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