Conclusion of the otolaryngologist Example. Pattern of writing the history of the disease in ENT diseases

1. Nose and incomplete sinuses: With an external inspection, the nasal shape is not changed (there is no rejection of the back of the nose from the midline, its ware is not marked), the palpation of the outer nose is painless, when the region's palpation of the incomplete sinuses, the output points of the V pair of brain nerves patient notes soreness; Nasal breathing is difficult through both halves, more on the right, the smell is weakened.

Front Rososcopy: Spearness of the nose is free, the nose partition is deflected to the right, the mucous membrane is pale, edema, in the middle nose during both sides of the polyps, lower turbinate The right is increased in volume, thick mucous membrane separated in the middle nose.

2. Harness. The oral cavity: the oral mucosa is pink, the tongue is not covered, without traces of the teeth, the condition of the teeth is satisfactory. The mouth of the pharynx (pharyngoscopy): almond niches deep, almonds are reduced in size, not hyperemic, without pathological content in the lacunas. Soft heaven, palatal arms without pathological changes. The state of the mucous membrane of the rear wall of the pharynx without pathological changes .. The neck lymph nodes are not increased, slightly palpable. The nasal part of the throat (rear rhinoscopy): the nasopharynx is free, the hypertrophied rear ends of the lower nose shells are visible. The nasal part of the throat without pathological changes, the Hoans are free, the sipstage almond is not increased, the mouth hearing pipes Not changed, pipe almonds are not increased. Gunted part of the pharynx (hypoparianoscopy): the tongue almond is not increased, Vallechalya without pathological changes, pear-shaped sines are free.

3. Large - the voice of the sonorous, the breath is calm, rhythmic, not broken; With external inspection, the condition of the cartilage larynx without pathological changes, shifted, the symptom of attitudes is positive. Indirect laryngoscopy - the outer ring of the larynx is not changed. The nastestrian is deployed in the form of a leaf covering the front departments voice folds. Voice folds white color, in the rear third mobility in full.

Right ear: Own sink externally without pathological changes, the right shape, painlessly during palpation and pressure on the goat. Percussion of the area of \u200b\u200bthe deputyoid process is painless. The outer hearing pass is a normal width, there is a small exostosis at the front-bottom wall of the external auditory passage. Drumpatch - with all identifiable items, gray. Pathological discharge, membranes were not detected.

Left ear: Own sink externally without pathological changes, the correct shape, painless when palpation. Percussion of the area of \u200b\u200bthe deputyoid process is painless. The outer hearing pass is normal width. Drumpatch - with all identifiable items, gray. Without pathological detachable, refill perforations were not detected.

MedElement offers comprehensive management solutions medical practice: from registration of patients to accounting of funds.

The automation system "MedElement Electronic Clinic" is based on the use of cloud technologies. The cloud system works via the Internet, and the clinic connection to the system is a little more complicated than creating an email box. For system operation, no programs are needed other than a web browser.

Electronic Cabinet Otorinolaryngologist

For the convenience of work, in the MedElement system created electronic rooms of doctors of various specialties.

The main features of the electronic cabinet otorhinolaryngologist:

• Manage reception schedules - electronic recording calendar reception.
• Reduction of "paper" work - electronic medical maps patients.
• Making data on the reception in several clicks with mouse - convenient data entry patterns.
• Specialized templates of objective inspection of otorhinolaryngologist (nose, area of \u200b\u200bsinuses, nasopharynk, rhinoscopy, oral cavity, almonds, larynx, throat, laryngoscopy, ear sinks, nerves).
• Creating your text templates of inspection, diagnoses, destinations, appointments, recommendations.
• Interpretation of laboratory research results.
• Archive results tool Research (Attaching pictures and files to the history of the disease).
• Printing information on the reception in the form of standard forms.

What our customers say

Director of the Lor Centers "Satim"Elsa Alikhanovna Mahambetova:
The system makes the transparent load of each doctor

"First of all, I would like to note the ordering of the registrar. The patient's recording system a month ahead for each doctor is conducted individually. Electronic archiving of patient visits is carried out. There is a good use of electronic mailings.
The resulting database, saves the operation of the registrar and the doctor to make data and design discharge for the patient. Solved the problem of paper routine work.

Doctors have access to the control of the entire process of the patient's movement in the clinic, including payment and testing.

The submission of reports for all the desired indicators is very convenient for the results of the work of the day or month. The system makes the transparent load of each doctor, helps track the cyclicality of patients passing, the level of recession or lifting visits to our clinic.

Another version of the template (form) inspection by therapist:

Inspection therapist ​

Date of inspection: ______________________
FULL NAME. Patient:_______________________________________________________________
Date of Birth:____________________________
Complaints for pain behind the sternum, in the field of heart, shortness of breath, rapid heartbeat, interruptions in the work of the heart, swelling lower extremities, persons headache, dizziness, noise in the head, in the ears ___________________________________________________________________

_
_______________________________________________________________________________

Anamnesis of the disease:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________

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

Allergological history: Not burdened, burdened ________________________________
_______________________________________________________________________________

The general condition is satisfactory, relatively satisfactory, middle degree Severity, heavy. Body position active, passive, forced
Build: Asthenic, normostic, hyperstandic _____________________
Growth __________ see, weight __________ kg., BMI ____________ (weight, kg / height, m²)
Body Temperature: ________ ° С

Skin Covers: painting pale, pale pink, marble, yellow, redness,
hyperemia, cyanosis, acricyanosis, bronze, earthy, pigmentation _____________________
_______________________________________________________________________________
Leather wet, dry _________________________________________________________
Rash, scars, strlicies, calculations, abrasions, vascular stars, hemorrhagia, ethomate _______________________________________________________________________________

Mucous oral cavity : Pink, hyperemia ____________________________________

Conjunctiva: Pale pink, hyperemic, jaundice, white-porcelain, extinguished,
The surface is smooth, loosened ___________________________________________________

Subcutaneous-zhirovyykyt pulver expressed excessively, poorly, moderately.

Subcutaneous lymph nodes: not palpable, not increased, increased __________
_______________________________________________________________________________

The cardiovascular system. Thinks are clear, loud, muted, deaf, rhythmic, arrhythmical, extrasystolia. Noise: No, systolic (functional, organic), is localized on the top, in t. Botkin, above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Arterial pressure ________ and ________ mm.rt.st. CSS ________ in 1 minute.

Respiratory system. Dyspnea is absent, inspiratory, expiratory, occurs at _________________________________________________________. Frequency respiratory movements: ________ in 1 minute. Percussion sound Clear light, dull, shortened, tympanic, box, metallic ___________________________
________________________. Light boundaries: one-sided, bilateral omit, shift up lower boundaries ______________________________ In the lungs with auscultation, the breath is vesicular, rigid, weakened on the left, right, in the upper, lower departments, on the front, rear, side surface ____________________________. Warms are absent, single, multiple, fine-medium-rigous, dry, wet, whistling, creative, stagnant, on the left, on the right, on the front, rear, side surface, in the upper, middle, lower departments _____________________
_____________________________. Sputum_____________________________________.

Digestive system. Smell from the mouth ____________________________________. Language is wet, dry, clean, covered with a hollow __________________________________________
The stomach ____ increased by the P / Fat Fiber, Outlines, Herge Speakers _______________________________________________________, with Palpation Soft, painless, painful _____________________________________________________
The symptom of irritation of the peritoneum is, no ___________________________________________
The liver around the edge of the Röbea arc, increased ___________________________________________,
____ painful, dense, soft, surface smooth, buggy _____________________
_______________________________________________________________________________
Searel ____ increased ______________________________________, ____ painful. Peristalistic ____ is violated _________________________________________________.
Defecation ______ times a day / week, painless, painful, calmed, liquid, brown, without impurities of mucus and blood ____________________________
____________________________________________________________________________

urinary system. Symptom of the harness on the lower back: negative, positive left, right, on both sides. Urination 4-6 times a day, painless, painful, rapid, rare, niccountura, oliguria, anouria, urine of light straw color ___________________________________________________________
_______________________________________________________________________________
Diagnosis:_______________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

The diagnosis is made on the basis of the information obtained during the patient's questioning, the history of life and illness, the results of the physical examination, the results of instrumental and laboratory research.

Examination plan(counseling specialists, ECG, Ultrasound, FG, OAM, OAK, blood glucose, biochemical analysis blood): ______________________________________________
_______________________________________________________________________________

Plan of treatment:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature _______________________ Full name

For a complete version of the document, see Appendix to the message.

The examination from the sick body is beginning, in the pathology of the ear begin with a healthy ear, in the absence of complaints, the surveys begin with the nose, then inspect the throat, larynx, ears.

1) Outdoor inspection Persons, necks, ears (ear region) - estimate the color of the skin, the shape of the nose, own sinks, Lained.

2)Palpation The front walls of the incomplete sinuses, mastoid processes, dressing larynx, lymph nodes (trimmed and submandibular, cervical and varnish).

4)Inspection of LOR - organs:

but) front rosicopy: The color of the mucous membrane of the nasal cavity, the volume of the nasal shells, the shape of the nasal partition, the content of the nasal strokes

(an example of a description of the norm: The nose shape is not changed. Nasal breathing Free. The smell is not broken. The tribe of the nose is free. Nasal partition in the midline. Nasal shells are not increased. Nasal moves are free. The mucous membrane of pink color, wet. Selection of moderate, mucous).

b) farmingoscopy: Color, humidity of the mucous membrane of the mouth, rotogling, state of gum, teeth, language, output ducts salivary glands, solid sky, state of sky tonsils: lacun content, availability of adhesions, degree of mobility of soft sky

(an example of a description of the norm: The mucous membrane of the usual color. Teeth are sanitized. Language is clean wet. Solid sky without features. The soft sky is not changed, moving. Sky almonds are not increased (I degree). Lacus free. Studies pink, with almonds are not laughing. The rear wall of the pharynx is not changed).

in) rear Rososcopy. Manufactured by the teacher: The cavity of the nasopharynx, boasts, the rear ends of the nasal sinks, the state of the pharyngeal and pipe almonds, the mouth of the hearing pipes

(an example of a description of the norm Hoan, mouth eustachian pipes And the arch is free. Middle line couch).

d) indirect laryngoscopy conducted by the teacher: color,
Humidity of the mucous membrane of the larynx and the alignment, condition
Peer-shaped pits, tongue almonds, hassle, color, humidity
Premotional and voice folds, voice slot form, condition
Prochess space

(an example of a description of the norm: breathing free. Vote
Saved, not changed. Pear-shaped sines are free. Epiglottis
ordinary form. Cherpealonadcantic folds are contoured. Ducks ne
Modified, moving, interchangeable space freely.
Pre-remote and voice folds are not changed, not limited in mobility. Voice folds during the lantern are closed along the midline. Swim space freely).

e) Otoscopy.: The condition of the skin of the outer auditory passage, its
Width, the color of the eardrum, the presence and localization of perforations, its
Issign melements of the membrane (handle, light reflex, folds,
short process hammer);

(an example of a description of the norm: The skin of the deputyid processes is not changed, palpation and percussion is painless. External hearing aisters are free. The eardrum of pearl color, identification points are well expressed).

Akumetry

Vestibulose:

Nistagm spontaneous

Nistagm Pressory

Nistagm post-free

O.R. (Zd. I, II, III Art.)

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

Surname I.O. __________________________________________________ I / B number _______________ B / Sheet __________________ Date of Birth: _______ ___________ ______________ _______________________________ age Place of work, position _______________________________________________________________ Location ______________________________________________________________________ treatment in hospital Date _____________________________________________________________ diagnosis on admission: _______________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

Complaints:

- on admission:

- At the time of the corporation:

The history of life ( anamnesis. vitae. ) : - Transferred diseases: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Bl. Botkin (), Venus. diseases (),tBCS. () - transfusion: _________________________________________________________________________ - trauma, surgery: _______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ - family history: _________________________________________________________________ - allergic history: ______________________________________________________________ _________________________________________________________________________________________

Harmful habits: ______________________________________________________________________ - Gynecological anamnesis: _______________________________________________________________ History of the disease ( anamnesis. morbi. ) : - the beginning of the disease: feels sick with ___________________________________________________ when symptoms appeared ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - the disease: _________________________________________________________________________ _________________________________________________________________________________________ - cause of the disease: links with their disease _____________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - access to a doctor (date, place): __________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ - spent treatment, including and independent (date, place, its effectiveness): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General state:

General state:__________________________________________________________________________

Body type:____________________________________________________________________________

Height Weight:______________________

Food condition -____________________________________________________________________

Skin cover, visible mucous membranes -________________________________________________

Subcutaneous fatty fiber -__________________________________________________________

Peripheral edema -_________________________________________________________________

The lymph nodes-______________________________________________________________________

Muscular system -________________________________________________________________________

Kostoy-articular system -______________________________________________________________

LOR-STATUS:

- nose (external inspection, palpation of the outer region of the nose and paranasal sinuses): _________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - rinoskopii (nasal vestibule, septum, mucosal color, state of the nasal passages, nasal turbinate, the detachable nature and localization): _______________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Pharynx. Oral cavity;the condition of the mucous membrane, teeth. The mouth of the throat (Pharyngoscope) soft palate palatine arch, palatine tonsil - size, color, consistency, triangular fold gap and their contents under pressure on the area of \u200b\u200bfront arches, raids: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ condition of the mucous membranes of the rear wall of the pharynx: Cervical lymph nodes _____________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________ ___________________________________________________________________________________________ _______________________________________________________________________________________________________ nose part pharynx (pharyngorrhinoscopy): arch bow of the pharynx, the state choanal, pharyngeal tonsils, mouth of the auditory tube: _____________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gunted part of the pharynx (hypoparianingoscopy); The state of the tongue almonds, Vallechaul, the Nastestrian, pear-shaped sinuses _____________________________________________________________________________________________________________________________________________________________________________________________________________________ - Gortan - voice, breathing: external examination, the state of the cartilage of the larynx, their displaceability symptom crepitations: ____________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Indirect laryngoscopy - The state of the sneak-shaped cartilage and intersperpalo-shaped space, silence-haul folds, predvement and voice folds, color, symmetry of movements, the degree of mobility, the width of the voice gap, closing when the lantern. Pierce space, visible driving trachea: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - Ears (right and left separately); The state of the oarse shell, the area of \u200b\u200bthe preceding process. The width of the external auditory passage, eardrum - identifying points, color. Separated - character. Employment of the membrane - place, sizes. Polyps, granulation, auditory tube patency: __________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hearing passport

Conclusion of the state of the audio analyzer:

Vestibulose:

Dizziness character.

Spontaneous Nistagm (+) (-), its characteristic.

Spontaneous deviation of hands.

Palcepan sample.

Finger-finger sample.

Resistance in the pose of Romberg.

Sample on adiadochokines.

Straight gait.

Flange gait.

Fistula test. Conclusion of the status of the vestibular function:

The state of the Elor organs:

Diagnosis:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

examination and treatment plan: _________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Attending doctor:_____________________________/___________________________/