Writing Up the Physical Examination

Listed here are examples of the write-up for the examinations of the oral cavity and pharynx.

• The lips appear normal. The mucosa of the oral cavity is red and without masses, leukoplakia, or other lesions. There is good dentition and good dental hygiene. The tongue is midline and does not deviate to either side. The tonsils are absent. The pharynx appears normal. The palate is normal, without ulcers or masses.

• There is a 1- to 2-cm, painful vesicular lesion at the mucocutaneous junction on the right side of the mouth. There is tonsillar hypertrophy with a purulent discharge in the crypts of both tonsils. There is bilateral anterior triangle lym-phadenopathy, greater on the right. The remainder of the examination of the oral cavity is unremarkable.

• There is a whitish pseudomembrane over the hard and soft palates, as well as over the tongue. When it is lifted, its erythematous base is friable and bleeds. The rest of the mouth and throat appears normal.

• The lateral border of the tongue has an ulcerated, indurated lesion, 2 x 1 cm.

• The palate has a dome-shaped 3-cm mass to the right of midline. Biopsy is recommended.

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