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Assessment of the Mouth, Nose, Throat and Sinuses

History of Present Health Concern


Areas
A. Tongue and Mouth
Sores and lesions
a. Pain
b. Occurrence/ recurrence
c. Extent

Gum, tooth problems


a. redness, swelling,
bleeding, pain
b. occurrence
c. loss of teeth
B. Nose and Sinuses
a. Pain
b. Bleeding (extent and
character)

c. Drainage

d. Breathing
e. Seasonal allergies
f. Changes in the ability to
smell or taste

C. Throat
a. Difficulty in chewing or
swallowing
b. Occurrence/Extent

Findings

a. Apthous stomatitis (canker sore); herpes simplex


(cold sore)
b. Non-healing; persistent red and white patches
c. rough, crusty, eroded (may be warning signs of
cancer)
a. redness and swollen gums( gingivitis)
b. destruction of the gums with tooth loss
(peridontitis)
c. Pain and inflammation (may be later signs of oral
cancer)

a. Pressure and pain over sinuses (sinusitis)


b. May be a result in the overuse of nasal sprays,
excessively dry mucosa, hypertension, leukemia,
thrombocytopenia, and other blood disorders
c. Thin, watery, clear nasal drainage (rhinorrhea)
may indicate chronic allergy or past head injury
(CSF leak); yellowish mucous drainage indicative of
sinus infection; clear mucous drainage indicative of
rhinitis, common colds
d. Sinus congestion, obstruction, deviated septum
e. Seasonal rhinitis caused by triggering factors Eg.
Dust, pollens
f. decrease in the ability to smell caused by URI,
smoking, cocaine use or neurologic lesion or tumor
in the frontal lobe of the brain or olfactory tract
Decrease in the ability to taste may be due to URI
or lesions of the facial nerve
Changes in the perception of smell may be due to
zinc deficiency or menopause
a. Dysphagia may be seen in esophageal disorders,
anxiety,
Difficulty in chewing caused by poor fitting
dentures or neurologic disorders

c. Pain and soreness

d. Hoarseness

b. persistence of problems with swallowing or


chewing may be late signs oral cancer
c. Throat irritation and soreness with sinus
drainage may be indicative of viral or bacterial
infection. Persistence may signal throat cancer
d. Associated with URI, allergies, hypothyroidism,
overuse of voice, smoking or inhaling other irritants
and cancer of the larynx

Past Health History


1. Oral, nasal or sinus surgery
2. Sinus infection; signs and symptoms
3. Use of nasal sprays
Family History
History of mouth, throat, nose or sinus cancer
Lifestyle and Health Practices
1. Smoking
2. Drinking alcohol
3. Teeth grinding
4. Care of the gums, teeth or dentures
4. For those who wear braces
a. Care
b. avoidance of specific type of foods
c. dietary intake
5. Fitting of dentures
Physical Examination
Materials:
Gloves
4 x 4-inch gauze pad
Penlight
Tongue depressor
Nasal speculum
Procedure:
* Ask the client to assume sitting position with the head erect. (Best if the clients
head is at your eye level.)
A. Inspection and Palpation
1. Inspect the lips for consistency and color
Normal findings: Lips are smooth and moist without lesions or swellings. Color
of lips would depend on clients complexion.

Abnormal findings: Pallor around the lips; cyanosis; reddish lips, swelling
2. Inspect the teeth and gums. Ask client to open mouth. Note the number, color
and alignment of teeth. Put on gloves and retract the clients lips and cheeks to
check gums for color and consistency.
Normal findings: 32 pearl-white teeth with smooth surfaces and edges (28
teeth if 4 wisdom teeth have not erupted yet). Upper molars rest directly on the
lower molars. Front upper incisors should slightly override the lower incisors. Gums
are pink, moist and frim with tight margins to the tooth. No lesions or masses.
Abnormal Findings: Yellow of brownish teeth; tooth decay/ dental caries
appear as brown dots; missing teeth; chalky white teeth; Malocclusion seen when
upper or lower incisors protrude. Receding gums in younger clients; red, swollen
gums; Bluish black or grey-white line along the gum line (seen in lead poisoning)
3. Inspect the buccal mucosa. Use a penlight or tongue depressor to retract the lip
and cheeks to check color and consistency

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