M1 H&P: Head, Neck, Nose and Throat

Devin Nickol, M.D.

I. Head

- 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:






II. Neck

- 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
Sample Write-ups: