HEENT Objective Data Collection for Tina Jones

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

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

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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