ABSTRACT
NOSE You are a PRHO in general practice and Miss Davies has come to see you complaining of a blocked nose. Please take a short history and conduct an examination of her nose.
Introduces self and seeks permission to take a history and examine Confirms patient’s name and age
History
Enquires about characteristics of nasal obstruction – unilateral/bilateral/alternating, is obstruction constant or does it vary with time of day/season? Enquires about associated features – rhinorrhoea, facial pain, sneezing, swelling, itch, paroxysmal nocturnal dyspnoea, sense of smell, catarrh Establishes impact on patient’s life Enquires about possible causes – allergies, hayfever, injury, pets, use of nasal sprays/drops Enquires about previous ENT surgery Asks if patient is currently in any pain
Examination
Positions patient appropriately Examines the external nose (inspects for deformity and septal deviation) Assesses nasal patency (using a metal tongue blade) Assesses for functional/alar collapse Examines internal nose with an otoscope (comments on septum, turbinate, mucosa and presence/absence of polyps)
Cleans hands by washing or using alcohol gel
Fluency of examination Competence in presenting findings, summarizing and forming differential diagnoses
KEY As a medical student, examination of the nose is not something that you will have had much opportunity to practise and it is worth attending an ENT clinic to be taught how to do it properly and to familiarize yourself with the equipment that is required – tongue blade, special Thudicum speculum and an otoscope. To examine the nose, your patient should be positioned upright in a chair. To assess for septal deviation, you need to lift the tip of the patient’s nose using your thumb. Nasal patency is assessed using a metal tongue blade; you block one of the patient’s nostrils using your thumb and place the blade underneath the nose, asking the patient to breathe in and out whilst observing for condensation on the blade. If condensation forms, the nostril that you have not blocked is patent. To observe for alar collapse, block one of the patient’s nostrils with your thumb and ask him/her to breathe in very quickly.
