A HEENT examination is a portion of a physical examination that principally concerns the head, eyes, ears, nose, and throat.
Steps
- 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
| 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
- 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.
- Deutsch, Laurence M. (2001). Medical Records for Attorneys. ALI-ABA. p. 57. ISBN 9780831808174. Retrieved 18 January 2018.
| Medical examination and history taking | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Medical history | |||||||||||||||||||||||
| Physical examination |
| ||||||||||||||||||||||
| Assessment and plan | |||||||||||||||||||||||