HEENT assessment examines the Head, Eyes, Ears, Nose, and Throat. This systematic approach ensures comprehensive evaluation of these interconnected systems.
Inspection:
Sample Narration: "I'm going to begin with inspection of the head. I'm looking at the overall size and shape of the head, which appears normocephalic and symmetric. I'm examining the scalp and hair distribution, which appears even and healthy. I'm checking for any visible lesions, scars, or deformities - I don't see any. The facial features appear symmetric with normal expression."
Palpation:
Sample Narration: "Now I'm going to palpate the scalp gently, feeling for any masses, tenderness, or unusual depressions. The scalp feels normal without any masses or tender areas. I'm palpating the temporal arteries - they feel normal without enlargement or tenderness. Let me check the TMJ by placing my fingers here and asking you to open and close your mouth. The TMJ moves smoothly without clicking or tenderness."
Documentation Points:
Visual Inspection:
Sample Narration: "Moving to the eye examination, I'm first inspecting the eyes and surrounding structures for symmetry. The eyes appear symmetric and appropriately positioned. I'm checking the eyelids - they appear to be at normal position without ptosis or drooping. I'm examining the conjunctiva and sclera - the conjunctiva appears clear and pink, the sclera is white. Looking at the pupils, they appear equal in size, round, and symmetric."
Functional Assessment:
Sample Narration: "Now I'll test visual acuity. Please cover your left eye and read the smallest line you can see clearly... Now cover your right eye and repeat. Now let me test your extraocular movements. Please keep your head still and follow my finger with your eyes only. I'm testing the six cardinal directions of gaze - up and right, right, down and right, down and left, left, and up and left. The movements appear smooth and coordinated.
Now I'm going to test your pupillary reflexes. I'll shine this light into your right eye - I can see the right pupil constricting, that's the direct response, and the left pupil is also constricting, that's the consensual response. Now the left eye - both pupils are responding appropriately. Let me test accommodation - please look at my finger far away, now look at it up close. Both pupils constrict appropriately when focusing on the near object."
Ophthalmoscopic Examination:
Sample Narration: "I'm going to examine the internal structures of your eyes with this ophthalmoscope. Please look straight ahead at a fixed point on the wall. First, I'm checking for the red reflex - I can see a clear red reflex in both eyes, which indicates the media is clear. Now I'm examining the optic disc - it appears pink with sharp, well-defined borders. The retinal vessels appear normal with appropriate arterial-to-venous ratio. The macula appears healthy without any lesions or hemorrhages."
Documentation Points:
External Inspection:
Sample Narration: "Now I'll examine the ears. I'm inspecting the external ears or auricles - they appear symmetric in size and shape and are positioned appropriately. The skin around the ears looks healthy without any redness, swelling, or lesions. I don't see any discharge or foreign bodies in the external ear canal."
Otoscopic Examination:
Sample Narration: "I'm going to examine the ear canals and eardrums using the otoscope. I'm selecting an appropriate-sized speculum and will insert it gently into the outer third of the ear canal only. Looking into the right ear canal, I can see it's clear with minimal cerumen. The tympanic membrane appears pearly gray and translucent with visible landmarks including the light reflex and handle of the malleus. The eardrum appears to be in normal position. Now examining the left ear - similar findings with a clear ear canal and normal-appearing tympanic membrane."
Hearing Assessment:
Sample Narration: "Let me test your hearing with a simple whisper test. Please cover your left ear while I whisper some words near your right ear... Now cover your right ear while I test the left. You were able to hear the whispered words bilaterally. Now I'm going to use a tuning fork to test your hearing. This is the Weber test - I'm placing the vibrating tuning fork on the center of your forehead. Do you hear it equally in both ears or more in one ear? You report hearing it equally - that's normal. Now the Rinne test - I'm placing the tuning fork on the bone behind your right ear, tell me when you stop hearing it... Now I'm moving it to the front of your ear - you should still hear it, and you do. This indicates normal air conduction."
Documentation Points:
External Inspection:
Sample Narration: "Moving to the nose examination, I'm inspecting the external nose for symmetry and alignment - it appears midline and symmetric. The skin condition looks healthy without any lesions or discoloration. I'm checking the nares or nostrils - they appear patent and open."
Internal Examination:
Sample Narration: "Now I'm going to examine the inside of the nose using my penlight. I'm gently looking into each nostril. The nasal septum appears to be midline without significant deviation. The nasal mucosa appears pink and moist, which is normal. I don't see any polyps, unusual discharge, or foreign bodies. The turbinates appear normal in size and color."
Functional Assessment:
Sample Narration: "Let me test the patency of each nostril. Please press on your left nostril and breathe through your right nostril only... Now press on your right nostril and breathe through your left. Both nostrils appear to have good airflow."
Documentation Points:
Oral Cavity Inspection:
Sample Narration: "Finally, I'll examine the throat and oral cavity. I'm inspecting the lips first - they appear pink, moist, and symmetric. Looking at the teeth, they appear to be in good alignment and condition. The gums appear pink and healthy without swelling or bleeding. Please stick out your tongue - it appears pink with normal texture and is positioned in the midline. The tongue has good mobility when you move it from side to side. I'm examining the buccal mucosa or inside of the cheeks - it appears pink and moist. Looking at the hard and soft palate - they appear pink and intact."
Throat Examination:
Sample Narration: "Now I need to examine your throat. I'm going to use this tongue depressor - please open your mouth wide and say 'ahh.' I'm looking at the uvula - it's positioned in the midline and moves appropriately when you say 'ahh.' I'm examining the tonsils - they appear normal in size and color without any redness, swelling, or white patches. The posterior pharynx or back of the throat appears clear and pink without any lesions or exudate."
Functional Assessment:
Sample Narration: "I'm going to test your gag reflex by gently touching the back of your throat with this tongue depressor - you have an appropriate gag reflex. I've been listening to your voice quality throughout the examination and it sounds clear and normal. Your swallowing appears to be functioning normally as well."
Documentation Points:
Use objective, descriptive terms:
Remember: Practice makes perfect. Review anatomy, practice your technique, and familiarize yourself with normal variations before your filmed assessment.