HEENT Objective Data Collection for Tina Jones
Objective Data Collection: 24.59 of 25 (98.36%)
Inspected head and face
1 of 1 point
Skull Symmetry (1/3 point)
– Symmetric
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Facial Feature Symmetry (1/3 point)
– Symmetric
Appearance (1/3 point)
– No visible abnormal findings
– Rash
– Papules, pustules, or comedones
– Skin growths (freckles, moles, or birthmarks)
– Excessive hair growth
– Evidence of skin trauma (scar, laceration, or bruising)
– Red, chapped nose
Inspected eyes and orbital area
0.75 of 1 point
Orbital Area (1/4 point)
– No visible abnormal findings
– Ptosis
– Eyelid edema
– Lesion
– Allergic shiners
Sclera (No point)
– White
– Injection
– Icterus
Conjunctiva (1/4 point)
– Moist and pink
– Pale
– Dry appearance
– Erythema
– Edema
Conjunctival Discharge (1/4 point)
– No discharge
– Clear, watery discharge
– Purulent discharge
Inspected nasal cavities
1 of 1 point
Color (1/4 point)
– Pink
– Pale
– Erythemic
– Bluish
Discharge (1/4 point)
– No discharge
– Clear discharge
– Bloody discharge
– Purulent discharge
Turbinate Patency (1/4 point)
– Patent
– Decreased patency
– Not patent
Observations (1/4 point)
– No additional visible abnormal findings
– Foreign body present
– Polyp
– Septum perforated
– Septum deviated
– Lesion
Inspected ears
1 of 1 point
Right: Auditory Canal Color (1/10 point)
– Pink
– Red
– Pallor
Right: Tympanic Membrane Color (1/10 point)
– Pearly gray
– Red
– Opaque
– Yellow
– Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
– No visible abnormal findings
– Fluid observed
– Visible scars
– Bulging
– Perforation
– Retraction
Right: Cone Of Light (1/10 point)
– 5:00
– Cone of light distorted
Right: Discharge (1/10 point)
– No discharge
– Cerumen
– Clear discharge
– Bloody discharge
– Purulent discharge
Left: Auditory Canal Color (1/10 point)
– Pink
– Red
– Pallor
Left: Tympanic Membrane Color (1/10 point)
– Pearly gray
– Red
– Opaque
– Yellow
– Not visible because of cerumen
The Role of Innovation and Creativity in the Development and Success of Entrepreneurial SMEs Essay
Left: Tympanic Membrane Appearance (1/10 point)
– No visible abnormal findings
– Fluid observed
– Visible scars
– Bulging
– Perforation
– Retraction
Left: Cone Of Light (1/10 point)
– 7:00
– Cone of light distorted
Left: Discharge (1/10 point)
– No discharge
– Cerumen
– Clear discharge
– Bloody discharge
– Purulent discharge
Inspected mouth and throat
0.17 of 1 point
Oral Mucosa (1/6 point)
– Moist and pink
– Dry appearance
– Erythemic
Tonsils (No point)
– No visible abnormal findings
– Edema
– Erythema
Tonsil Grade (No point)
– 0: Tonsils fit within tonsillar fossa
– 1+: Tonsils <25% of space between pillars
– 2+: Tonsils <50% of space between pillars
– 3+: Tonsils <75% of space between pillars
– 4+: Tonsils >75% of space between pillars
Posterior Oropharynx Color (No point)
– Pink
– Erythemic
Posterior Oropharynx Texture (No point)
– No abnormal findings
– Cobblestoning
– Exudate
Post Nasal Drip (No point)
– No discharge
– Clear discharge
– Purulent discharge
Inspected neck
1 of 1 point
Symmetry (1/2 point)
– Symmetric
– Asymmetric
Appearance (1/2 point)
– No visible abnormal findings
– Swelling
– Visible pulsation
– Visible mass
– Discoloration
Palpated scalp
1 of 1 point
Tenderness (1/2 point)
– None reported
– Tenderness reported
Observations (1/2 point)
– No additional abnormal findings
– Balding or thinning areas in hair distribution
– Palpable masses
Palpated sinuses
1 of 1 point
Frontal (1/2 point)
– None reported
– Tenderness reported
Maxillary (1/2 point)
– None reported
– Tenderness reported
Palpated temporal arteries
1 of 1 point
Right: Vibration (1/4 point)
– No thrill
– Thrill
Right: Intensity (1/4 point)
– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse
Left: Vibration (1/4 point)
– No thrill
– Thrill
Left: Intensity (1/4 point)
– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse
Palpated carotid arteries
1 of 1 point
Right: Vibration (1/4 point)
– No thrill
– Thrill
Right: Intensity (1/4 point)
– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse
Left: Vibration (1/4 point)
– No thrill
– Thrill
Left: Intensity (1/4 point)
– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse
Palpated jaw
1 of 1 point
Observations (1/1 point)
– No palpable abnormal findings
– Limited range of motion
– Popping or clicking
Palpated lymph nodes
1 of 1 point
Head And Neck (1/3 point)
– No palpable nodes
– Palpable nodes on right side
– Palpable nodes on left side
Supraclavicular (1/3 point)
– No palpable nodes
– Palpable nodes on right side
– Palpable nodes on left side
Axillary (1/3 point)
– No palpable nodes
– Palpable nodes on right side
– Palpable nodes on left side
Palpated thyroid gland
1 of
1 point
Observations (1/2 point)
– No palpable abnormal findings
– Nodules
– Enlarged
– Irregular
Tenderness (1/2 point)
– None reported
– Tenderness reported
Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
– Present in all areas
– Diminished in some areas
– Absent in some areas
Adventitious Sounds (1/3 point)
– No adventitious sounds
– Wheezing
– Fine crackles
– Stridor
– Rhonchi
– Rales
Location (1/3 point)
– All areas clear
– Adventitious sounds in anterior right upper lobe
– Adventitious sounds in anterior right middle lobe
– Adventitious sounds in anterior right lower lobe
– Adventitious sounds in anterior left upper lobe
– Adventitious sounds in anterior left lower lobe
– Adventitious sounds in posterior right upper lobe
– Adventitious sounds in posterior right lower lobe
– Adventitious sounds in posterior left upper lobe
– Adventitious sounds in posterior left lower lobe
Auscultated temporal arteries
1 of 1 point
Right (1/2 point)
– No bruit
– Bruit
Left (1/2 point)
– No bruit
– Bruit
Auscultated carotid arteries
1 of 1 point
Right (1/2 point)
– No bruit
– Bruit
Left (1/2 point)
– No bruit
– Bruit
Tested pupillary reaction
1 of 1 point
Observations With Penlight (1/1 point)
– No visible abnormal findings (PERRL)
– Unequal
– Irregular
– Miosis
– Mydriasis
– Non-reactive to light
Tested extraocular eye movements
1 of 1 point
Cardinal Fields (1/2 point)
– No visible abnormal findings
– Nystagmus
– Fixed pupil
Convergence (1/2 point)
– No visible abnormal findings
– Unequal bilaterally
– Fixed pupil
Tested peripheral vision
1 of 1 point
Observations (1/1 point)
– No abnormal findings
– Reduced right visual field
– Reduced left visual field
Examined fundus with ophthalmoscope
1 of 1 point
Right: Retina (1/4 point)
– No visible abnormal findings
– Myelinated nerve fibers
– Papilledema
– Glaucomatous cupping
– Drusen bodies
– Cotton wool bodies
– Hemorrhage
Right: Disc Margin (1/4 point)
– Sharp
– Blurred
Left: Retina (1/4 point)
– No visible abnormal findings
– Myelinated nerve fibers
– Papilledema
– Glaucomatous cupping
– Drusen bodies
– Cotton wool bodies
– Hemorrhage
Left: Disc Margin (1/4 point)
– Sharp
– Blurred
Tested visual acuity
1 of 1 point
Right (1/2 point)
– 20/100
– 20/70
– 20/50
– 20/40
– 20/30
– 20/25
– 20/20
– 20/15
– 20/13
– 20/10
Left (1/2 point)
– 20/100
– 20/70
– 20/50
– 20/40
– 20/30
– 20/25
– 20/20
– 20/15
– 20/13
– 20/10
Performed Weber test
1 of 1 point
Results (1/1 point)
– Normal
– Conductive or sensorineural loss
Performed Rinne test
1 of 1 point
Right (1/2 point)
– Normal
– Conductive loss
Left (1/2 point)
– Normal
– Conductive loss
Performed whisper test
1 of 1 point
Right (1/2 point)
– Normal
– Unable to hear whispered words
Left (1/2 point)
– Normal
– Unable to hear whispered words
Tested gag reflex
1 of 1 point
Observations (1/1 point)
– Intact
– Absent
– Hypersensitive
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