HEENT Examination - Wikipedia

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Appearance move to sidebar hide From Wikipedia, the free encyclopedia Portion of a physical examination

A HEENT examination is a portion of a physical examination[1] that principally concerns the head, eyes, ears, nose, and throat.[2]

Steps

[edit]
  • IPPA
    • Inspection of scars or skin changes
    • Palpation of temporomandibular joint, thyroid, and lymph nodes
    • Percussion may involve the skin above the frontal sinuses and paranasal sinuses to detect any signs of pain
    • Auscultation for carotid bruits
  • Tests specific to HEENT examination
    • Eyes: eye examination and acuity (including ophthalmoscope)
    • Ears: hearing examination and evaluation of tympanic membrane (TM) (otoscope used in evaluation of ears, nose, and mouth)

A neurological examination is usually considered separate from the HEENT evaluation, although there can be some overlap in some cases.

Sample write-up

[edit]
Category Item Sample text
Head "NC/AT" or "Normocephalic, atraumatic"
Eyes ophthalmoscope "EOM intact, PERRLA, anicteric, no injection, fundus WNL (within normal limits), no papilledema"
Ears otoscope "TM intact, noninflamed"
Nose otoscope "No congestion"
Throat otoscope "Oropharynx WNL" or "no erythema or exudate"
Mouth otoscope "Moist mucous membranes, no thrush, no vesicles, no lesions, good dentition"
Neck "No LAD, thyroid WNL, neck supple" (JVD and bruit may be reported here or in CV)

References

[edit]
  1. ^ Swaminatha V. Mahadevan; Gus. M. Garmel (5 July 2005). An introduction to clinical emergency medicine. Cambridge University Press. pp. 267–. ISBN 978-0-521-54259-3. Retrieved 6 March 2011.
  2. ^ Deutsch, Laurence M. (2001). Medical Records for Attorneys. ALI-ABA. p. 57. ISBN 9780831808174. Retrieved 18 January 2018.
  • v
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Medical examination and history taking
Medical history
  • Chief complaint
  • History of the present illness
  • Systems review
  • Nursing assessment
  • Allergies
    • Medications
  • Past medical history
  • Family history
  • Social history
  • Psychiatric history
  • Progress notes
  • Mnemonics
    • SAMPLE
    • OPQRST
    • SOAP
    • COASTMAP
Physical examination
General/IPPA
  • Inspection
  • Auscultation
  • Palpation
  • Percussion
Vital signs
  • Temperature
  • Heart rate
  • Blood pressure
  • Respiratory rate
HEENT
  • Eye examination
    • Ophthalmoscopy
    • Swinging light test
  • Hearing
    • Weber
    • Rinne
Respiratory
  • Respiratory sounds
Cardiovascular
  • Cardiac examination
  • Peripheral vascular examination
  • Heart sounds
  • Other
    • Abdominojugular test
    • Ankle–brachial pressure index
Abdominal
  • Liver span
  • Rectal examination
  • Bowel sounds
Musculoskeletal
  • Knee examination
  • Hip examination
  • Shoulder examination
  • Elbow examination
  • GALS screen
Neurological
  • Mental status
    • Mini–mental state examination
  • Cranial nerve examination
  • Upper limb neurological examination
Neonatal
  • Apgar score
  • Ballard Maturational Assessment
Gynecological
  • Well-woman examination
  • Pap test
  • Breast examination
Sports
  • Athletic heart syndrome
  • Sudden cardiac death
  • RED-S
Assessment and plan
  • Medical diagnosis
  • Differential diagnosis
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