M1 H&P: Head, Neck, Nose and Throat
Devin Nickol, M.D.
Sample Write-ups:- Assess size, shape, symmetry, involuntary movements- Scalp characteristics including lesions- Temporal artery tenderness, appearance- Facial size, shape, symmetry- Nose and sinuses:- Patency of nares- Nasal mucosa: color, bleeding or discharge- Nasal septum: integrity, deviation- Lateral walls: turbinates, meatal discharge- Frontal and maxillary sinuses:- Tenderness to percussion or palpation- Transillumination of maxillary sinus
-Mouth:- Lips: color, lesions, symmetry- Tongue: dorsal and lateral surfaces- Palate- Gingival surface- Buccal mucosa- Teeth: integrity, number- Posterior oropharynx:
- Inspect including tonsills and peritonsillar tissue- Note color, presence or absence of drainage, ulcers, masses or other lesions- If patient's tongue obstructs view, ask patient to pant
- Describe lesions with appropriate terminology- erythema- posterior drainage (purulent, clear, bloody)- peritonsillar masses- ulcers (describe color and drainage, if present)- vesicles- plaques (including color and ability to be scraped off)- purulent drainage from tonsillar crypts
Sample Write-ups:- Assess muscle symmetry- Trachea position- Thyroid gland: size, tenderness, masses- Carotid arteries: check for bruits, note pulse characteristics- Lymph nodes:- Preauricular- Postauricular- Submandibular- Anterior cervical- Supraclavicular