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S4, commonly described as sounding like “Ten-nes-see,” occurs just before S1, after atrial contraction. The S4 sound indicates increased resistance to ventricular filling. It results from vibrations caused by forceful atrial ejection of blood into ventricles that are enlarged or hypertrophied and don’t move or expand as much as they should. Auscultating for murmurs Murmurs occur when structural defects in the heart’s chambers or valves cause turbulent blood flow. Turbulence may also be caused by changes in the viscosity of blood or the speed of blood flow.
Do you smoke or use other types of tobacco? • Do you have neck pain or tenderness, neck swelling, or trouble moving your neck? Examining the ears Use the techniques of inspection, palpation, and auscultation to examine the patient’s ears. An ear assessment also requires the use of an otoscope. External observations Begin by observing the ears for position and symmetry. Inspect the auricle for lesions, drainage, nodules, or redness. Pull the helix back and note whether it’s tender. If pulling the ear back hurts the patient, he may have otitis externa.
The elderly patient’s eardrum may appear cloudy. “Timing” the light reflex? Now, examine the membrane for the light reflex. In the right ear, this reflex should be between 4 and 6 o’clock; in the left ear, between 6 and 8 o’clock. If the reflex is displaced or absent, the patient’s tympanic membrane may be bulging, inflamed, or retracted. Use an otoscope to examine your patient’s inner ear. qxd 28/8/08 14:44PM Page 25 ASSESSING THE EARS, NOSE, AND THROAT A closer look Using an otoscope Here’s how to use an otoscope to examine the ears.