    Sclera : no yellowish

    Conjunctiva : no pale

    Cornea : no opaque and cloudy

    Pupils : reacting to light

    Eye movements : normal

    Vision : 6/6

    Chest
    Respiratory pattern : 24 breaths/ min and normal pattern

    Breast : symmetrical and no masses present

    Inspection : no scars and lesions

    Palpation : no masses present

    Percussion : no fluid collection present

    Auscultation : s1 and s2 sound heard

    Abdomen
    Size and shape : flat shape

    Inspection : no scars and no swelling

    Palpation : no masses and tenderness present


    Percussion : no fluid collection present

    Auscultation : normal bowel movements

    Genitalia
    Female genitalia : no foul smelling discharges and no perineum intact

    Back
    Spinal curvature : no lordosis, kyphosis, and scoliosis

    Vertebrae : no tenderness

    Lesions : no lesions and rashes

    ROM: possible

    Extremities
    Upper extremities : symmetrical, range of motion is possible , venflon presented in right arm
    and 5 fingers and nails present. No deformities.

    Lower extremities : symmetrical, range of motion is possible , 5 fingers and nails present. No
    deformities.

    Systemic assessment
    Ears
    Pinnae : normal position and size
    Ear canal : discharges presented
    Tympanic membrane : no perforated
    Hearing : normal hearing acuity

    Nose
    Size and shape : short
    Septum : deviated septum present
    Nasal mucosa : red and rhinitis present
    Patency : obstructed in mucus
    Sinuses : tenderness present
    Mouth and pharynx
    Lips : dry

    Teeth : normal alignment and dental caries present

    Gums : no gingivitis

    Buccal mucosa : dry

    Tongue : dry and no coated tongue

    Neck
    Appearance : short neck

    Thyroid gland : palpable and no enlargement

    Lymph nodes : palpable

    Trachea : presented midline


    ASSIGNMENT
    ON
    ENT

    SUBMITTED TO:
    Prof. Mrs. Sunithatheresa,
    Dept. of Medical Surgical Nursing
    ICON.

    SUBMITTED BY:
    K.Kanakavel,
    M.Sc. Nursing, I-Year,
    ICON.

    SUBMITTED ON:
    05.06.2015
    ASSIGNMENT
    ON
    ENT

    SUBMITTED TO:
    Prof. Mrs. Sunithatheresa,
    Dept. of Medical Surgical Nursing
    ICON.

    SUBMITTED BY:
    G.Malathi,
    M.Sc. Nursing, I-Year,
    ICON.

    SUBMITTED ON:
    05.06.2015

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