Documentation of the Nose, Mouth, and Throat Examiner: Date: Patient: Age: Reason for Visit: Health History – Nose 1

Documentation of the Nose, Mouth, and Throat Examiner: Date: Patient: Age: Reason for Visit: Health History – Nose 1. Any nasal discharge noted? 2. Unusually frequent of severe colds? 3. Any sinus pain or sinusitis? 4. Any trauma or injury to the nose? 5. Any nosebleeds? How often? 6. Any allergies or hay fever? 7. Any changes or loss in the sense of smell? Health History – Mouth 1. Any sores in the mouth or on the tongue? 2. Any sore throat? How often? 3. Any bleeding gums or toothache? 4. Any hoarseness or voice change? 5. Any difficulty swallowing? 6. Any change in the sense of taste? 7. Do you smoke? How much per day? How long? 8. Drink alcohol? How many times per week? How many drinks per occasion? 9. Do you use nasal sprays? 10. Do you get regular dental checkups? Brush your teeth and floss daily? Health History – Throat 1. Any neck pain? 2. Any lumps or masses in the neck? 3. Any surgery on the neck? 4. Any history of thyroid problems? Physical Assessment 1. Inspect the nose and palpate sinuses a. Symmetrical? b. Nares patent? c. Deviated septum? d. Mucous membranes pink and moist? e. Discharge or inflammation? f. Any tenderness in frontal or maxillary sinuses? 2. Inspect the mouth a. Lips symmetrical? Lesions? Dry or chapped? b. Dentition intact? Caries? c. Gums inflamed? d. Any lesions in the mouth? Membranes pink and moist? e. Tongue midline? Able to move? f. Uvula rises with phonation? g. Hard palate intact? h. Tonsils present? Inflamed? 3. Inspect and palpate the neck a. Trachea midline? b. Thyroid enlarged or nodules present? c. Perform ROM d. ROM against resistance – head and shoulders e. Palpate lymph nodes – any tenderness or inflammation? Regional Write-Up 1. Subjective (Health History) 2. Objective (Physical Assessment) 3. Assessment of Risks and Plan (Include two risks)