HEENT examination

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

Steps

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

  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.
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