Tina Jones HEENT Shadow Health Objective Data

Tina Jones HEENT Shadow Health Objective Data

Collection of Objective Data: 24.42 out of 25 (97.68%)

Inspected head and face
Skull Symmetry

Symmetric
Asymmetric

Facial Feature Symmetry

Symmetric
Asymmetric

Appearance

No visible abnormal findings
Rash
Papules, pustules, or comedones
Skin growths (freckles, moles, or birthmarks)
Excessive hair growth
Evidence of skin trauma (scar, laceration, or bruising)
Red, chapped nose

Inspected eyes and orbital area
Orbital Area

No visible abnormal findings
Ptosis
Eyelid edema
Lesion
Allergic shiners

Sclera

White
Injection
Icterus

Conjunctiva

Moist and pink
Pale
Dry appearance
Erythema
Edema

Conjunctival Discharge

No discharge
Clear, watery discharge
Purulent discharge

Inspected nasal cavities
Color

Pink
Pale
Erythemic
Bluish

Discharge

No discharge
Clear discharge
Bloody discharge
Purulent discharge

Turbinate Patency

Patent
Decreased patency
Not patent

Observations

No additional visible abnormal findings
Foreign body present
Polyp
Septum perforated
Septum deviated
Lesion

Inspected ears
Right: Auditory Canal Color

Pink
Red
Pallor

Right: Tympanic Membrane Color

Pearly gray
Red
Opaque
Yellow
Not visible because of cerumen

Right: Tympanic Membrane Appearance

No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction

Right: Cone Of Light

5:00
Cone of light distorted

Right: Discharge

No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge

Left: Auditory Canal Color

Pink
Red
Pallor

Left: Tympanic Membrane Color

Pearly gray
Red
Opaque
Yellow
Not visible because of cerumen

Left: Tympanic Membrane Appearance

No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction

Left: Cone Of Light

7:00
Cone of light distorted

Left: Discharge

No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge

Inspected mouth and throat
Oral Mucosa

Moist and pink
Dry appearance
Erythemic

Tonsils

No visible abnormal findings
Edema
Erythema

Tonsil Grade

0: Tonsils fit within tonsillar fossa
1+: Tonsils <25% of space between pillars
2+: Tonsils <50% of space between pillars
3+: Tonsils <75% of space between pillars
4+: Tonsils >75% of space between pillars

Posterior Oropharynx Color

Pink
Erythemic

Posterior Oropharynx Texture

No abnormal findings
Cobblestoning
Exudate

Post Nasal Drip

No discharge
Clear discharge
Purulent discharge

Inspected neck
Symmetry

Symmetric
Asymmetric

Appearance

No visible abnormal findings
Swelling
Visible pulsation
Visible mass
Discoloration

Palpated scalp
Tenderness

None reported
Tenderness reported

Observations

No additional abnormal findings
Balding or thinning areas in hair distribution
Palpable masses

Palpated sinuses
Frontal

None reported
Tenderness reported

Maxillary

None reported
Tenderness reported

Palpated temporal arteries
Right: Vibration

No thrill
Thril

Right: Intensity

0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Left: Vibration

No thrill
Thrill

Left: Intensity

0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Palpated carotid arteries
Right: Vibration

No thrill
Thril

Right: Intensity

0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Left: Vibration

No thrill
Thrill

Left: Intensity

0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Palpated jaw
Observations

No palpable abnormal findings
Limited range of motion
Popping or clicking

Palpated lymph nodes
Head And Neck

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side

Supraclavicular

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side

Axillary

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side

Palpated thyroid gland
Observations

No palpable abnormal findings
Nodules
Enlarged
Irregular

Tenderness

None reported
Tenderness reported

Auscultated breath sounds
Breath Sounds

Present in all areas
Diminished in some areas
Absent in some areas

Adventitious Sounds

No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales

Location

All areas clear
Adventitious sounds in anterior right upper lobe
Adventitious sounds in anterior right middle lobe
Adventitious sounds in anterior right lower lobe
Adventitious sounds in anterior left upper lobe
Adventitious sounds in anterior left lower lobe
Adventitious sounds in posterior right upper lobe
Adventitious sounds in posterior right lower lobe
Adventitious sounds in posterior left upper lobe
Adventitious sounds in posterior left lower lobe

Auscultated temporal arteries
Right

No bruit
Bruit

Left

No bruit
Bruit

Auscultated carotid arteries
Right

No bruit
Bruit

Left

No bruit
Bruit

Tested pupillary reaction
Observations With Penlight

No visible abnormal findings (PERRL)
Unequal
Irregular
Miosis
Mydriasis
Non-reactive to light

Tested extraocular eye movements
Cardinal Fields

No visible abnormal findings
Nystagmus
Fixed pupil

Convergence

No visible abnormal findings
Unequal bilaterally
Fixed pupil

Tested peripheral vision
Observations

No abnormal findings
Reduced right visual field
Reduced left visual field

Examined fundus with ophthalmoscope
Right: Retina

No visible abnormal findings
Myelinated nerve fibers
Papilledema
Glaucomatous cupping
Drusen bodies
Cotton wool bodies
Hemorrhage

Right: Disc Margin

Sharp
Blurred

Left: Retina

No visible abnormal findings
Myelinated nerve fibers
Papilledema
Glaucomatous cupping
Drusen bodies

Tina Jones HEENT Shadow Health Objective Data