Normal Heent Exam Documentation
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- Pain can suggest a possible underlying infection. External inspection: all components of the eyes that are externally visible should be inspected. Look out for jaundice, bleeding, infection, inflammation, and really anything that is out of the...
- Realistically this is very difficult to do properly especially without dilating the patient and other instruments are better suited for this procedure an ophthalmology consult should be called in many situations for further investigation of the...
- Infection and even shingles can be observed in this component of the exam. Clinical presentation of shingles on the outer ear of a patient source Otoscopic examination: using an otoscope, we are able to observe the internal structures of the ear. There are a variety of different findings that can be observed, however we generally are looking to see a non diseased inner ear canal, and intact tympanic membrane. Anatomy of a normal tympanic membrane source NOSE Sense of smell: this can be assessed by asking the patient if they have observed any issues with their sense of smell.
- If further investigation is required refer to the cranial nerve exam page CN I specifically External inspection: beginning with the external inspection we can appreciate large scale abnormalities of the nose and can also hear things such as a runny nose, etc. Patient with a deviated septum that is observable with external examination source Internal inspection: using the otoscope, we are also able to look directly in the nasal canal for any abnormal finings. Give that we unavoidably have access to the oral cavity for the internal throat exam, we chose to include this section under the throat component of the HEENT exam. External inspection of mouth: are the lips cracked? Any external findings? Make sure to ask the patient more about any finding and properly characterize it.
- Make sure to look behind the lips and under the tongue as well! There are many findings that are too numerous to go over here. At the very least if you find anything that is out of the ordinary, ask the patient about it, characterize it any pain, what does it look like, where is it, etc. Palpation of the oral cavity: if time allows, or unusual findings suggest the need to do so, gloving up and palpating within the oral cavity under the tongue as well can be informative. Physical manifestation of child with parotitis source Oropharynx: looking in the back of the throat, with help of a tongue depressor can be very useful and informative.
- Exudative pharyngitis seen in a patient with a streptococcal infection source Neck exam: beginning initially with inspection, we can also palpate any abnormal findings we come across. Lymph nodes are one example of structures we want to palpate for even if nothing is seen visibly. Palpation locations of the lymph nodes in the head and neck source Thyroid test: while realistically an ultrasound and further imaging will be more informative if we suspect abnormalities with the thyroid, in the absence of a clear goiter, we can palpate the thyroid in the following manner. Move your fingers down and feel for a cartilaginous notch that is part of the cricoid cartilage Move your fingers below this point and feel for the first pharyngeal cartilage arch. The connection between the sides of the thyroid are below this level.
- Move your hands right below this first arch do not push down here because this is very uncomfortable for the patient! Move your hands slightly to the sides of this location the location of the thyroid lobes and have the patient swallow while you apply gentle pressure. If anything seems suspicious upon palpation in conjunction with the patient history further imagine can be informative.
- Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. External inspection of the ears and nose showed no scars, lesions, or masses. Lips, teeth, and gums showed normal mucosa. The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal. NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt. LUNGS: Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.
- The liver span was approximately cm in the right midclavicular line by percussion. The liver edge was nontender. The spleen was not palpable. There were no inguinal or umbilical hernias noted. No ascites was noted. Sphincter tone was normal. There was no external hemorrhoids or rectal masses. Stool Hemoccult was negative. The prostate was normal size without any nodules appreciated men only. There was no tenderness or effusions noted. Muscle strength and tone were normal. Normal affect. Gait was normal. Normal deep tendon reflexes with no pathological reflexes. Sensation to touch was normal. Other Related Samples: Be the first to comment - What do you think? Posted by MTHelpLine.
- He is in no acute distress. He does have an area of purpura over his left periorbital area. There is also a small laceration over his forehead. The sinuses are otherwise nontender. Pupils are equal and reactive. The nares are patent. Oropharynx reveals poor dentition but is clear without lesions. NECK: Supple without lymphadenopathy. No crackles or wheezes are heard. Inguinal area is normal.
- Skin: Warm and dry without any rash. There is no costovertebral angle tenderness. No evidence of trauma. Ears: No acute purulent discharge. Eyes: Conjunctivae pink with no scleral jaundice. Nose: Normal mucosa and septum. NECK: Supple with no cervical or supraclavicular lymphadenopathy. Trachea is midline. Thyroid: Not palpable. Coarse breath sounds with some rhonchi. No peripheral edema. SKIN: Normal color, turgor and temperature. No ulcerations or rashes noted. No wheezing. No crackles. The patient has a loud systolic ejection murmur. No organomegaly. Normoactive bowel sounds. GCS is Skin: Warm and dry without exanthem. Pupils are equal, round and reactive to light. Extraocular movements are intact. Oral mucosa is moist. There is no obvious bleeding in the gum.
- Oropharynx is without erythema or exudate. Lungs: Breath sounds are clear bilaterally without rales, rhonchi or wheezing. Heart: No elevation of JVP. Heart is irregularly irregular with no appreciable gallops, rubs, murmurs or extra heart sounds. Abdomen: Soft, nontender, nondistended in all quadrants. No audible bowel sounds. No palpable masses. Extremities: Warm without clubbing, edema or cyanosis. Neurological: The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric. General: A well-developed, well-nourished male with pleasant affect.
- Extraocular movements full. Sclerae anicteric. Neck: Supple. Free of masses or thyromegaly. No carotid bruits. Lungs: Clear. Symmetrically expanding. Cardiac: Rhythm is sinus. No murmurs or gallops. Abdomen: Obese, soft with obvious inflammation focused within the right subumbilical area. Scattered healed maculopapular ulcerations are distributed along the subumbilical transverse belt line. Surrounding one of the ulcerations, right infraumbilical region, is significant edema and erythema, which expands in a band-like distribution along the belt line across the right lateral abdomen to the midaxillary line level. Early fluctuance is developing around the epicenter of the inflammation, and there is some minor purulent drainage therefrom.
- No intraabdominal masses, hepatic or splenic enlargement. No peritoneal signs are present. Neurologic: No focal deficits. Chest is clear. Heart is regular. The right eyelid is closed; she is able to open it. Both pupils are equal, reactive to light and accommodation. There appears to be no overt nystagmus with the exception of perhaps a mild tap on the left and leftward gaze in the left eye. Both TMs and canals are occluded with cerumen. He is alert and oriented x3. Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Nares appeared normal. Mouth is well hydrated and without lesions. Mucous membranes are moist. Posterior pharynx clear of any exudate or lesions. NECK: Supple. No lymphadenopathy or thyromegaly. Positive bowel sounds. No hepatosplenomegaly was noted. SKIN: No ulceration or induration present. Temperature Pulse noted to range from as low as 36 beats per minute to above 62 beats per minute.
- Respiratory rate He was lying in bed comfortably. SKIN: There were fading ecchymotic lesions on thighs and arms. Eyes: Extraocular muscles were intact. The patient was anicteric. Pupils were equally reactive to light. Ears: There were no lesions. Nose: No lesions were noted. Throat: There was no thrush, no exudate, no erythema.
- There was no evidence of gum bleeding. There was no JVD. No bruit was heard over the carotids. There were slight basilar crackles, left more than right. Bowel sounds were present. There were no masses in the rectum. There was full range of motion in all the extremities. There was no edema.
- August 28, Documentation serves two very important purposes. First, it keeps you out of jail. Okay, okay, incarceration might not be totally realistic, but there are plenty of scenarios in which your actions as a healthcare provider might be called into question. Documenting your findings on a physical exam as well as the reasoning for your plan of care serves as a defense in the event another provider, patient etc. Second, documentation helps with continuity of care. Documenting your findings and plan for the patient allows other providers to continue caring for the individual in your absence.
- Or, it allows for others to provide care in conjunction with yours without interfering with your part of the care plan. Keep everyone in the loop by documenting exam findings and your next steps with the patient. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities. There is a fine balance between spending too much time on charting and including too little in your documentation. The amount you are paid for each patient encounter is based on your documentation, so cutting corners can directly affect your wallet. In most cases, you do not need to examen and provide documentation for each and every body system.
- For purposes of a general overview, in this template we will give a down and dirty overview of each body system. Finally disclaimer alert! With certain patients, you may need to note findings that are not included in this sample write-up. Are You Ready to Thrive? Learn more about our online residency program; we pair clinical and professional development to take advanced practice providers to the next level. No acute distress. Well developed, hydrated and nourished. Appears stated age. Skin: Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing. Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed. Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.
- Ears: The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice. Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally. Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates.
- Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. No JVD. Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity. Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes.
- Resonance is normal upon percussion of all lung fields. Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted. No external masses or lesions. Stool is normal in appearance.
- External genitalia is normal in appearance without lesions, swelling, masses or tenderness. Vagina is pink and moist without lesions or discharge. Cervix is non-tender without lesions or erosions. Uterus is anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or enlargement. Spine: Neck and back are without deformity, external skin changes, or signs of trauma. Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits. No tenderness noted on palpation of the spinous processes. Spinous processes are midline. Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm. No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.
- Straight leg raise test is negative bilaterally. Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally. Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. Steady gait noted. Naurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Sensation is intact bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact.
Emergency Medicine Documentation Pearls And Pitfalls: The Neuro Exam
No gait abnormalities are appreciated. Psychiatric: Appropriate mood and affect. Good judgement and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.- Gait Sample Basic Normal Exam Documentation Documentation of a basic, normal neuro exam should look something along the lines of the following: The patient is alert and oriented to person, place, and time with normal speech. Sensation is intact bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.
The Physical Examination - Clinical Methods - NCBI Bookshelf
Sample Detailed Normal Exam Documentation If you are documenting a more in-depth neurological exam, your corresponding documentation for a normal exam should look something along the lines of the following: Mental Status: The patient is alert and oriented to person, place, and time with normal speech. Visual fields normal in all quadrants. Pupils are round, reactive to light and accommodation.- Extraocular movements are intact without ptosis. V Facial sensation is intact to bilaterally to dull, sharp, and light touch stimuli. VII Facial muscle strength is normal and equal bilaterally. VIII Hearing is normal bilaterally. IX, X Palate and uvula elevate symmetrically, with intact gag reflex. Voice is normal. XI Shoulder shrug strong, and equal bilaterally. XII Tongue protrudes midline and moves symmetrically. No clonus. Plantar reflex is downward bilaterally. Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact. Motor: Good muscle tone. Cerebellar: Finger-to-nose and heel-to-shin test normal bilaterally. Balances with eyes closed Romberg. Rapid alternating movements normal. Gait is steady with a normal base. Coordination is intact as measured by heel walk and toe walk. Abnormals on a neurological exam may include: Confused, disoriented Disoriented to person, time, place, situation Memory impairment noted acute or chronic Decreased muscle strength or tone flaccid, atrophy Decreased sensation.
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