Assessment of the Mouth, Nose, Throat and Sinuses

History of Present Health Concern

AreasFindings

A. Tongue and Mouth

Sores and lesions a. Pain b. Occurrence/ recurrence c. Extenta. Apthous stomatitis (canker sore); herpes simplex (cold sore)b. Non-healing; persistent red and white patchesc. rough, crusty, eroded (may be warning signs of cancer)

Gum, tooth problems a. redness, swelling, bleeding, pain b. occurrence c. loss of teetha. 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)

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 tastea. 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 disordersc. 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 coldsd. Sinus congestion, obstruction, deviated septume. Seasonal rhinitis caused by triggering factors Eg. Dust, pollensf. 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 tractDecrease in the ability to taste may be due to URI or lesions of the facial nerveChanges in the perception of smell may be due to zinc deficiency or menopause

C. Throat

a. Difficulty in chewing or swallowing b. Occurrence/Extent c. Pain and soreness

d. Hoarsenessa. Dysphagia may be seen in esophageal disorders, anxiety, Difficulty in chewing caused by poor fitting dentures or neurologic disordersb. persistence of problems with swallowing or chewing may be late signs oral cancerc. Throat irritation and soreness with sinus drainage may be indicative of viral or bacterial infection. Persistence may signal throat cancerd. Associated with URI, allergies, hypothyroidism, overuse of voice, smoking or inhaling other irritants and cancer of the larynx

Past Health History1. Oral, nasal or sinus surgery2. Sinus infection; signs and symptoms3. Use of nasal sprays

Family HistoryHistory of mouth, throat, nose or sinus cancer

Lifestyle and Health Practices1. Smoking2. Drinking alcohol3. Teeth grinding4. Care of the gums, teeth or dentures4. For those who wear bracesa. Careb. avoidance of specific type of foodsc. dietary intake5. Fitting of dentures

Physical ExaminationMaterials:Gloves4 x 4-inch gauze padPenlightTongue depressorNasal 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 Palpation1. Inspect the lips for consistency and colorNormal 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, swelling2. 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