Question

Module 05 Lab Assignment – Documentation of an Assessment of the Head, Ears, and Eyes

You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, identify actual or potential risks, and submit this in a Word document. please write separate objective, subjective, and potential risk factors.

Answer 1

Conjunctivitis:

An inflammation of conjuctiva often due to infection .

Assessment of head , ears and eyes:

Physical examination : The examination of patient's body with the use of such methods as inspection , palpation, percussion and Auscultation. Head assessment including, eyes and ears are an important part of Physical examination.  

History collection associated with the medical condition:

Subjective data:

Mr. J, 18 years old, presented with the complaints of irritation, redness, itching of the eyes and more tears than usual and headache.

Assessment:

Head:

Scalp: clean scalp, No dandruff is present

Hair : Symmetrical distribution, no alopecia

Palpation: No tenderness or trauma

Cranial nerve test:

Facial nerve : asked the patient to close the eyes, puff out cheeks, smile or frawn. he done in easy way. No difficulty in doing such things, so facial nerve is working properly.  

Complaints of headache

Ears :

External ear: No discharge or crust

Pinna : intact

Mastoid process: no swelling and tenderness (palpation )

Tympanic membrane: Intact

Vestibulocochlear nerve test: block one ear , and whisper two words in the another ear, and ask the patient to repeat the words: Patient repeated the same two words. No dysfunction with Vestibulocochlear nerve .

No complaints of ear pain , No hearing loss

Eyes:

Eye lid: Redness in the inner eyelid

Conjunctivita : Redness in the white of the eye and swelling

Eye lashes: Thick yellow discharge and its crusts

Excessive tearing observed

Blurred vision due to exessive tearing

Complaints of burning and light sensitivity.  

( No light test conducted as the patient's Eyes are sensitive to light. No PERRLA examination: Pupil , Equal, reactive , round , light, accommodation )

Actual and potential risks:

* Actual risks are irritation ,itching, pain and tearfullness of eyse makes the person to restrict from social and recreational activities.  

* Potential risk: Risk for transmission of infection

Conjunctivitis ( pink eye) is a contagious disease. Risk of spreading to other members in the family. He has to keep distance from others, perform hand hygiene , Don't touch the house hold things after touching the eyes. Objects or fomites can transmit the disease.