Template for writing a case history for ENT diseases. Registration of medical documentation by an ENT doctor

MedElement offers comprehensive management solutions medical practice: from patient registration to financial accounting.

The automation system "Electronic Clinic MedElement" is based on the use of cloud technologies. The cloud system works over the Internet, and connecting a clinic to the system is not much more complicated than creating an email box. The system does not require any software other than a web browser.

Otorhinolaryngologist electronic cabinet

For the convenience of work, electronic offices of doctors of various specialties have been created in the MedElement system.

Key features of the otorhinolaryngologist's electronic office:

• Appointment scheduling - electronic appointment calendar.
• Reduction of "paper" work - electronic medical records patients.
• Entering reception data in a few mouse clicks - convenient data entry templates.
• Specialized templates for an objective examination by an otorhinolaryngologist (nose, sinuses, nasopharynx, rhinoscopy, oral cavity, tonsils, larynx, pharynx, laryngoscopy, auricles, nerves).
• Create your own text templates for examination, diagnoses, referrals, appointments, recommendations.
• Interpretation of laboratory results.
• Results archive instrumental research (attaching pictures and files to the medical history).
• Printing out information on reception in the form of standard forms.

What our clients say

Director of ENT centers "Sezim"Elza Alikhanovna Makhambetova:
The system makes the workload of each doctor transparent

"First of all, I would like to note the orderliness of the registrar's work. The system for registering a patient for a month in advance for each doctor is maintained individually. Electronic archiving of patient visits is carried out. There is a good opportunity to use electronic mailings.
The resulting database saves the work of the registrar and the doctor for entering data and preparing statements for the patient. The problem of paper routine has been solved.

Doctors have access to control the entire process of patient movement in the clinic, including making payments and taking tests.

Filing a sweep of reports on all desired indicators is very convenient for drawing up the results of the day or month. The system makes the workload of each doctor transparent, helps to track the cycle of patients passing through, the level of decline or rise in visits to our clinic.

Surname I.O. __________________________________________________ I / B No. _______________ B / Sheet __________________ Date of birth: _______ ___________ ______________ age _______________________________ Place of work, position _______________________________________________________________ Place of residence ______________________________________________________________________ Date of admission to the hospital _____________________________________________________________ Diagnosis upon admission: _______________________________________________________________ ________________________________________________________________________________________________

Complaints:

- upon enrolment:

- at the time of supervision:

Life story ( anamnesis vitae ) : - previous diseases: ______________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ - chronic diseases: ________________________________________________________________ _________________________________________________________________________________________

- bn Botkin (), venereal. diseases (),tbcs () - blood transfusion: _________________________________________________________________________ - injuries, operations: _______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ - hereditary history: _________________________________________________________________ - allergological history: ______________________________________________________________ _________________________________________________________________________________________

Bad habits: ______________________________________________________________________ - gynecological history: _______________________________________________________________ Disease history ( anamnesis morbi ) : - onset of the disease: considers himself ill with ___________________________________________________ when symptoms appeared _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - visit to the doctor (date, place): __________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ - treatment performed, incl. and independent (date, place, its effectiveness): _______________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General state:

General state:__________________________________________________________________________

Body type:____________________________________________________________________________

Height Weight:______________________

Power status -________________________________________________________________________

Skin, visible mucous membranes --________________________________________________

Subcutaneous adipose tissue -______________________________________________________________

Peripheral edema -_____________________________________________________________________

The lymph nodes-______________________________________________________________________

Muscular system -________________________________________________________________________

Osteoarticular system -__________________________________________________________________

ENT status:

- Nose (external examination, palpation of the external nose and the area of \u200b\u200bthe paranasal sinuses): _________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Rhinoscopy (the vestibule of the nose, the septum, the color of the mucous membrane, the state of the nasal passages, nasal concha, the nature of the discharge and its localization): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Pharynx. Oral cavity;condition of the mucous membrane, teeth. Mouth pharynx (pharyngoscopy): soft palate, palatine arches, palatine tonsils - size, color, consistency, triangular fold, lacunae and their contents when pressed on the area of \u200b\u200bthe anterior arches, plaques: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________ Nasal part of the pharynx (posterior rhinoscopy): fornix of the nasal part of the pharynx, state of the choanas, pharyngeal tonsil, orifices of the auditory tubes: _____________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Laryngeal part of the pharynx (hypopharyngoscopy); condition of the lingual tonsil, vallecules, epiglottis, piriform sinuses _____________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Larynx - voice, breathing: external examination, the condition of the cartilages of the larynx, their displacement, the symptom of crepitus: ____________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Indirect laryngoscopy - the condition of the arytenoid cartilage and intercaryngeal space, scooped-epiglottis folds, vestibular and vocal folds, color, symmetry of movements, degree of mobility, width of the glottis, closure during phonation. Sublining space, visible trachea: __________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Ears (right and left separately); the condition of the auricle, the area of \u200b\u200bthe mastoid process. Width of the external auditory canal, eardrum - identification points, color. Detachable is character. Membrane perforation - location, size. Polyps, granulations, patency of the auditory tubes: __________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Auditory passport

Conclusion on the state of the sound analyzer:

Vestibulometry:

The nature of dizziness.

Spontaneous nystagmus (+) (-), its characteristics.

Spontaneous hand deviation.

Finger test.

Finger-finger test.

Stability in the Romberg position.

Test for adiadochokinesis.

Straight gait.

Flank gait.

Fistula test. Conclusion on the state of vestibular function:

ENT organs condition:

Diagnosis:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Plan of examination and treatment: _________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Therapist:_____________________________/___________________________/

Working as a doctor in a district hospital very often does not have enough time for a more complete initial examination doctor and his documentation. Therefore, I tried to create a template, using which, it is almost impossible to miss one or another body system, plus it takes less time to fill.

Initial examination by a doctor ________________________

COMPLAINTS: __________________________________________________________________________

____________________________________________________________________________________
ANAMNESIS MORBI.

Ill got sick acutely, gradually. Onset of the disease with _______________________________________

For medical help (not) applied to the PIU, VA ____________ to the doctor _________________. Outpatient treatment: no, yes: ______________________________________________________________________
Treatment effect: yes, no, moderate. Appeal to the SMP: no, yes ___ time (s). Delivered in ave.
emergency indications (yes, no) from the scene of an accident, street, house, work, public place through ____
min, hour, day SMP done: ______________________________________________________________
Hospitalized in the _________________________ department of the Central District Hospital.

ANAMNESIS VITAE.
TCD / CHILD: from ___ ber, ___ childbirth (natural, opera). Pregnancy: b / patol., Complicated by _______________________________________________________________ in the period of ________ weeks.
Was born full-term (oh) (yes, no), at ____ weeks, weighing ______ g,
height ____ cm. Breastfeeding (yes, no, mixed) until ___ year (s). Vaccinations on time, honey
Recusation due to _________________________Pediatrician examination is regular (yes, no). General development corresponds to age (yes, no), gender (yes, no), male / female development.
Consists of "D" (yes, no) doctor ____________________ with DZ: ___________________________________
Regularity of treatment (yes, no, amb, station) Last hospital .____________ where __________________
Transferred zab: TBS no, yes ______ g. Vir. Hepatitis no, yes _______ brucellosis no, yes __________ g
Operations: no, yes ___________________________ complications _________________________________
Blood transfusion: no, yes _________ g, complications __________________________________________
Allergic anamnesis: calm, burdened with _____________________________________________________
Living conditions: (not) satisfactory Food (not) sufficient.
Heredity (not) burdened by _______________________________________________________
Epidemiological history: contact with an info patient with symptoms: _____________________________ (yes, no),
where when____________________________________________
Bad habits: smoking no, yes ____ years, no alcohol, yes ____ years, no drugs, yes _____ years.

STATUS PRAESENS OBJECTIVUS
General condition (moderate, severe, extremely severe, terminal) severity, (un) stable
due to ___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Consciousness (clear, inhibited, somnolent, stuporous, soporous, coma ___ st)
Glasgow _____ points Behavior: (dis) oriented, agitated, calm.
for examination: calm, negative, whining. Patient position: active, passive, forced
____________________________________________________________________________________
Constitution: asthenic, normosthenic, hypersthenic. Proportional yes, no __________
______________________________ Symmetrical yes, no ___________________________________
Skin: clean, rashes ______________________________________________________________
Normal color, pale, (sub) icteric, earthy, hyperemic ________________________
Cyanosis: no, yes, diffuse, local ___________________________________________________
Humidity: dry, normal, high, hyperhidrosis Visible mucous membranes: pale, pink, hyperemic _____________________________________________________________________ Humidity: dry, low, normal, high. Features ____________________________
Fatty tissue: weak, moderate, excessively expressed, (not) uniform ___________________
Peripheral libraries: no, yes, generalized, local ______________________________________
Peripheral l / nodes increased: no, yes _________________________________________ T _________ * C_
Muscles: hypo, normo, hyper tone. Developed: weak, moderate, pronounced. Height _____ cm, weight _____ kg.
Convulsions: no, yes. Tonic, clonic, mixed ._____________________________________
Respiratory organs: breathing through the mouth and nose is free yes, no __________________________________
Gr. Cage: symmetrical yes, no ________________ deformation no, 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 additional muscle groups in the act of breathing: no, yes _____________________________________
Palpation: pain: no, yes on the right along the ___________________ line, at ur _____________ ribs,
on the left along the _________________________________ line, at ur __________________ ribs.
Voice jitter is conducted 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, pueril, hard, bronchial, laryngotracheal,
saccadic, amphoric, weakened, like Kussmaul, Biot, Cheyne-Stokes, Grokk Nad
all lungs, right, left, upper, middle, lower parts ________________________ Wheezing:
no, yes; dry (high, low, medium tone), wet (fine, medium, coarsely bubbly, crepitus),
over all the lungs, right, 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 system.
On examination: Jugular veins swollen yes, no. C-m * dances carotid * neg, pol. C-m Musset neg, pol.
The apical impulse is determined no, yes in ______ m / r. Heart impulse no, yes, spilled.
Epigastric pulsation no, yes ________________________________________________________
Palpation: S-m * Feline purring * neg, gender, above the aorta, at the apex, ___________________
Percussion: The boundaries 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, tense, satisfactory properties, empty, thread
evidently absent. Ps frequency ____ per minute. Pulse deficit: no, yes ____________ per minute
HELL ____________________________________ mm Hg. CVP ___________________ cm H2O.
Gastrointestinal organs.
Tongue: moist, dryish, dry. Clean, coated with ______________________ bloom ________________
Swallowing impaired no, yes ______________________________________________________________
We pass the esophagus: yes, difficult, no ___________________________________________________
Belly: regular shape yes, no ________________________________________________________

Hernial protrusions: no, yes __________________________________________________________
_____________________________________________________________________________________
Size: sunken, normal, increased due to obesity, ascites, pneumatosis to-ka, tumor, obstruction.
On palpation: soft, muscular defense, tense. Painful no, yes in _____________________
_____________________________________________________________________________________
_________________________________________________________________________________ region
S. Kocher Paul, neg. St. Voskresensky floor, neg. S. Rovzinga floor, neg. S-m Sitkovsky floor, neg.
S. Krymova floor, neg. S. Volkovich 1-2 sex, neg. S. Ortner floor, neg. S. Zakharyin floor, neg.
St. Mussi-Georgievsky floor, neg. S-m Kerte floor, neg. St. Mayo-Robson floor, neg.
Fluctuation of free liquid 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, firm. Edge: sharp, rounded. Sensitive: no, yes ___________
Gall bladder: palpable - no, yes ___________________________________, painful: no, yes.
Spleen: palpable no, yes. Increased: no, yes, dense, soft. Percussion length ______ cm.
Stool: regular, constipated, frequent Consistency: watery, mucous, liquid, mushy,
normally shaped, firm. Color: regular, yellow, green, acholic, black.
Impurities: no, mucus, pus, blood. Smell: normal, offensive. No helminths, yes ___________________
Urinary system.
The renal area is visually changed: no, yes, right, left ____________________________________
_____________________________________________________________________________________
S. Pasternatsky neg, floor, right, left. Palpable: no, yes, right, left ___________________
Diuresis: preserved, regular, decreased, frequent, in small portions, ishuria (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: none, mucous membranes, purulent, bloody, etc.___________________
The reproductive system.
The external genital organs are developed according to husband, wife, mixed type. Correct: yes, no ___________
_____________________________________________________________________________________
Husband: visually the scrotum is enlarged no, yes, left, right. There are no varicose veins, yes, on the left ____ degree.
Painful palpation no, yes, right, left. Hernia, no protrusion, yes, right, left. Character__
_____________________________________________________________________________________
_____________________________________________________________________________________
Female: Vaginal discharge scanty, moderate, abundant. Character: slimy, cheesy,
bloody, blood. Color: transparent, yellow, greenish. Fetid no, yes _________________
Visible damage: no, yes, nature __________________________________________________
STATUS NERVOSUS.
The face is symmetrical: yes, no. Smoothness of the nasolabial triangle: left, right.
Eye slits D S. Main apples: centered, converged, diverged, sync. Left, sync. Right.
Pupils D S. Photoreaction: lively, sluggish, absent. Pupil diameter: OD narrowed, medium, dilated.
OS narrowed, medium, extended. Movement of the main apples: preserved, limited ______________________
_____________________________________________________________________________________

Nystagmus no, yes: horizontal, vertical, rotation; large-, medium-, small-sweeping; constant,
in the marginal assignments. Paresis: no, yes. Hemiparesis: left, right. Paraparesis: lower, upper.
Tetraparesis. Language deviation: no right, left. Swallowing impaired: no, yes ____________________
_____________________________________________________________________________________
Palpation of nerves, trunks and exit points is painful: no, yes _________________________________
_____________________________________________________________________________________
Muscle tone D S. Hypo-, a-, normo-, tonic (left, right). Tendon reflexes: on the right are revived,
reduced, absent, on the left, revived, reduced, absent .______________________
Meningeal signs: Rigidity of the occipital muscles on the _____ finger. S. Kernig, neg. ___________
S-m Brudzinsky det, floor. Root marks: S-m Lasega neg, pol ._______ Additional data:
STATUS LOCALIS: _______________________________________________________________________
_______________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

PRELIMINARY DIAGNOSIS:
________________________________________________________________________________________

__________________________________________________________________________________

SURVEY PLAN:
1 UAC (deployed), OAM. 5 ultrasound.
2 BHK, COAGULOGRAM, Blood Gr. And Rh. 6 ECG.
3 M / R, RW. 7 FL.ORG.G. CELL.
4 Feces per i / g, scatology, bacterial seeding of feces. 8 FGDS

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

MAINTENANCE PLAN:

MODE ____ TABLE No. ____
1
2
3
4
5

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

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

Examination by a therapist ​

Inspection date: ______________________
FULL NAME. patient:_______________________________________________________________
Date of Birth:____________________________
Complaints pain behind the breastbone, in the region of the heart, shortness of breath, palpitations, interruptions in the work of the heart, edema lower limbs, persons, 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 severity, heavy. Body position active, passive, forced
Body type: asthenic, normosthenic, hypersthenic _____________________
Height __________ cm., Weight __________ kg., BMI ____________ (weight, kg / height, m²)
Body temperature: ________ ° С

Skin: color pale, pale pink, marble, icteric, redness,
hyperemia, cyanosis, acrocyanosis, bronze, earthy, pigmentation _____________________
_______________________________________________________________________________
Skin moist, dry _____________________________________________________________
Rash, scars, stretch marks, scratches, abrasions, spider veins, hemorrhages, swelling _______________________________________________________________________________

Mucous oral cavity : pink, hyperemia ____________________________________

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

Subcutaneous adipose tissue expressed excessively, poorly, moderately.

Subcutaneous the lymph nodes : not palpable, not enlarged, enlarged __________
_______________________________________________________________________________

The cardiovascular system... The tones are clear, loud, muffled, muffled, rhythmic, arrhythmic, extrasystole. Murmurs: no, systolic (functional, organic), localized at the apex, including Botkin, above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Blood pressure ________ and ________ mm Hg. 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, boxy, metallic ___________________________
____________________________. Borders of the lungs: unilateral, bilateral descent, upward displacement of the lower borders ______________________________ In the lungs during auscultation, breathing is vesicular, hard, weakened on the left, right, in the upper, lower parts, along the front, back, lateral surfaces ____________________________. Wheezing is absent, single, multiple, fine- medium- large-bubble, dry, wet, wheezing, crepitant, stagnant on the left, right, on the front, back, lateral surface, in the upper, middle, lower parts _____________________
_________________________________. Sputum_____________________________________.

Digestive system... Smell from the mouth ____________________________________. Tongue moist, dry, clean, coated with a coating __________________________________________
Abdomen ____ is enlarged due to p / fatty tissue, edema, hernial protrusions ___________________________________________________________, on palpation it is soft, painless, painful _____________________________________________________
There is a symptom of peritoneal irritation, no ___________________________________________
Liver along the edge of the costal arch, enlarged ___________________________________________,
____ painful, dense, soft, smooth, bumpy surface _____________________
_______________________________________________________________________________
The spleen ____ is enlarged ______________________________________, ____ is painful. Peristalsis ____ is disturbed _________________________________________________.
Defecation ______ once a day / week, painless, painful, formalized, liquid, brown stool, without mucus and blood ____________________________
____________________________________________________________________________

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

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

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

Treatment plan:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature _______________________ Full name

See the full version of the document in the attachment to the message

1. Nose and paranasal sinuses: during external examination, the shape of the nose is not changed (there is no deviation of the nasal dorsum from the midline, its retraction is not noted), palpation of the external nose is painless, palpation of the area of \u200b\u200bthe paranasal sinuses, the exit point of the V pair of cranial nerves, the patient notes soreness; nasal breathing difficult through both halves, more on the right, weakened sense of smell.

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

2. Pharynx. Oral cavity: the mucous membrane of the oral cavity is pink, the tongue is not coated, no teeth marks, the condition of the teeth is satisfactory. Oral part of the pharynx (pharyngoscopy): amygdala 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 was without pathological changes. The cervical lymph nodes were not enlarged, slightly palpable. The nasal part of the pharynx (posterior rhinoscopy): the nasopharynx is free, the hypertrophied posterior ends of the inferior turbinates are visible. The vault of the nasal part of the pharynx without pathological changes, the choanas are free, the pharyngeal tonsil is not enlarged, the mouth auditory tubes not changed, tubal tonsils are not enlarged. Laryngeal part of the pharynx (hypopharyngoscopy): the lingual tonsil is not enlarged, vallecules are without pathological changes, the pear-shaped sinuses are free.

3. Larynx - Resonant voice, breathing calm, rhythmic, not disturbed; upon external examination, the state of the cartilage of the larynx without pathological changes, displaceable, the symptom of crepitus is positive. Indirect laryngoscopy - the outer ring of the larynx is not changed. The epiglottis is expanded in the form of a leaf covering the anterior sections of the vocal folds. Vocal folds white, in the posterior third, full mobility.

Right ear: auricle outwardly without pathological changes, regular shape, painless on palpation and pressure on the tragus. Percussion of the mastoid area is painless. The external auditory canal is of normal width, there is a slight exostosis on the anterior-inferior wall of the external auditory canal. Eardrum - with all identification points, gray. Pathological discharge, membrane perforations were not revealed.

Left ear: auricle externally without pathological changes, regular shape, painless on palpation. Percussion of the mastoid area is painless. The external auditory canal is of normal width. The tympanic membrane - with all identifying points, gray. Without pathological discharge, no perforation of the membrane was found.