Health assessment is conducted with the help of a physician or a qualified medical practitioner. It is a critical component of determining a person’s medical condition that then informs the appropriate medical intervention (Sharon, 2018). The assessment can be performed on different organs of the body. The following sections of the paper are limited to the evaluation of the tympanic membrane and thyroid glands, the conditions that these organs encounter, and methods of assessment of these conditions.
Information on Health Assessment Histories
Health assessment constitutes a plan of care performed by a medical practitioner to help understand the demands of a patient. The physician then develops criteria to address the needs where the patient is handled through a systemic health care system or a specialized nursing installation. The procedure involves undertaking a detailed examination of the health status through a systemic bodily examination. It is required that the evaluation be performed after understanding the patient’s medical history (Carolyn, 2019). The medical examination needs to be accompanied by evaluating the health continuum to determine the most suitable treatment approach.
Two critical steps have to be observed in understanding the medical history of the patient. The first step involves developing rapport with the customer through an introduction to one another and greetings in a professional manner. The patient has to be invited to a place where their privacy is guaranteed and there is eye contact. The objective is to ensure that the patient feels confident and secure. The second step is to invite the patient to tell their story, which can begin by prompting them to tell the reason why they have come to see a doctor. The approach here is to understand the ‘chief complaint or the CC’ for the patient, which covers the reason why the patient desired to seek the doctor’s services (Carolyn, 2019). During this session, it is not advisable to interrupt the patient such that they freely express themselves.
Tympanic Membrane Assessment
Tympanic membrane, also called the eardrum, is an anatomic feature in a human being. It is a cone-shaped and thin membrane that divides the external ear from the middle ear. The eardrum helps to transmit sound from the outer environment to the ossicles located in the middle ear and afterwards to the oval window located in the cochlea (Weber, 2021). Therefore, it not only converts vibration in the surroundings into a signal but also augments this vibration signal.
One major condition that can affect a patient around the eardrum is the Tympanic membrane perforation (TMP), which is caused by a sickness, careless wax removal or cleaning of the ear, injury or extreme distress (Carolyn, 2019). It can either be temporary or permanent and its effect is mainly in varying the size and location on the surface of the eardrum or there is an association of this condition with a pathological condition.
Examination of the tympanic membrane can also reveal another condition called the cholesteatoma disorder. It is a non-infected tympanic perforation that is not painful but results in reduce hearing due to interruption from whistling sounds in the ear. Cholesteatoma causes a sanguineous overflowing purulent drainage in both acute and chronic opening. The condition also causes skin cells to grow behind the eardrum and can cause damage to it. Its effect can spread to the middle ear, facial nerves, brain-ear barrier sometimes the inner ear, and blood vessels to the brain (Carolyn, 2019). It manifests in the form of chronic ear infection, serious hearing problems, dizziness and strong ear illness. Cholesteatoma disorder can also cause meningitis and brain damage and incapacitate the patient’s ability to move. The tissue damage caused by the condition can distort normal configurations of the affected area.
Thyroid Gland Assessment
Health assessment of the thyroid gland can be conducted in three main portions, which are inspection, palpation, and data synthesis. The examination phase covers two main approaches beginning with inspecting the anterior look of the organ. A normal thyroid weighs between 10gms to a maximum of 20gms. The major observable condition is the enlargement of the thyroid, which is called goiter (Carolyn, 2019). During inspection the patient is required to either sit or stand in a straight posture. A cross-lighting is used to enhance shadows, making it easy to observe a growth. The patient can also be required to enable spotting any growth by stretching out the neck to show any overlying tissues. The doctor should provide clean and safe drinking water to the patient to swallow, hence facilitating the movement of the gland.
The anterior inspection is followed by the lateral checking of the anterior gland. It involves inspecting the patient’s neck from one side and observing from the cricoid cartilage down to the suprasternal notch and assessing its structure by using a ruler to.measure tits stature (Carolyn, 2019). The thyroid gland can also be assessed using the palpation approach. It involves a physical examination of the body by the use of fingers to feel or touch a given surface. Palpation also involves the anterior and posterior feeling of an organ or body part to discern its size, texture, location, and tenderness. The patient is examined while sitting using one hand to retract the sternocleidomastoid muscle gently and use the other hand to palpate the thyroid. The thymus isthmus is felt by feeling regions between the cricoid cartilage and the suprasternal notch (Weber, 2021). The patient can be required to swallow some drinking water and be palpated to enable the doctor to feel the thyroid gland’s activity.
Laboratory Tests Tympanic Membrane and Thyroid Glands
The outcome of the anterior and lateral examination can be verified in the laboratory. Tympanic membrane perforations can tested routinely using otoscopy. Otomicroscopy is performed to assess small perforations in the ear. Additionally, audiometry tests always reveals normal hearing (Sharon, 2018). If the readings exceed 30 dB, the patient is likely to have perforations that cause conductive hearing loss.
Thyroxine (T4) is the main laboratory test performed to monitor thyroid disorder. In general, there are three possible outcomes on assessment of the thyroid gland. First, it can be found to be normal or small, with a lateral promise of less than 2mm. Second, a patient may be found to have a goiter if the thyroid gland has a size exceeding two times the normal size with a lateral stature of over 2mm (Carolyn, 2019). Finally, the outcome may be inconclusive necessitating further examination by a specialist.
SOAP Notes on the Patient’s Findings
A SOAP (Subjective, Objective, Assessment, and Plan) note is a tool used by medical practitioners to document remarks regarding the health assessment of a patient. It involves four components each with its informational content based on the medical scrutiny of a patient. The subjective component outlines a patient’s chief complaint, or the CC, which is a reference of their purpose of visiting the health facility. The objective component describes an examiner’s findings of a patient after observation using different methods, such as medical history, vital signs, and diagnostic tests. The assessment component contains a short description of the patient including the symptoms, the latest diagnostic tests and the etiology of the patient’s pains. Finally, the plan component encompasses the strategy or the interventions recommended by the health care provider in the best interest of the patient (Carolyn, 2019). Examples include referrals, further laboratory tests and procedures, and medication. An example of hyperthyroid SOAP assessment is described below;
- S: Slight but relentless pain at the neck region, patient reports of jutting out at the neck.
- O: Hyperthyroidism detected. The Struma is palpated and highly visible, no edema.
- A: Recommended for an ultrasound. The patient can use Tyrosine, Cytomel, and Levoxyl to manage the condition.
- P: Carry on with daily dosage of drugs and favorable diet. The patient is due for discharge tomorrow.
Health assessment is a critical medical undertaking intended to uncover a patient’s medical condition and history. It can also be performed notwithstanding a medical patient’s history. The assessment of the tympanic membrane and the thyroid gland mainly involves a physical examination that can be reinforced through laboratory tests. The lab tests can provide a conclusive diagnosis of a patient’s condition.
The tympanic membrane is anatomically located in the ear and transmits sound waves to the inner ear. It can be affected by diseases that lead to serious damage to it and its functioning. The thyroid gland is a hormonal gland located in the neck region. It can also be affected by a disease and cause hyperthyroidism or hypothyroidism. Infection to both organs can be examined in the laboratory and through physical inspection by a doctor.
Carolyn, J. (2019). Physical examination and health assessment, (8th ed.). Saunders.
Sharon, J. (2018). Nursing health assessment: A best practice approach (3rd ed.). LWW.
Weber, J. R. (2021). Nurses’ handbook of health assessment (10th Ed.). LWW.