Inspection and palpation of each part of the head was done separately in order for us to give focus on each part and be more systematic. Ms. Jones assessment did not reveal any significant findings. Other than her telling us that she wears corrective lenses, her HEENT assessment is normal for a healthy person. Her head is normocephalic, PERRLA bilaterally, whispered words heard bilaterally, gag reflex intact, dentition does not show evidence of caries or infection and no bruits heard on auscultation of the
PATIENT ANALYSIS AND HEALTH 7 carotid. Palpation did not reveal any mass, lumps, tenderness or nodules. Neck has full ROM with strength 5/5. Specific intervention for Ms. Jones regarding HEENT is for her to have a follow up visit to her eye doctor yearly. Respiratory . Physical assessment of the thorax and lungs follows a technique of inspection of the patient, observing the body positioning and posture, inspection of the chest taking note of the chest shape and breathing pattern, palpation of the chest to check for tenderness, mass or lesion, percussion of the chest and auscultation of breath sound and voice. Doing the inspection first gives us a general idea whether a person has some presenting respiratory problem. How the patient sit, shape of the chest and the breathing pattern will tell us that the patient may have a respiratory problem that they didn’t even know. An example of this is a barrel chest. In a barrel chest, the AP-to-lateral ratio near 1:1, round shape. Ribs are more horizontal and costal margin is widened. This finding will reveal a patient that has COPD, chronic asthma or normal aging (Jensen & Sabin, 2015 p.449). On the case of Ms. Jones, we did the assessment following the technique on the anterior chest first starting from inspection, palpation, percussion to auscultation. After doing the anterior, we then proceeded to do the posterior chest following the same technique. Ms. Jones assessment did not reveal any abnormal findings. She has no mass, lesions or tenderness, tactile fremitus is equal bilaterally both on anterior and posterior, percussion is resonant and lung sounds are clear to auscultation. For Ms. Jones respiratory intervention, we will let her carry an emergency medicine all the time such as Epipen including her inhaler Proventil and continue her current medication regimen.
PATIENT ANALYSIS AND HEALTH 8 Cardiovascular . Assessment of the cardiovascular starts with asking the patient for risk factors to identify how likely the patient is to develop or already has a problem with cardiovascular disease. Gathering of the objective data is focused mainly on the neck vessels and precordium including taking the blood pressure, listening for heart sounds and checking for circulation and tissue perfusion (Jensen & Sabin, 2015 p. 467).
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- Fall '17
- Shadow Health Tina Jones