Oto Primary Care FINALhigh

Chapter 2

Evaluating and Keeping

Track of Patients

Taking an Otolaryngology History and Performing

a Head and Neck Exam

The ENT history begins with the

chief complaint

followed by a descrip-

tion of the

location, duration, frequency, and quality

of the presenting

symptoms. In addition, always inquire about the

aggravating and reliev-

ing factors

. Next, ask the patient about

associated symptoms

. The follow-

ing is a short list that can be used:

General/systemic symptoms (fever, chills, cough, heartburn, dizziness,

•

etc);

Otologic (tinnitus, otalgia, otorrhea, aural fullness, hearing loss, ver-

•

tigo);

Facial (swelling, pain, numbness);

•

Nasal (congestion, rhinorrhea, post-nasal drip, epistaxis, decreased

•

smell);

Sinus (pressure, pain);

•

Throat (soreness, odynophagia, dysphagia, globus sensation, throat

•

clearing);

Larynx (vocal changes or weakness, hoarseness, stridor, dyspnea); and

•

Neck symptoms (pain, lymphadenopathy, torticollis, supine dyspnea).

•

The head and neck exam

involves inspection (and palpation if practical)

of all skin and mucosal surfaces of the head and neck. Otolaryngologists

utilize special equipment to better assess the ears, nose, and throat. A bin-

ocular microscope provides an enlarged, three-dimensional image, giving

the physician a superior view of the ear canal and tympanic membrane.

The microscope also permits the bimanual removal of wax and foreign

bodies. Indirect mirror exam with a headlight permits examination of the