Ent Physical Exam Template Form
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People also ask ear exam documentation
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What is a physical exam for ENT?
A full ENT examination includes examination of oral cavity including gums and buccal mucosa, inspection of the oropharynx with a tongue depressor and palpation of the neck. Suspicious areas on the tongue or in the mouth are palpated. Some patients will tolerate palpation of the oropharynx.
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How do you document general appearance?
General appearance: include information on the patient's overall condition. It is appropriate to comment on level of comfort or distress, as well as general grooming and hygiene.
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How to document a normal ENT exam?
Sample Normal Exam Documentation Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. ... Eyes – Visual acuity is intact. ... Ears – The pinna, tragus, and ear canal are non-tender and without swelling. ... Nose – Nasal mucosa is pink and moist.
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How to document a normal eye assessment?
Eyes: VA with Snellen card & corrective lenses: OD = 20/20; OS = 20/20; OU = 20/20. Visual fields: all four quadrants intact & symmetrical to confrontation.
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How do you document a normal nose exam?
Normal findings might be documented as: “External nose is symmetrical with no discolouration, swelling or malformations. Nasal mucosa is pinkish red with no discharge/bleeding, swelling, malformations or foreign bodies.” Abnormal findings might be documented as: “Bright red nasal mucosa with purulent discharge.”
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What are the 4 components of physical exam?
A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds, usually with a stethoscope) Percussion (producing sounds, usually by tapping on specific areas of the body)
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How to describe ears on a physical exam?
The ear canal is skin-coloured and lined with small hairs and usually some yellowish brown earwax. The eardrum is normally pearly white or light grey, and you can see through it. Also, one of the tiny bones in the middle ear can be seen. The eardrum moves slightly when a puff of air is blown into the ear.
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What is a normal ENT exam?
A complete ENT examination includes inspection of the face, ears, nose, throat and neck. We generally screen for hearing loss and we use pressure testing to examine the eardrum for fluid (pneumatic otoscopy or tympanometry).
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