Chapters 15 &16-Regional Write Up-Eyes &Ears Name:___________________________________________Date:__

Chapters 15 &16-Regional Write Up-Eyes &Ears Name:___________________________________________Date:_________________________ Patient Initials:______________________________Age:____________Gender:_____________ I. Health History-Subjective Data Eyes and Ears (yes no answers-all yes answers explain) 1. Any difficulty seeing or blurred vision_____________________________________________ 2. Any eye pain?________________________________________________________________ 3. Any history of crossed eyes?____________________________________________________ 4. Any redness, swelling, in eyes?__________________________________________________ 5. Any watering or tearing?_______________________________________________________ 6. Any injury or surgery to eye?____________________________________________________ 7. Do you wear glasses or contacts?_________________________________________________ 8. Last vision test?_______________________________________________________________ 9. Ever tested for glaucoma?_______________________________________________________ 10. Any earache or ear infections?__________________________________________________ 11. Any ringing or buzzing in your ears?_____________________________________________ 12. Any discharge from ears?______________________________________________________ 13. Any hearing loss?____________________________________________________________ 14. Are you exposed to loud noises at home or work?___________________________________ 15. Ever felt vertigo (spinning)?____________________________________________________ 16. Do you clean your ears, explain?________________________________________________ 17. Taking any medications?______________________________________________________ II. Physical Examination Eyes 1. Test visual acuity Snellen Eye Chart_______________________________________________________________ 2. Test visual fields Confrontation Test______________________________________________________________ 3. Inspect extraocular muscle function Corneal light reflex______________________________________________________________ **Perform cover test only if corneal light reflex is abnormal**___________________________ Diagnostic Positions Test_________________________________________________________ 4. Inspect external eye structures General_______________________________________________________________________ Eyebrows______________________________________________________________________ Eyelids and eyelashes____________________________________________________________ Eyeballs_______________________________________________________________________ Conjunctiva and sclera___________________________________________________________ 5. Inspect anterior eyeball structures Cornea________________________________________________________________________ Iris___________________________________________________________________________ Pupil size___Rt______________Lt_________________ Accommodation___________________ Pupil direct & consensual light reflex________________ Physical Examination Ears 1. Inspect and palpate external ear Size and shape__________________________________________________________________ Skin condition__________________________________________________________________ Tenderness____________________________________________________________________ External auditory meatus_________________________________________________________ 2. Inspect using an otoscope External canal__________________________________________________________________ Tympanic membrane color and characteristics_________________________________________ 3. Test hearing acuity Whispered voice test_____________________________________________________________ Summary Eyes and Ears Write a paragraph reporting all of your subjective and objective findings SCIENCE HEALTH SCIENCE NURSING NUR 2092

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