Ears, nose, throat (ENT)

{Ears, nose, throat (ENT)}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Mouth/throat symptoms: 
[-] sore throat
[-] xerostomia
[-] bleeding gums
[-] toothache
[-] altered taste
[-] mouth ulcers/sores/vesicles
[-] dysphonia
[-] enlarged lymph nodes
[-] trismus
[-] halitosis
[-] dentures

Right ear symptoms:
[-] pain
[-] discharge
[-] hearing loss
[-] tinnitus
[-] crackling
[-] pressure/fullness

Left ear symptoms:
[-] pain
[-] discharge
[-] hearing loss
[-] tinnitus
[-] crackling
[-] pressure/fullness

Right nose/sinus symptoms:
[-] nasal discharge
[-] nasal stuffiness
[-] post-nasal drip
[-] epistaxis

Left nose/sinus symptoms:
[-] nasal discharge
[-] nasal stuffiness
[-] post-nasal drip
[-] epistaxis

Other symptoms:
[-] vertigo
[-] dizziness

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[+] 
[-]

PHYSICAL EXAMINATION
Relevant examination findings:
  Mouth/throat: 
    [-] erythema
    [-] exudate
    [-] tonsillar enlargement
    [-]tonsillar exudate
    [-] vesicles
    [-] ulcers
  External canals: 
    Right: 
      [-] dermatitis
      [-] erythema
      [-] fungal infection
      [-] narrowed
      [-] excess wax
      [-] occluded
    Left: 
      [-] dermatitis
      [-] erythema
      [-] fungal infection
      [-] narrowed
      [-] excess wax
      [-] occluded
  Tympanic membranes: 
    Right: 
      [-] not visible
      [-] wet perforation
      [-] dry perforation
      [-] effusion
    Left: 
      [-] not visible
      [-] wet perforation
      [-] dry perforation
      [-] effusion
  Nose/sinuses:
    Right: 
      [-] discharge
      [-] mucosal swelling
      [-] bleeding
      [-] septal deviation
      [-] enlarged turbinates
      [-] sinus tenderness
    Left: 
      [-] discharge
      [-] mucosal swelling
      [-] bleeding
      [-] septal deviation
      [-] enlarged turbinates
      [-] sinus tenderness

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Ears, nose, throat (ENT)

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