Rasmussen Minneapolis Minnesota Nose Mouth and Throat Health History Documentation

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Description

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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