Writing Up the Physical Examination

Listed here are examples of the write-up for the examinations of the ear and nose.

• The external ear appears normal without evidence of inflammation or lesions. The patient has no difficulty hearing the whispered word. The Weber test result is midline. Rinne test result: AC > BC. The external canals are normal, as are the tympanic membranes. There is no injection of the external canals or the tympanic membranes. No discharge is present.

• A 1-cm, round, hard, painless mass is present on the right pinna. The patient has no problem with hearing. The Weber test result shows no lateralization. The external canals and tympanic membranes are normal.

• The external structures of the ears are within normal limits. There is a hearing loss in the left ear. The Weber test result lateralizes to the left ear. The left tympanic membrane appears opaque. The ossicles are not seen on the left. The right tympanic membrane appears normal. The ossicles appear normal on the right.

• The nose is not deviated. No swellings are seen. The anterior septum appears pink without discharge or vascular engorgement. The septum is midline. No sinus tenderness is present.

• The nose appears deviated to the right. The nasal mucous membranes are bright red and moist. A whitish-yellow discharge is present on a deviated septum to the right. The sinuses are not tender.

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