Lesson 6 Written Examination: The Eyes and Ears
History/Subjective Data:
S.V. is 54 years old white Caucasian male, with Bosnian ethnicity, having Bosnian as his first language, married for 28 years to his wife, having Islam as his religious background without practicing it, and having deep belief in helping others in need. He believes that if he helps others in need, God will grant him the good health. He loves gardening and fixing garden machines what help him to relieve the stress. Client has bee sting allergy; takes no medication, and he is a smoker (pack year=20). He works as machine operator in the rubber industry and wears safety glasses and hearing protectors when indicated.
Client denies any changes in vision, any blurred or …show more content…
Physical Examination/Objective Data Eyes: When central vision tested (removed reading glasses) using the Snelling eye chart, no hesitancy, squinting, leaning forward or misreading letters. Visual acuity in bilateral eyes 20/20. Near vision was tested with reading glasses on, with result 14/14 in each eye, without hesitancy or moving the newspaper further away. Results of the peripheral vision or the visual field test included, finger was seen (by both of us) at about 60 degree nasally, about 50 degrees superiorly, about 90 degrees temporally, and about 70 degrees inferiorly. When corneal light reflex tested, reflection of the light on the corneas was exactly the same spot on each eye, and white dots seen symmetrically. During the cover test, uncovered eye remained with steady fixed gaze. No muscle weakness observed, as the uncovered eye stared straight ahead. During the diagnostic position test, leading the eyes through the six cardinal position of gaze, none of eyes produced any muscle weakness during the movement. No nystagmus, no lid lag observed. Further, on inspection of the external structures, it was observed relaxed facial expression, …show more content…
The skin is pink-red, consistent with the client’s facial skin color. Further, skin is intact, without the lumps or lesions. No evidence of tenderness when the pinna moved and when pushed on tragus. No evidence of pain observed, when palpated mastoid process, bilaterally. The external auditory meatus without swelling, redness, or discharge. No cerumen present. The examination by the otoscope showed no redness and swelling, lesions, foreign bodies, or discharge in the external canal. The eardrum is flat, slightly pulled in. It is shiny and translucent with a pearl gray color, and is intact. The client correctly repeated the whispered numbers, “999,” and “666,” when his hearing was tested bilaterally. Sound heard equally in both ears with the Weber test. The Rinne test showed that an air-conduction is twice as long as the bone conduction.
Interpretation of Data:
Eyes: Healthy vision function and healthy eye structures: visual acuity 20/20 bilaterally, sclera white, conjunctiva pink; pupils constrict 4mm to 2mm; equally, round, and reactive to light and accommodation (PERRLA); disk margins sharp, no hemorrhages or exudates.
Ears: Healthy ear structures and accurate hearing: acuity good to whispered voice; tympanic membranes (TMs) with good cone of light; Weber: midline; Rinne: AC>
History/Subjective Data:
S.V. is 54 years old white Caucasian male, with Bosnian ethnicity, having Bosnian as his first language, married for 28 years to his wife, having Islam as his religious background without practicing it, and having deep belief in helping others in need. He believes that if he helps others in need, God will grant him the good health. He loves gardening and fixing garden machines what help him to relieve the stress. Client has bee sting allergy; takes no medication, and he is a smoker (pack year=20). He works as machine operator in the rubber industry and wears safety glasses and hearing protectors when indicated.
Client denies any changes in vision, any blurred or …show more content…
Physical Examination/Objective Data Eyes: When central vision tested (removed reading glasses) using the Snelling eye chart, no hesitancy, squinting, leaning forward or misreading letters. Visual acuity in bilateral eyes 20/20. Near vision was tested with reading glasses on, with result 14/14 in each eye, without hesitancy or moving the newspaper further away. Results of the peripheral vision or the visual field test included, finger was seen (by both of us) at about 60 degree nasally, about 50 degrees superiorly, about 90 degrees temporally, and about 70 degrees inferiorly. When corneal light reflex tested, reflection of the light on the corneas was exactly the same spot on each eye, and white dots seen symmetrically. During the cover test, uncovered eye remained with steady fixed gaze. No muscle weakness observed, as the uncovered eye stared straight ahead. During the diagnostic position test, leading the eyes through the six cardinal position of gaze, none of eyes produced any muscle weakness during the movement. No nystagmus, no lid lag observed. Further, on inspection of the external structures, it was observed relaxed facial expression, …show more content…
The skin is pink-red, consistent with the client’s facial skin color. Further, skin is intact, without the lumps or lesions. No evidence of tenderness when the pinna moved and when pushed on tragus. No evidence of pain observed, when palpated mastoid process, bilaterally. The external auditory meatus without swelling, redness, or discharge. No cerumen present. The examination by the otoscope showed no redness and swelling, lesions, foreign bodies, or discharge in the external canal. The eardrum is flat, slightly pulled in. It is shiny and translucent with a pearl gray color, and is intact. The client correctly repeated the whispered numbers, “999,” and “666,” when his hearing was tested bilaterally. Sound heard equally in both ears with the Weber test. The Rinne test showed that an air-conduction is twice as long as the bone conduction.
Interpretation of Data:
Eyes: Healthy vision function and healthy eye structures: visual acuity 20/20 bilaterally, sclera white, conjunctiva pink; pupils constrict 4mm to 2mm; equally, round, and reactive to light and accommodation (PERRLA); disk margins sharp, no hemorrhages or exudates.
Ears: Healthy ear structures and accurate hearing: acuity good to whispered voice; tympanic membranes (TMs) with good cone of light; Weber: midline; Rinne: AC>