EarNoseMouthandThroatchecklist-2023
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School
Weber State University *
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Course
MISC
Subject
Medicine
Date
Apr 3, 2024
Type
Pages
7
Uploaded by kellbrown98
Ears, Nose, Mouth, & Throat Name:
Kelly Jamison
Date: 02/07/2024
# of minutes:
10
Preceptor Name: Chelsea Ekins
Preceptor Signature: Chelsea Ekins
History
Remember to look at each history component as it relates to the head, face, and neck. Ask
the patient the following:
x Do you have…
x Hearing loss?
x Vertigo?
x Tinnitus?
x Ear drainage?
x Earache?
x Nasal congestion?
x Nosebleed?
x Mouth and dental pain?
x Sore throat?
x Hoarseness?
x Do you have balance problems?
x Do you have drainage from your ears? If yes, how much and what color?
x Have you had recent head trauma?
x Are you exposed to noise pollution at work or in your home environment?
x Are you on any prescribed or OTC medications?
x Do you have problems or complaints related to your Ears, nose, mouth or throat?
x Do you have allergies to any medications, foods, or environmental factors?
x Do you have any health problems?
x Are you on any medications, prescribed, or over the counter?
INSPECT
Findings
OTHOSCOPIC EXAM
INSPECT
Findings
Physical Assessment
Equipment
Gather equipment needed for exam:
x Thermometer
x Gloves
x Penlight
x Tongue blade
x Stethoscope
x Otoscope
x Gauze
x Cup of water
Position
Sitting
Technique
First, scan your patient head to toe checking for speciWic signs of diseases, affecting other
organ systems that might alter the head, face, and neck.
Inspection, Palpation, Percussion, Auscultation
External Ear
☐
Angle of attachment
☐
Size, shape, symmetry
☐
Condition of skin, drainage
PALPATE
☐
Consistency, tenderness, nodules
☐
Helix, tragus, mastoid process
x WNL or
x WNL or
x WNL or
x WNL or
x WNL or
External Ear Canal
☐
Color, position of landmarks, integrity
of TM, mobility of TM
x WNL or
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INSPECT
Findings
INSPECT
INSPECT
Tympanic Membrane
☐
Color, position of landmarks, integrity
of TM, mobility of TM
HEARING TESTS (Test Each Ear
Separately)
☐
Whisper Voice Test
☐
Ticking Watch Test
☐
Weber Test
x WNL or
x WNL or
x WNL or
x WNL or
Sinuses
☐
Edema
PALPATE
☐
Tenderness
PERCUSS
☐
Tenderness
Findings
x WNL or
Findings
x WNL or
Findings
x WNL or
Nose
☐
Position, septal deviation, discharge, Wlaring
☐
Nasal mucosa color, intact septum,
turbinates, polyps
PALPATE
☐
Patency
Findings
x WNL or
x WNL or
Findings
x WNL or
Mouth and Throat
☐
Lips:
Color, lesions, purse-lip, odor
☐
Oral mucosa:
Color, lesions
☐
Gingivae:
Color, bleeding, retraction,
hypertrophy
☐
Teeth:
Occlusion, number, condition,
color
☐
Tongue:
Color, lesions, texture, position,
mobility
☐
Oropharynx/soft and hard palate/
tonsils:
Color, condition, lesions, drainage,
exudates
PALPATE
☐
Lips and tongue:
Tenderness, muscle
tone, lesions
☐
Oropharynx:
Test gag reWlex
Findings
x WNL or
x WNL or
x WNL or
x WNL or
x WNL or
x WNL or
Findings
x WNL or
x WNL or
Document
Document your Dindings and develop your plan of care using “SOAP”:
S
ubjective data,
O
bjective data,
A
ssessment/clinical judgement, and
P
lan.
S
Patient came in for their annual check up and wanted to make sure everything
was going okay. Patient stated they felt Wine, but they were just wanting a check
up.
O
Patient appears to be within normal limits of their visit with us last year and seem
to be in little to no pain before the assessment
A
During the assessment I did not Wind anything that was concerning or anything
that is needing to be reported.
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P
Plan is to have the patient follow up in a couple of months for another check up or
to come sooner if they start to feel worse.