Ears, Nose, Throat

#Ears, Nose, Throat

S: Subjective

Mouth/Throat Symptoms: 
(-) sore throat
(-) xerostomia
(-) bleeding gums
(-) toothache
(-) altered taste
(-) mouth ulcers/sores/vesicles
(-) dysphonia
(-) enlarged lymph nodes
(-) trismus
(-) halitosis
(-) dentures
(-) other ->

Right Ear Symptoms:
(-) pain
(-) discharge
(-) hearing loss
(-) tinnitus
(-) crackling
(-) pressure/fullness
(-) other ->

Left Ear Symptoms:
(-) pain
(-) discharge
(-) hearing loss
(-) tinnitus
(-) crackling
(-) pressure/fullness
(-) other ->

Right Nose/Sinus Symptoms:
(-) nasal discharge
(-) nasal stuffiness
(-) post-nasal drip
(-) epistaxis
(-) other ->

Left Nose/Sinus Symptoms:
(-) nasal discharge
(-) nasal stuffiness
(-) post-nasal drip
(-) epistaxis
(-) other ->

Other Symptoms:
(-) vertigo
(-) dizziness
(-) other ->

O: Objective

Examination:
Mouth/Throat: 
(-) erythema
(-) exudate
(-) tonsillar enlargement
(-)tonsillar exudate
(-) vesicles
(-) ulcers
(-) other ->

External Canals: 
Right: 
(-) dermatitis
(-) erythema
(-) fungal infection
(-) narrowed
(-) excess wax
(-) occluded
(-) other ->

Left: 
(-) dermatitis
(-) erythema
(-) fungal infection
(-) narrowed
(-) excess wax
(-) occluded
(-) other ->

Tympanic Membranes: 
Right: 
(-) not visible
(-) wet perforation
(-) dry perforation
(-) effusion
(-) other ->

Left: 
(-) not visible
(-) wet perforation
(-) dry perforation
(-) effusion
(-) other ->

Nose/Sinuses:
Right: 
(-) discharge
(-) mucosal swelling
(-) bleeding
(-) septal deviation
(-) enlarged turbinates
(-) sinus tenderness
(-) other ->

Left: 
(-) discharge
(-) mucosal swelling
(-) bleeding
(-) septal deviation
(-) enlarged turbinates
(-) sinus tenderness
(-) other ->

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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