Registration of medical documentation by an ENT doctor. Rules

They begin the examination with a diseased organ, in case of ear pathology they begin with a healthy ear, in the absence of complaints, the examination begins with the nose, then the pharynx, larynx, and ears are examined.

1) External examination face, neck, ears (behind the ear) - assess the color of the skin, the shape of the nose, auricles, larynx.

2)Palpation facial walls of the paranasal sinuses, mastoid processes, cartilage of the larynx, lymph nodes (mandibular and submandibular, cervical and parotid).

4)Inspection of ENT - organs:

a) anterior rhinoscopy: color of the mucous membrane of the nasal cavity, the volume of the turbinates, the shape of the nasal septum, the content of the nasal passages

(example of a norm description: The shape of the nose is not changed. Nasal breathing is free. The sense of smell is not broken. The vestibule of the nose is free. Nasal septum along the midline. The turbinates are not enlarged. The nasal passages are free. The mucous membrane is pink, moist. Allocations are moderate, mucous).

b) pharyngoscopy: color, moisture of the mucous membrane of the mouth, oropharynx, condition of the gums, teeth, tongue, excretory ducts salivary glands, hard palate, the condition of the palatine tonsils: the contents of the gaps, the presence of adhesions, the degree of mobility of the soft palate

(example of a norm description: Mucous membrane of normal color. Teeth are sanitized. The tongue is clean and moist. Hard palate without features. The soft palate is not changed, mobile. The palatine tonsils are not enlarged (I degree). The lacunae are free. The temples are pink, not soldered to the tonsils. The posterior wall of the pharynx is not changed).

in) posterior rhinoscopy produced by the teacher: nasopharyngeal cavity, choanae, posterior ends of the turbinates, condition of the pharyngeal and tubal tonsils, orifices of the auditory tubes

(example of a norm description choanae, mouths of Eustachian tubes and fornix are free. Opener in the midline).

G) indirect laryngoscopy conducted by the teacher: color,
humidity of the mucous membrane of the larynx and laryngopharynx, condition
pyriform pits, lingual tonsil, epiglottis, color, moisture
vestibular and vocal folds, shape of the glottis, condition
subglottic space

(example of a norm description: free breathing. Voice
saved, not changed. Piriform sinuses are free. Epiglottis
normal form. The aryepiglottic folds are contoured. scooped up not
changed, mobile, interarytenoid space is free.
The vestibular and vocal folds are not changed, they are not limited in mobility. vocal folds during phonation, they close along the midline. The subglottic space is free).

e) Otoscopy: skin condition of the external auditory canal, its
width, color of the tympanic membrane, the presence and location of perforation, its
identification elements of the membrane (handle, light reflex, folds,
short process of the malleus);

(example of a norm description: the skin of the mastoid processes is not changed, palpation and percussion are painless. The external auditory canals are free. Eardrum mother-of-pearl color, identification points are well expressed).

ACUMETRY

VESTIBULOMETRY:

Nystagmus spontaneous

Pressor nystagmus

Post-rotational nystagmus

O.R. (building I, II, III st.)

V.R. (0, I, II, III st.)

1. Nose and paranasal sinuses: on external examination, the shape of the nose is not changed (there is no deviation of the back of the nose from the midline, its retraction is not noted), palpation of the external nose is painless, on palpation of the region of the paranasal sinuses, the exit point of the V pair of cranial nerves, the patient notes soreness; nasal breathing is difficult through both halves, more on the right, the sense of smell is weakened.

Anterior rhinoscopy: the vestibule of the nose is free, the nasal septum is deviated to the right, the mucous membrane is pale, edematous, there are polyps in the middle nasal passage on both sides, the lower turbinate on the right is increased in volume, thick mucous discharge in the middle nasal passage.

2. Throat. Oral cavity: the mucous membrane of the oral cavity is pink, the tongue is not lined, without traces of teeth, the condition of the teeth is satisfactory. Oral part of the pharynx (pharyngoscopy): tonsil niches are deep, tonsils are reduced in size, not hyperemic, without pathological contents in the lacunae. Soft palate, palatine arches without pathological changes. The condition of the mucous membrane of the posterior pharyngeal wall without pathological changes. The cervical lymph nodes are not enlarged, slightly palpated. The nasal part of the pharynx (posterior rhinoscopy): the nasopharynx is free, hypertrophied posterior ends of the inferior turbinates are visible. The arch of the nasal part of the pharynx is without pathological changes, the choanae are free, the pharyngeal tonsil is not enlarged, the orifices of the auditory tubes are not changed, the tubal tonsils are not enlarged. The laryngeal part of the pharynx (hypopharyngoscopy): the lingual tonsil is not enlarged, the vallecules are without pathological changes, the pyriform sinuses are free.

3. Larynx - The voice is sonorous, breathing is calm, rhythmic, not disturbed; on external examination, the condition of the cartilage of the larynx is without pathological changes, displaceable, the symptom of crepitus is positive. Indirect laryngoscopy - the outer ring of the larynx is not changed. The epiglottis is deployed in the form of a sheet covering the anterior sections of the vocal folds. vocal folds white color, in the posterior third mobility in full.

Right ear: auricle externally without pathological changes, correct form, painless on palpation and pressure on the tragus. Percussion of the mastoid region is painless. Outer ear canal normal width, there is a small exostosis on the anterior-lower wall of the external auditory canal. Eardrum - with all identification points, gray. Pathological discharge, membrane perforations were not detected.

Left ear: auricle externally without pathological changes, regular shape, painless on palpation. Percussion of the mastoid region is painless. The external auditory canal is of normal width. Eardrum - with all identification points, gray. Without pathological discharge, membrane perforations were not detected.

Working as a doctor in district hospital very often there is not enough time for a more complete primary examination of the doctor and its documentation. Therefore, I tried to create a template that makes it almost impossible to miss a particular body system, plus takes less time to fill.

Primary examination by a doctor ________________________

COMPLAINTS:________________________________________________________________________________

____________________________________________________________________________________
ANAMNESIS MORBI.

Acutely fell ill, gradually. The onset of the disease from _______________________________________

For medical assistance (not) applied to the PIU, VA ____________ to the doctor _________________. Outpatient treatment: no, yes: ____________________________________________________________________________
Effect of treatment: yes, no, moderate. Appeal to the SMP: no, yes ___ times (a). Delivered to rest by
emergency indications (yes, no) from the scene of an accident, street, home, work, public place through ____
min, hour, day. SMP done:______________________________________________________________
He is hospitalized in the _________________________ department of the Central District Hospital.

ANAMNESIS VITAE.
VZR / CHILD: from ___ ber, ___ childbirth (natural, opera). The course of pregnancy: b / patol., complicated by _______________________________________________________________ in the period of _______ weeks.
Born (was) full-term (oh) (yes, no), in the period of ____ weeks, weighing ______ g,
height____ cm. Breastfeeding (yes, no, mixed) up to ___ year(s). Vaccinations on time, medical
rejection due to _________________________ Examination of the pediatrician is regular (yes, no). General development corresponds to age (yes, no), sex (yes, no), male/female development.
Consists of "D" (yes, no) doctor ____________________ with DZ: ___________________________________
Regularity of treatment (yes, no, amb, stats). Last hospital. ____________ where __________________
Transferred zab: TBS no, yes ______ Vir. Hepatitis no, yes _______ d. Brucellosis no, yes __________ d
Operations: no, yes _________________________________ complications _________________________________
Blood transfusions: no, yes _________ d, complications __________________________________________
Allergy anamnesis: calm, burdened _________________________________________________________
Living conditions: (not) satisfactory. Food is (not) sufficient.
Heredity is (not) weighed down _____________________________________________________________
Epidemiological history: contact with an infectious patient with symptoms: _____________________________ (yes, no),
where when____________________________________________
Bad habits: no smoking, yes ____ years, no alcohol, yes ____ years, no drugs, yes ____ years.

STATUS PRAESENS OBJECTIVUS
General condition (moderate, severe, extremely severe, terminal) severity, (not) stable
noe, due to _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Consciousness (clear, retarded, somnolent, stuporous, soporous, coma___st)
Glasgow _____ points. Behavior: (mis)oriented, excited, calm. Reaction
on examination: calm, negative, tearful. Position of the patient: active, passive, forced
____________________________________________________________________________________
Constitution: asthenic, normosthenic, hypersthenic. Proportional yes, no __________
______________________________ Symmetric yes, no ___________________________________
Skin: clear, rash
Normal color, pale, (sub)icteric, earthy, hyperemic
Cyanosis: no, yes, diffuse, local ___________________________________________________
Humidity: dry, normal, increased, hyperhidrosis. Visible mucous membranes: pale, pink, hyperemic
Adipose tissue: weakly, moderately, excessively expressed, (not) uniform ___________________
Peripheral edema: no, yes, generalized, local ______________________________________
Peripheral l / nodes are enlarged: no, yes _____________________________________________ Т _________ * С_
Muscles: hypo, normal, hyper tone. Developed: weak, moderate, pronounced. Height _____ cm, weight _____ kg.
Seizures: no, yes. Tonic, clonic, mixed. _____________________________________
Respiratory organs: breathing through the mouth and nose is free yes, no __________________________________
Gr.cell: symmetrical yes, no ________________ no deformation, yes _____________________________
When breathing, the mobility of both halves is symmetrical yes, no ______________________________
Pathological retraction of the compliant areas of the chest: no, yes _____________
Participation of an additional muscle group in the act of breathing: no, yes _____________________________________
Palpation: soreness: no, yes on the right along the ______ line, on the ur _____________ ribs,
on the left along ________________________________ lines, on ur __________________ ribs.
Voice trembling is carried out evenly yes, no ___________________________________________
Percussion: normal pulmonary sound yes, no ____________________________________________
The lower borders of the lungs are displaced no, yes, up, down, right, left.____________________________
Auscultatory breathing: vesicular, puerile, hard, bronchial, laryngotracheal,
saccaded, amphoric, attenuated, Kussmaul, Biot, Cheyne-Stokes, Grokk Nad
all lungs, right, left, upper, middle, lower sections ____________________________ Wheezing:
no, yes; dry (high, low, medium tone), wet (finely, medium, coarsely blistered, crepitus),
over all the lungs, on the right, on the left, upper, middle, lower sections.
Pleural friction noise: no, yes, on both sides, right, left ___________________________________
Shortness of breath: no, yes, inspiratory, expiratory, mixed. NPV_______ per minute.
Cardiovascular s-ma.
On examination: Jugular veins swollen yes, no. S-m * dancing carotid * neg, half. S-m Musset neg, floor.
The apex beat is determined no, yes in ______ m / r. There is no cardiac impulse, yes, spilled.
Epigastric pulsation no, yes
Palpation: S-m * Cat's purr * negative, floor, above the aorta, at the apex, ___________________
Percussion: The borders of the heart are normal, shifted to the right, top, left ___________________________
Auscultatory: Tones are clear, muffled, weakened, sonorous due to an artificial valve,
features of tones _________________________________________________________________________
Heart murmurs - functional, organic. Features: ______________________________
_
____________________________________________________________________________________
Rhythm sin-yes, no. Tachycardia, bradycardia, tachyarrhythmia, bradyarrhythmia. Heart rate _____ per minute.
Pulse filling and tension: small, weak, full, intense, satisfactory, empty, thread-
visible, missing. Frequency Ps____ in min. Pulse deficit: no, yes ____________ per minute
BP____________________________________mm.Hg. CVP______ cm H2O.
Organs of the gastrointestinal tract.
Tongue: moist, dryish, dry. Clean, lined with ______________________ plaque ________________
Swallowing impaired no, yes ______________________________________________________________
We pass the esophagus: yes, it is difficult, no _________________________________________________
Abdomen: correct form yes, no ____________________________________________________________

Hernial protrusions: no, yes __________________________________________________________
_____________________________________________________________________________________
Size: sunken, normal, increased due to obesity, ascites, pneumatosis to-ka, tumors, obstruction.
Palpation: soft, muscular defense, tense. Painful no, yes in _____________________
_____________________________________________________________________________________
_________________________________________________________________________________ region
S-m Kocher floor, neg. St. Resurrection gender, neg. S-m Rovsing floor, neg. S-m Sitkovsky floor, neg.
S-m Krymov floor, neg. S-m Volkovich 1-2 sex, neg. S-m Ortner gender, neg. S-m Zakharyin sex, neg.
S-m Mussi-Georgievsky floor, neg. S-m Kerte floor, neg. S-m Mayo-Robson sex, neg.
Fluctuation of free fluid in the cavity: no, yes ______________________________________
Auscultatory: intestinal peristalsis: active, sluggish, absent. Liver: enlarged no, yes
____ cm below the costal arch, wrinkled, reduced, painful yes, no
Consistency: pl-elast, soft, hard. Edge: sharp, rounded. Sensitive: no, yes ___________
Gallbladder: palpable - no, yes ___________________________________, painful: no, yes.
Spleen: palpable no, yes. Increased: no, yes, dense, soft. Percussion length ______ cm.
Stool: regular, constipation, frequent. Consistency: watery, mucoid, liquid, mushy,
well-formed, firm. Color: regular,yellow,green,aholic,black.
Impurities: no, mucus, pus, blood. Smell: normal, offensive. Helminths no, yes ___________________
Urinary system.
The area of ​​the kidneys is visually changed: no, yes, on the right, on the left ____________________________________
_____________________________________________________________________________________
S-m Pasternatsky neg, floor, right, left. Palpable: no, yes, right, left ___________________
Diuresis: preserved, regular, reduced, frequent, in small portions, ischuria (acute, hron, parodoxal,
complete, incomplete), nocturia, oliguria _______ ml / day, anuria ______ ml / day.
Soreness: no, yes, at the beginning, at the end, during the entire urination.
Discharge from the urethra: no, mucous, purulent, sanious, bloody, etc. ___________________
Sexual system.
The external genital organs are developed according to male, female, mixed type. Correct: yes, no ___________
_____________________________________________________________________________________
Husband: visually enlarged scrotum no, yes, left, right. There are no varicose veins, yes, on the left ____ degrees.
Painful on palpation no, yes, on the right, on the left. There is no hernia, yes, on the right, on the left. Character__
_____________________________________________________________________________________
_____________________________________________________________________________________
Female: Vaginal discharge scanty, moderate, copious. Character: slimy, cheesy,
bloody, blood. Color: transparent, yellow, greenish. Fetid no, yes _________________
Visible damage: no, yes, character __________________________________________________
STATUS NERVOSUS.
The face is symmetrical: yes, no. Smoothness of the nasolabial triangle: left, right.
Eye fissures D S. Eyeballs: centered, converged, diverged, sync left, sync right.
Pupils D S. Photoreaction: lively, sluggish, absent. Pupil diameter: OD constricted, medium, dilated.
OS narrowed, medium, extended. Movements of the main apples: saved, limited ______________________
_____________________________________________________________________________________

Nystagmus no, yes: horizontal, vertical, rotation; large-, medium-, small-sweeping; constant,
in marginal leads. Paresis: no, yes. Hemiparesis: left, right. Paraparesis: lower, upper.
Tetraparesis. Tongue deviation: no right, left. Swallowing impaired: no, yes ____________________
_____________________________________________________________________________________
Palpation of the nerve trunks and exit points is painful: no, yes_________________________________
_____________________________________________________________________________________
Muscle tone D S. Hypo-, a-, normo-, tone (left, right). Tendon reflexes: brisk on the right,
reduced, absent, on the left animated, reduced, absent. ______________________
Meningeal signs: Stiffness of the occipital muscles on _____ fingers. S-m Kernig negative, floor ___________
C-m Brudzinsky neg., floor. Root marks: S-m Lasegue negative, gender _______Additional data:
STATUS LOCALIS:___________________________________________________________________________
_______________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

PRELIMINARY DIAGNOSIS:
________________________________________________________________________________________

__________________________________________________________________________________

SURVEY PLAN:
1 UAC (deployed), OAM. 5 ultrasounds.
2 BHC, COAGULOGRAM, Blood Gr. and Rh. 6 ECG.
3 M/R,RW. 7 FL.ORG.GR.CELLS.
4 Feces for I/g, scatology, tank culture of feces. 8 FGDS

9 R-graphy in two projections ____________________________________________________________
10 Doctor's consultation-________________________________________________________________

MANAGEMENT PLAN:

MODE____ DESK #____
1
2
3
4
5

Ibraimov N.Zh.
Anesthesiologist-resuscitator
Zhambyl Central District Hospital.

Another version of the template (form) examination by a therapist:

Therapist's examination ​

Date of inspection: ______________________
FULL NAME. patient:_______________________________________________________________
Date of Birth:____________________________
Complaints for pain behind the sternum, in the region of the heart, shortness of breath, palpitations, interruptions in the work of the heart, swelling lower extremities, face, headache, dizziness, noise in the head, in the ears ___________________________________________________________________

_
_______________________________________________________________________________

Medical history:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________

Information about diseases, injuries, operations (HIV, hepatitis, syphilis, tuberculosis, epilepsy, diabetes, etc.): __________________________________________________________________

Allergic history: not weighed down, weighed down ________________________________
_______________________________________________________________________________

General condition is satisfactory, relatively satisfactory, medium degree gravity, heavy. Body position active, passive, forced
Build: asthenic, normosthenic, hypersthenic _____________________
Height __________ cm, weight __________ kg, BMI ____________ (weight, kg / height, m²)
Body temperature: _______°C

Skin : color is pale, pale pink, marble, icteric, redness,
hyperemia, cyanosis, acrocyanosis, bronze, earthy, pigmentation _____________________
_______________________________________________________________________________
The skin is wet, dry _____________________________________________________________
Rash, scars, striae, scratches, abrasions, spider veins, hemorrhages, puffiness _________________________________________________________________________________

Mucous oral cavity : pink, hyperemia ____________________________________

Conjunctiva: pale pink, hyperemic, icteric, white-porcelain, edematous,
the surface is smooth, loosened ___________________________________________________

Subcutaneous adipose tissue expressed excessively, poorly, moderately.

subcutaneous lymph nodes: not palpable, not enlarged, enlarged __________
_______________________________________________________________________________

The cardiovascular system. The tones are clear, loud, muffled, deaf, rhythmic, arrhythmic, extrasystole. Noises: none, systolic (functional, organic), localized at the apex, in Botkin's t., above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Blood pressure ________ and ________ mmHg Heart rate _______ in 1 minute.

Respiratory system. Shortness of breath is absent, inspiratory, expiratory, occurs when _____________________________________________________________. Frequency respiratory movements: _______ in 1 minute. Percussion sound clear pulmonary, dull, shortened, tympanic, boxed, metallic _____________________
____________________________. The boundaries of the lungs: unilateral, bilateral descent, upward displacement of the lower boundaries ______________________________ In the lungs during auscultation, breathing is vesicular, hard, weakened on the left, right, in the upper, lower sections, along the anterior, posterior, lateral surface ____________________________. There are no rales, single, multiple, small-medium-large bubbling, dry, moist, whistling, crepitating, congestive on the left, on the right, on the anterior, posterior, lateral surface, in the upper, middle, lower sections _____________________
_________________________________. Sputum_____________________________________.

Digestive system. Smell from the mouth ____________________________________. Tongue wet, dry, clean, coated __________________________________________
The abdomen ____ is enlarged due to p / fatty tissue, edema, hernial protrusions ___________________________________________________________, palpation is soft, painless, painful _________________________________________________________
There is a symptom of peritoneal irritation, no ___________________________________________
The liver along the edge of the costal arch, enlarged ___________________________________________,
____ painful, dense, soft, surface smooth, bumpy _____________________
_______________________________________________________________________________
The spleen ____ is enlarged ______________________________________, ____ painful. Peristalsis ____ is disturbed _________________________________________________.
Defecation ______ times a day/week, painless, painful, stool formed, liquid, brown, free of mucus and blood ____________________________
____________________________________________________________________________

urinary system. The symptom of tapping on the lower back: negative, positive on the left, on the right, on both sides. Urination 4-6 times a day, painless, painful, frequent, rare, nocturia, oliguria, anuria, light straw-colored urine _______________________________________________________________
_______________________________________________________________________________
Diagnosis:_______________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

The diagnosis was established on the basis of information obtained during the questioning of the patient, data on the anamnesis of life and disease, the results of a physical examination, the results of instrumental and laboratory studies.

Survey plan(specialist consultations, ECG, ultrasound, FG, OAM, OAC, blood glucose, biochemical analysis blood): ______________________________________________
_______________________________________________________________________________

Treatment plan:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature _______________________ Full name

See the attachment to the message for the full version of the document.

ENT status (normal)

I. Face, nose and paranasal sinuses.

External examination and palpation . The face is symmetrical, the external nose is not deformed, the projection area of ​​the paranasal sinuses on the face is not visually changed, painless on palpation.

Breath through both halves of the nose is not difficult.

Smell . Distinguishes smells.

Anterior rhinoscopy . The vestibule of the nose is free, the nasal valves are of the correct configuration, the mucous membrane is pale pink, moderately moist. The septum is in the midline, the turbinates are not enlarged, the nasal passages are free, there is no discharge.

Posterior rhinoscopy (epipharyngoscopy). The vault of the nasopharynx and choanae are free. The pharyngeal tonsil is not enlarged (absent in adults). The posterior ends of the turbinates are not changed, the mouths of the auditory tubes are free. The mucous membrane is pale pink, moist, no discharge.

Finger examination The pharyngeal tonsil is not enlarged, there are no volumetric formations.

II. Throat (oropharynx). Mesopharyngoscopy.

a. Oral cavity.

The mucous membrane of the lips is pink. The mouth opens well. Swallowing is normal. The mucous membranes of the gums, cheeks are pale pink, clean. Teeth are sanitized. The tongue is clean, freely mobile. The bottom of the oral cavity is not changed. Hard palate of normal configuration. There is no smell from the mouth.

b. Throat area.

Zev wide, symmetrical. The soft palate is mobile, the uvula is not hypertrophied. Palatine arches of the correct configuration. Triangular folds are not expressed. The palatine tonsils are within the arches, their surface is smooth, the orifices of the lacunae are not dilated, there is no pathological secret in them.

in. Oropharynx.

The mucous membrane of the posterior wall is pink, moderately moist, single lymphoid follicles are not enlarged. The lateral ridges on both sides are not hypertrophied.

Regional lymph nodes at the corners mandible visually and palpation are not determined.

III Neck, hypopharynx, larynx.

a. The contours of the neck are not visually changed, movements in all directions are not limited. The lymph nodes not palpable. Palpation along the vascular bundles of the neck is painless, thyroid not increased.

b. Throat, larynx.

External inspection. The skeleton of the larynx is not expanded, the symptom of "crunch" is positive.

Palpation painless.

Indirect laryngoscopy ( hypopharyngoscopy).

hypopharynx.

The lingual tonsil is not enlarged, the vallecules and pyriform sinuses are free. The mucous membrane is pink, moist.

Larynx.

The epiglottis is in the form of a petal, mobile. The arytenoid cartilages and aryepiglottic folds are of the usual form, the interarytenoid space is free. The vestibule folds are not changed, their surface is smooth, pink. The vocal folds are gray in color, the surface is smooth, the edges are even, mobile during phonation and completely close. The glottis during breathing is triangular in shape, free. The lining section is free. Breathing is not difficult, the voice is sonorous.

IV Ears (AD and AS).

External examination and palpation. auricles normal form. The skin is not changed. Palpation of the parotid region and tragus is painless.

Otoscopy. The external auditory meatus is free. Sulfur in a small amount, parietal. There is no pathological discharge. Regular color skin. The tympanic membrane is grey-pink. Identification points (short process of the malleus, handle, light cone, anterior and posterior transitional folds) are pronounced.

Hearing AD and AS - 6 meters SR.

A functional study of the vestibular analyzer is performed when the patient complains of dizziness and imbalance.