otorhinolaryngolocial medical record

The Otorhinolaryngological Medical Recordincludes:

Present Disease

EARS

  • Otoscopy
  • Rinne Tinters, Weber
  • Auditory chart
  • Voice, tonal audiometry
  • Tympanometry
  • Sound reflexes
  • Challenged dynamics

    • Nystagmus

  • electron micrograph

    • Cranial Nerves

  • Control of personal nerve
  • Other brain conjugations

    • NOSE

  • rhinoscopy

    • ORAL CAVITY - PHARYNX

    LARYNX

    Neck

  • Thyroid
  • Cervical lymph nodes

    • Family - Hereditary History

  • Mother-Father-children etc

    • Previous Health Status

  • Childhood diseases - Venereal diseases
  • Imports to hospital - operations
  • Injuries-bruises
  • Gynecological history-Period (beginning-end-duration)
  • Birth - abortions etc
  • Drug Use
  • Allergies

    • Personal and Social History

  • Place of birth - accomodation
  • Religion - Education -Employment
  • Family life-problems
  • Hobbies - pets
  • Nutrition-alcohol
  • smoking-drugs consumption
  • Exposure to harmful environmental factors

    • Ατομικό Αναμνηστικό (κατά συστήματα)

  • γενικά
  • δέρμα
  • κεφαλή-τράχηλος
  • μάτια-αυτιά-μύτη-στόμα-φάρυγγας
  • μαστοί
  • αναπνευστικό
  • καρδιαγγειακό
  • πεπτικό
  • αιμοποιητικό-λεμφαδένες
  • ουροποιητικό
  • ερειστικό
  • νευρικό
  • ψυχικές λειτουργίες

    • Objective Examination

  • VITAL POINTS
    • Temperature -heartbeats-breaths
  • OVERALL IMPRESSION
    • Diaphragm-View-Nutrition-Height-Weight-BMI (Body Mass Index) Bedridden/ambulatory/edemas
  • PSYCHODIANOTIVE SITUATION
    • Good/Bad informant Emotional - indolent - confusing - comatose attention - orientation - memory - speech difficulty
  • SKIN
    • Hue- turgidity - hair loss - rashes etc
  • HEAD
    • Eyes - Nose - ears - mouth - pharynx
  • NECKING
    • Movements -thyroid - trachea - lymph nodes - big vessels

    Objective Examination II

  • BODY:
  • UPPER LIMBS:
    • Hands - palms - fingers - nails - muscle strength - joints - vessels
  • LEGS:
    • Edge - soles - fingers - claws - hammers - gastropneumonia - muscle strength - joints - vessels
  • BREASTS:
  • LYMPH NODES:
    • Cervical - supergy - axillary - inguinal - others

    Objective Examination III

  • RESPIRATORY:
    • Overview - attack - palpation - hearing
  • CARDIOVASCULAR:
    • Heart: thrust-tones-blasts-roots Vessels: heartbeats - blastings
  • ABDOMEN:
    • Overview - attack - palpation - hearing Liver - spleen - kidney Finger examination
  • UROPIOGENEAN MUSCULATION:
    • Muscle tone - muscle power joints
  • NERVOUS SYSTEM:
    • Consciousness - Communication - Orientation - Attitude - Buddhism Sensibility - mobility - Brain conjugations - cerebellum
     

    Expression of Interest

     
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