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HEENT Head and Face Observe head position o Expected: upright, midline, still o Unexpected: horizontal jerking or bobbing,

nodding, tilted Inspect facial features - Shape: observe eyelids, eyebrows, palpebral fissures, nasolabial folds, mouth at rest, during movement, with expression o Expected: variations according to race, sex, age, body build o Unexpected: change in shape. Unusual features: edema, puffiness, coarsened features, prominent eyes, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations. Tics. - Symmetry: note if asymmetry affects all features of one side or a portion of face o Expected: symmetric o Unexpected: facial nerve paralysis, facial nerve weakness, or problem with peripheral trigeminal nerve - Characteristic facies Inspect skull and scalp - Size/shape/symmetry o Expected: symmetric - Scalp condition o Unexpected: lesions, scabs, tenderness, parasites, nits, scaliness - Systematically part hair from frontal to occipital region o Expected: bitemporal recession or balding over crown in men. - Hair pattern: pay special attention to areas behind ears, at hairline, at crown o Unexpected: random areas on alopecia or alopecia totalis Palpate head and scalp - Symmetry: palpate in gentle, rotary motion from front to back o Expected: symmetric and smooth with bones indistinguishable. Ridge of sagittal fissure occasionally palpable o Unexpected: indentations or depressions Palpate hair - Texture/color distribution o Expected: smooth, symmetrically distributed o Unexpected: splitting or cracked ends. Coarse, dry or brittle. Fine and silky. Palpate temporal arteries - Note course of arteries o Unexpected: thickening, hardness or tenderness Auscultate temporal arteries and over skull and eyes o Expected: no bruits Inspect salivary glands - Symmetry/size: palpate if asymmetry noted. Have pt open mouth and press on salivary duct to attempt to express material o Unexpected: Asymmetry or enlargement. Tenderness. Discrete nodule. Neck Inspect neck

Symmetry: inspect in usual position, in slight hyperextension, and during swallowing. Look for landmarks of anterior and posterior triangles o Expected: bilateral symmetry of SCM and trapezius mm. o Unexpected: asymmetry, torticollis Trachea: inspect in usual position, in slight hyperextension, and while pt swallows

HEENT

o Expected: midline placement o Unexpected: masses, webbing, excessive posterior skin folds, unusually short neck, distention
of jugular vein, prominence of carotid arteries, or edema - Condition of neck Evaluate range of motion -Have pt flex, extend, rotate, laterally turn head and neck o Expected: smooth o Unexpected: pain, dizziness, or limitations of motion Palpate neck - Trachea: place thumb on each side of trachea in lower portion of neck, and compare space between trachea and SCM on each side o Expected: midline position o Unexpected: deviation to right or left - Hyoid bone/thyroid and cricoid cartilages o Expected: smooth, moves during swallowing o Unexpected: tender - Cartilaginous rings of trachea o Expected: distinct o Unexpected: tender - Tracheal tug: with neck extended, palpate or movement with index finger and thumb on each side of trachea below thyroid isthmus o Unexpected: tug synchronous with pulse Palpate lymph nodes - Size/consistency, mobility/condition o Unexpected: enlarged, matted, tender, fixed, warm Palpate thyroid gland - Symmetry: observe from frontal and lateral positions while pt hyperextends neck. Then observe as pt sips water while neck is hyperextended o Unexpected: asymmetry, enlarged and visible thyroid gland - Size/shape/configuration/consistency: stand either facing or behind pt. have pt hold head slightly forward and tipped toward side being examined. Lightly palpate isthmus and lateral lobes. Give water to pt to facilitate swallowing. From the front, examine the left lobe by sitting on the left side of the pt and pressing the trachea to the left with the left thumb. Place the first three finders in the thyroid bed just medial to the SCM. Keep your finders still while the pt again swallows, thereby moving the gland beneath your fingers. Repeat on the right side. If the gland is enlarged, auscultate for vascular sounds with bell of stethoscope. o Expected: lobes (if felt) small and smooth. Gland rises freely with swallowing. Right lobe as much as 25% larger than left. Tissue firm and pliable o Unexpected: enlarged, tender nodules (smooth or irregular, soft or hard); coarse tissue, gritty sensation. Bruit. Visual Testing Measure visual acuity in each eye separately - Distance vision: use Snellen chart, Landolt C or HOTV chart. If testing with and without corrective lenses, test without lenses first and record readings separately. o Expected: vision 20/20 with or without lenses with near and far vision in each eye o Unexpected: myopia, amblyopia or presbyopia - Near vision: use near-vision card - Peripheral vision: test nasal, temporal, superior, inferior fields by moving your finger into field from outside o Expected: vision 20/20

HEENT

o Unexpected: fields of vision more limited than temporally, 50 degrees superiorly, 70 degress
inferiorly External Examination of the Eye Inspect eyebrows - Size/extension o Expected: unusually thin if plucked o Unexpected: end short of temporal canthus - Hair texture o Unexpected: coarse Inspect orbital areas o Unexpected: edema, puffiness not related to aging or sagging tissue below orbit. Xanthelasma. Inspect eyelids - Eyelid position o Unexpected: extropion or entropion - Ability to open wide and close completely: examine with eyes lightly closed, closed tightly, open wide o Expected: superior eyelid covering a portion of iris when open o Unexpected: fasciculations when lightly closed. Ptosis. Lagophthalmos. - Eyelid margin o Unexpected: flakiness, redness, or swelling. Hordeola. - Eyelashes o Expected: present on both lids, turned outward Palpate eyelids o Unexpected: nodules Palpate eye o Expected: can be gently pushed into orbit without discomfort o Unexpected: firm and resists palpation Pull down lower lids and inspect conjunctivae and sclerae - Color: inspect upper tarsal conjunctivae only if presence of foreign body is suspected o Expected: conjunctivae clear and inapparent. Sclerae white and visible above irides only when eyelids are wide open o Unexpected: conjunctivae with eruthema. Sclerae uellow or green. Sclerae with dark, rustcolored pigment anterior to insertion of medial rectus muscle. - Condition o Unexpected: exudate, pterugium, corneal arcus senilis or opacities Inspect lacrimal gland region - Lacrimal gland puncta: palpate lower orbital rim near inner canthus. If temporal aspect of upper lid feels full, evert lid and inspect gland. o Expected: slight elevations with central depressions on both upper and lower lid margins o Unexpected: enlarged glands, dry eyes Test corneal sensitivity- touch wisp of cotton to cornea o Expected: bilateral blink reflex Inspect external eyes - Corneal clarity: shine light tangentially on cornea o Unexpected: blood vessels present - Irides o Expected: clearly visible pattern. Similar color - Papillary size/shape o Expected: round, regular, equal is size o Unexpected: miosis, mydriasis, anisoccoria or coloboma - Papillary response to light

HEENT

o Expected: constricting with consensual response of opposite pupil Papillary accommodation o Expected: constricting when pupils focus on near object or dilating when focus changes from near to distant object Afferent papillary testing o Expected: the pupil toward which the light is moving dilates and then constricts as the light shines onto it o Unexpected: the pupil continues to dilate when the light shines into it

Extraocular Eye Muscles (EOMs) Evaluate muscle balance and movement of eyes - Six cardinal fields of gaze: hold pts chin, and ask pt to watch finger or penlight. o Expected: a few horizontal nystagmic beats. Smooth, full coordinated movement of eyes o Unexpected: sustained or jerking nystagmus. Exposure of sclera from lid lag. Inability of eye to move in all directions. - Corneal light reflex: direct light at nasal bride from 30 cm (12 inches). Have pt look at nearby object. o Expected: light reflected symmetrically from both eyes - Cover-uncover test: perform if imbalance found with corneal light reflex test. Have pt stare ahead at near, fixed object. Cover one eye and observe other; remove cover and observe uncovered eye. Repeat with other eye. o Unexpected: movement of covered or uncovered eye Ophthalmoscopic Examination Inspect internal eye - Lens clarity - Anterior chamber: shine focused light tangentially at limbus. Note illumination of iris nasally. o Unexpected: shallow chamber if observed, avoid mydriatics - Use ophthalmoscope: with pt looking at distant object, direct light at pupil from about 30 cm. move toward pt, observing. - Red reflex o Unexpected: opacities - Fundus o Expected: yellow or pink background, depending on race. Possible crescents or dots of pigment at disc margin, usually temporally o Unexpected: discrete areas of pigmentation away from disc. Lesions. Drusen bodies. Hemorrhages. - Blood vessel characteristics: follow blood vessels distally in each quadrant, noting crossings of arterioles and venules o Expected: possible venous pulsations (should be documented). A/V ratio 3:5 or 2:3. o Unexpected: nicking tortuosity - Disc characteristics o Expected: yellow to creamy pink, varying by race. Sharp, well-defined margin, especially in temporal region; 1.5mm diameter o Unexpected: myelinated nerve fibers, papilledema. Glaucomatous cupping. - Macula densa characteristics: ask pt to look directly at light o Expected: yellow dot surrounded by deep pink Ears Inspect auricles and mastoid areas -Examine lateral and medial surfaces and surrounding tissue - Size/shape/symmetry

HEENT

o Expected: familial variations. Auricles of equal size and similar appearance. Darwin tubercle o Unexpected: unequal size or configuration. Cauliflower ear and other deformities
Lesions

o Unexpected: moles, cysts, or other lesions, nodules or tophi


Color

o Expected: same color as facial skin o Unexpected: blueness, pallor or excessive redness
Position: draw imaginary line between inner canthus and most prominent protuberance of occiput. Draw imaginary line perpendicular to first line and anterior to auricle. o Expected: top of auricle touching or above line. Vertical position. o Unexpected: auricle positioned below line (low-set), unequal alignment. Lateral posterior angle greater than 10 degrees. - Preauriclar area o Expected: preauricular pits or smooth skin o Unexpected: openings in preauricular area, discharge - External auditory canal o Expected: no discharge, no odor; canal walls pink o Unexpected: serous, bloody or purulent discharge, foul smell Palpate auricles and mastoid area o Expected: firm and mobile, readily recoils from folded position; nontender o Unexpected: tenderness, swelling, nodules. Pain from pulling on lobe Inspect auditory canal with otoscope o Expected: cerumen in varying color and texture. Uniformly pink canal. Hairs in outer third of canal. o Unexpected: cerumen obscures tympanic membrane, odor, lesions, discharge, scaling, excessive redness, foreign bodies Inspect tympanic membrane - Landmarks: vary light direction to observe entire membrane and annulus o Expected: visible landmarks (umbo, handle of malleus, light reflex) o Unexpected: perforations, landmarks not visible - Color o Expected: translucent, pearly gray o Unexpected: amber, yellow, blue, deep red, chalky, white, dull, white flecks, or dense white plaques; air bubbles or fluid level - Contour o Expected: slightly conical with concavity at umbo o Unexpected: bulging (more conical, usually with loss of bony landmarks and distorted light reflex) or retracted (more concave, usually with accentuated bony landmarks and distorted light reflex) - Mobility: seal canal with speculum, and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment or by asking pt to valsalvus. o Expected: movement in and out o Unexpected: no movement Asses hearing - Questions during history o Expected: responds to questions appropriately o Unexpected: excessive requests for repetition. Speech with monotonous tone and erratic volume

HEENT

Whispered voice: have pt mask hearing in one ear by moving finger rapidly up and down in ear canal. Stand 1-2 ft from other ear and softly whisper three letter and number combinations (3,T,9 or 5,M,2). Repeat with untested ear. o Expected: pt repeats words correctly more than 50% of the time o Unexpected: pt unable to repeat whispered words Weber test: place base of vibrating tubing fork on midline vertex of head. Repeat with out ear occluded. o Expected: sound heard equally in both ears (unoccluded). Sound heard better in occluded ear o Unexpected: see table Rinne test: place base of vibrating tuning fork against mastoid bone, note seconds until sound is no longer heard then quickly move fork 1-2 cm from auditory canal and note seconds until sound is no longer heard. Repeat with other ear o Expected: measurement of air-conducted sound twice as long as measurement of boneconducnted sound o Unexpected: see table Weber Test No lateralization Lateralization to deaf ear unless sensorineural loss Lateralization to better-hearing ear unless conductive loss Rinne Test AC>BC (2:1 ratio) BC>AC in affected ear Rinne negative AC>BC in affected ear but less than 2:1 ratio

Interpretation of Tuning Fork Tests Expected findings Conductive hearing loss Sensorineural hearing loss

Noses and Sinuses Inspect external nose - Shape/size o Expected: smooth. Columella directly midline, width is not greater than diameter of naris o Unexpected: swelling or depression of nasal bridge. Transverse crease at junction of nose cartilage and bone - Color o Expected: conforms to face color - Nares o Expected: oval. Symmetrically positioned o Unexpected: asymmetry, discharge, flaring, narrowing Palpate ridge and soft tissues of nose -Place one finger on each side of nasal arch and gently palpate from nasal bridge to tip o Expected: firm and stable structures o Unexpected: displacement of bone and cartilage, tenderness, or masses Evaluate patency of nares -Occlude one naris with finger on side of nose, ask pt to breathe through nose. Repeat with other naris. o Expected: noiseless, easy breathing o Unexpected: noisy breathing, occlusion Inspect nasal mucosa and nasal septum -Tilt pts head toward opposite shoulder. Pull auricle upward and back while gently inserting speculum. Assess canal from meatus to tympanic membrane. - Color o Expected: mucosa deep pink and glistening. Turbinates same color as surrounding area o Unexpected: increased redness of mucosa or localized redness and swelling in vestibule. Turbinates bluish gray or pale pink - Shape

HEENT

o Expected: septum close to midline and fairly straight, thicker anteriorly than posteriorly.
Inferior and middle turbinates visible

o Unexpected: asymmetry of posterior nasal cavities, septal deviations


Condition o Expected: possibly film of clear discharge on septum. Possible hairs in vestibule. Turbinates firm. o Unexpected: discharge, bleeding, crusting, masses or lesions. Swollen, boggy turbinates. Perforated septum. Polyps.

Additional See neuro for sense of smell testing Inspect frontal and maxillary sinus area -Press thumb up under bony brow on each side of nose. Palpate with thumbs or index or middle fingers under zygomatic processes. o Expected: nontender on palpation o Unexpected: tenderness or swelling Mouth Inspect and palpate lips with mouth closed -Have pt remove lipstick if applicable. - Symmetry o Expected: symmetric vertically and horizontally at rest and while moving o Unexpected: asmmetric - Color o Expected: pink, distinct border between lips and facial skin o Unexpected: pallor, circumoral pallor, bluish purple or cherry red - Condition o Expected: smooth o Unexpected: dry, cracked; swelling, angioedema; cheilosis; lesions; plaques; vesicles Inspect teeth - Occlusion: have pt clench teeth and smile with lips spread o Expected: upper molars interdigitates with groove on lower molars. Premolars and canines interdigitate fully. Upper incisors slightly overriding lower incisors. o Unexpected: malocclusion. Protrusion of lower incisors. Problems with bite - Color o Expected: ivory, stained yellow or brown o Unexpected: discolorations may indicate caries - Condition o Expected: 32 teeth, firmly anchored o Unexpected: caries and loose or missing teeth Inspect buccal mucosa -Have pt remove any dental appliances and then partially open mouth. Use tongue blade and bright light to assess. - Color o Expected: pinkish red o Unexpected: deeply pigmented. Whitish or pinkish scars. - Condition o Expected: smooth and moist. Whitish yellow or whitish pink. Stensen duct. Fordyce spots o Unexpected: adherent thickened white patch; white round, or oval ulcerative lesions; red spot at opening of Stensen duct; stones or exudate from Stensen duct. Inspect and palpate gingiva -Use gloves to palpate

HEENT Color

o Expected: slightly stippled and pink o Unexpected: blue-black line about 1 mm from gum margin
Condition o Expected: clearly defined, tight margin at each tooth o Unexpected: inflammation, swelling, bleeding or lesions under dentures or on gingiva; induration, thickening, masses, or tenderness. Enlarged crevices between teeth and gum margins. Pockets containing debris at tooth margins. Inspect tongue - Size/symmetry o Expected: midline, no fasciculations o Unexpected: atrophied, deviation to one side - Color o Expected: dull red - Dorsum surface: have pt extend tongue and hold extended o Expected: moist and glistening. Anterior is smooth yet roughened surface with papillae and small fissures. Posterior is smooth, slightly uneven or rugated surface with thinner mucosa than anterior. o Unexpected: smooth red slick; hairy, swollen, coated, ulcerated, fasciculations or limitation of movement - Ventral surface and floor of mouth: have pt touch tip of tongue to palate behind upper incisors o Expected: ventral surface pink and smooth with large veins between frenulum and fimbriated folds. Wharton ducts apparent on each side of frenulum. o Unexpected: difficulty touching hard palate. Swelling, varicosities - Lateral borders: wrap tongue with gauze and pull to each side. Scrape white or red margins to remove food particles. o Unexpected: leukoplakia, ulceration, induration Palpate tongue and floor of mouth o Expected: smooth and even o Unexpected: lumps, nodules, induration, ulcerations, or thickened white patches Inspect palate and uvula -Have pt tilt head back - Color and landmarks: o Expected: hard palate (whitish and dome-shaped with transverse rugae) contiguous with pinker soft palate. Bony protuberance of hard palate at midline (torus palatinus) o Unexpected: nodule on palate, not at midline - Movement: ask pt to say ah while observing soft palate (depress tongue if necessary) o Expected: soft palate rises symmetrically, with uvula remaining in midline o Unexpected: failure of soft palate to rise bilaterally. Uvula deviation. Bifid uvula. Inspect oropharynx -Depress tongue with tongue blade - Tonsils: inspect the tonsillar pillars and size of tonsils o Expected: tonsils, if present, blend into pink color of pharynx. Possible crypts in tonsils where cellular debris and food particles collect. o Unexpected: tonsils projecting beyond limits of tonsillar pillars. Tonsils red, enlarged, covered with exudate - Posterior wall of pharynx o Expected: smooth, glistening, pink mucosa with some small, irregular spots of lymphatic tissue and small blood vessels o Unexpected: red bulge adjacent to tonsil extending beyond midline. Yellowish mucoid film in pharynx. Grayish membrane. -

HEENT Elicit gag reflex -Touch posterior wall of pharynx on each side o Expected: bilateral response o Unexpected: unequal response or no response

HEENT Here is a script for something similar to how you report these findings during the practical examination test.
Skin, Head & Face Inspect skin & check mobility & turgor Inspect Facial features Inspect Hair & Palpate Scalp Diffuse macules throughout sun exposed areas. Skin is mobile and turgor is brisk at less than 2 seconds Head is normocephalic. Face is symmetrical with no signs of fasciculations or tremors. Hair is clean, no excessive oiliness or brittleness. Distribution is normal pattern for age and sex with no alopecia. Scalp mobile with no tenderness noted. Temporal arteries are non-bounding and non-tender. No tenderness of frontal or maxillary sinuses. No crepitus, no tenderness. FROM. CN5 sensory and motor intact CN7 intact.

Palpate Temporal Arteries Percuss frontal and maxillary sinuses Palpate TMJ (Have pt open and close jaw, move jaw back and forth, and push bottom jaw out and pull back in Test CN5 (motor: clench jaw, sensory: touch face over 3 branches) Test CN7 (smile, frown, puff cheeks, raise eyebrows, squint eyes shut, try to pull eyes apart)

Ears & Otoscopic Exam Inspect & palpate auricles & mastoid. Whisper Test Weber and Rinne Test (CN8) Otoscopic Exam & Inspect Tympanic Membrane

External ears are symmetrical bilaterally, no lesions, no tenderness, no erythema. Patient has acuity to a whisper bilaterally. Weber is midline and does not lateralize. Rinne is normal with AC > BC. CN8 intact. Before placing otoscope in: When I ask will you hold your nose and gently blow. Brace otoscope, pull on auricle, watch the tip go in THEN look through scope. The external auditory canals are patent with minimal brown(or yellow) colored cerumen (wax) present. There is no erythema nor exudates. The tympanic membranes are pearly grey with a good cone of light. Maleus, incus, and stapes are visible. The tympanic membrane is non-bulging with no fluid accumulation or erythemia. Now please hold your nose and gently blow. Tympanic membrane is mobile

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HEENT

Neck Inspect and palpate C-Spine (paravertebral, trapezius and sternocleidomastoid ms.)

No excessive lordosis. No masses or tenderness of C-spine. Bilateral symmetry.

ROM & Muscle Strength C-spine has FROM with strength of 5/5. (ROM: ask patient to touch chin to chest, raise chin to ceiling, touch ear to shoulder, then other ear to shoulder, turn chin to shoulder, then other Mouth & Pharynx chin to shoulder. Inspect lips (remember to use light source) Lips are pink and moist. No ulcers or cyanosis. Strength: have patient resist against your hands placing on forehead, Smooth with no masses. back of head, side of head, other side of head, cheek, other cheek and on top of breath odor Observe shoulders.) No hallotosis, no fruity odor, no precesne of alcohol consumption on breath. CN XI (shoulder Shrug) Inspect oral mucosa, palates and floor of mouth Palpate & ausculatate carotids Inspect teeth for color, # & surface character. Inspect teeth. Percuss& Palpate Trachea Palpate thyroid Check tongue for color, character, symmetry. CN11 intact. Oral muscosa is pink in color, no ulcers or leukolakia. No lesions or nodules noted. Stensons duct (inside of cheek) is non-enlarged. Carotids are non-tender. No bruits. Gingival is pink in color, no swelling or ulcerations. Smooth with no masses. Teeth are present, uncracked, Neck symmetric and trachea midline. clean and white, and (after percuss with tongue blade) firmally intact in gums. Thyroid is smooth without nodules. Non-enlarged and nonTongue is symmetrical. tender. No lesions, buccal mucosa is moist and free of lesions, hard

and soft palate and uvula have no lesions. Please raise your tongue. Whartons Palpate Lymph Nodes duct is non-enlarged. Lymph nodes are all non-tender and non-palpable. (occipital, post auricular, pre auricular, tonsillar, submandibular, submental, (protrude cervical,move side to side) Test CN12 posterior tongue, anterior cervical, supraclavicular) Stick out your tongue. Tongue midline without atrophy or fasiculations. CN12 intact. Inspect oropharynx: uvula, tonsils & posterior pharynx Test CN10 (say Ahhhh) Test CN9 (simulate gag reflex) (Say ahhh) Tonsils are present, but not enlarged, no exudates. Pharynx is healthy, pink ,and clear without erythema, exudates or lesion. Uvula midline. CN10 intact. I would simulate gag reflex. CN9 intact.

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HEENT Last years checklist: This is how we were instructed to approach the neuro exam. The italics are normal findings that you should note in your objective. This was very basic, but helped put it in a logical sequence. 1. Head and Neck a. General appearance: Inspect head, hair, face, and neck Normocephalic, normal hair pattern b. Palpate skull, scalp and face No nodules c. Palpate temporal arteries Non tender d. Palpate parotid, submandibular, and sublingual glands No enlargement e. Palpate lymph nodes (occipital, preauricular, postauricular, submandibular, submental, tonsillar, anterior cervical, posterior cervical and supraclavicular) No lymph nodes noted f. Palpate neck and trachea Trachea midline g. Inspect and palpate thyroid No enlargement, no nodules Eyes a. Measure visual acuity OS 20/20, OD 20/20 OU 20/20 b. Inspect eyebrows No scaling c. Palpate periorbital area No swelling or pain d. Inspect eyelids, eyelashes and for ptosis No scaling or ptosis e. Inspect and palpate lacrimal apparatus Non tender f. Inspect conjunctiva and sclera Clear and white g. Inspect cornea and iris Clear, no shadow on iris h. Inspect pupils i. Inspect direct and consensual response to light of pupils j. Inspect test pupils for convergence and accommodation k. Verbalize combined results for H, I, J PEERLA l. Inspect cornela light reflex Light reflex centered m. Inspect EOMs in 6 cardinal fields EOMs full n. Observe for presence of nystagmus No nystagmus Ophthalmoscopic exam a. Inspect red reflex Red reflex intact b. Inspect focus through layers, change diopters Lens clear c. Focus and inspect retina Orange/red d. Inspect arteries and veins in 4 quadrants No A/V nicking e. Inspect disc Disc margins clear, cup to disc ratio 2:1 f. Inspect macula Unable to see g. Technique State would dim light, have pt focus on distant object, change diopters and light intensitiy. Ears a. Perform masked whisper test Able to hear whisper b. Weber test Weber midline c. Rinne test AC>BC d. Inspect and palpate auricles and tragus, including preauricular areas No lesions, non tender e. Inspect and palpate mastoid Non tender Otoscopic exam a. Inspect external auditory canals Canals clear no erythema b. Inspect tympanic membranes Pearly gray, light reflex in the 5 oclock or 7 oclock position (depends on which ear you are looking in it should point anteriorly) c. Inspect bones of hearing and air-fluid levels of the middle ear No air-fluid levels. d. Inspect TM while pt valsalvas or using insufflator bulb TM mobile Nose and Sinuses

2.

3.

4.

5.

6.

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HEENT

a. b. c. d.
7. Mouth

Test both nares for patency patent nares bilaterally Inspect and palpate nose Non tender Palpate or percuss frontal and maxillary sinuses Non tender Inspect mucosa, septum, and turbinates with nasal speculum No polyps, mucosa pink, no deviation of septum Observe breath Normal breath Inspect and palpate lips No cyanosis, no lesions Inspect oral mucosa Pink without lesions Inspect and palpate gingival Pink without lesions Inspect and palpate tongue Pink without lesions Inspect teeth In good repair Percuss teeth with tongue blade Non tender Inspect palates and uvula No lesions Inspect tonsils, if present No exudates or enlargement Test for intact gag reflex using tongue blade Simulate Perform bimanual exam of oral cavity (include Wharton and Stenson ducts), must wear gloves No lesions or tenderness

a. b. c. d. e. f. g. h. i. j. k.

Here is an example of the write up I had last year. This may help you with the way you present or comment on the findings from the exam. Obviously, this isnt as comprehensive as PA Moore would like ours to be. But it is an example of the objective findings documentation. Head/Neck and ENT Write Up Head and Neck Inspection and palpation: - normocephalic general appearance with normal female hair distribution - no nodules - non tender temporal arteries - non enlargement of parotid, submandibular or sublingual salivary glands - no lymph nodes noted - trachea midline with no enlargement or nodules noted on thyroid Ears Inspection and palpation: - no lesions, non tender auricles - non tender mastoid Tests performed: - able to hear whisper AU - Weber midline observed - auditory conduction greater then bone conduction Otoscopic exam: - canals clear with no erythema - pearly grey tympanic membrane with positive light reflex - no air-fluid levels observed - TM mobile, determined using Valsalvas Nose and Sinuses Upon inspection and palpation: - non tender external nose - no polyps on paranasal sinuses with pink mucosa

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HEENT - no deviation of septum - non tender paranasal sinuses Patency partial occlusion of right nare, patency of left nare Mouth Observation - no unusual breath odor Inspection and palpation: - no cyanosis or lesions on the lips - oral mucosa and gingiva pink without lesions - tongue pink without lesions - teeth in good repair - no lesions of palates and uvula - no exudates or enlargements of tonsils Percussion teeth non tender Gag reflex present (simulation) Bimanual exam no lesions or tenderness of Whartons or Stensons ducts Eyes Write-Up Visual Acuity - 20/20 with corrective lenses OS, OD, OU Inspection and Palpation - No scaling of eyebrows - No swelling or pain of periorbital area - No scaling or ptosis of eyelids - Non tender lacrimal apparatus - Conjunctiva and sclera clear and white - Cornea and iris clear with no shadow on iris - PERRLA - Corneal light reflex centered - Full range of EOMs - No Nystagmus Ophthalmoscoic Exam - Red reflex intact - Lenses clear - Orange/red retina - No A/V nicking - Disc margins clear, cup to disc ratio 1:2 - Unable to see macula

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