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