1.0 Approach to the Otolaryngology–Head and Neck Surgery Patient
This book is organized into brief chapters addressing specific clinical entities. To enable readers to focus readily on their information needs, the chapters are arranged in a similar manner:
Key Features
Epidemiology
Clinical
Signs and symptoms
Differential diagnosis
Evaluation, including history, exam, imaging, and other testing
Treatment options, including medical and surgical treatments
Follow-up care
This first chapter is an exception because it deals entirely with the evaluation step. Specifically, we review in detail the approach to an efficient and effective otolaryngology patient history and physical examination, which should be especially useful to those new to the care of such patients.
History
The generally accepted organization of the history and physical examination for a new patient is outlined in Table 1.1 .
Chief complaint History of present illness Past medical history Past surgical history Current medications Medication allergies Social history Family history Review of systems Physical examination Laboratory testing/imaging Impression Plan |
The History of Present Illness is the subjective narrative regarding the current problem. It should include a focused summary of the complaint, including location, time of onset, course, quality, severity, duration, associated problems, and previous testing or treatment.
Physical Exam
The physical examination in otolaryngology is typically a complete head and neck exam. This should include an evaluation of the following:
General
The general appearance of the patient (i.e., well- or ill-appearing, acute distress)
Vital signs (temperature, heart rate, blood pressure, respiratory rate, weight, possibly BMI)
Stridor, abnormal respiratory effort/increased work of breathing
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